Enterobacteriaceae, Legionella, Diarrheal Diseases, Hepatitis Flashcards
Where are Enterobacteriaceae natural inhabitants?
GI tract
This gram-negative bacterial family is ubiquitous in environment and in gut
Enterobacteriacaeae
Enterobacteriaceae cause ____ of bacteremias
1/3
Enterobacteriaceae cause more than ____% of UTIs
80%
Basic description of enterobacteriaceae
Gram negative rods
Non-spore forming
facultative anaerobes
What agar is used to differentiate enterobacteriaceae?
MacConkey agar
Do all enterbacteriaceae ferment lactose?
No, both lactose fermenters or non-lactose fermenters
What common antigen do all enterbacteriaceae have
Enterobacterial common antigen (ECA)
selective and differential medium that inhibits gram + organism and differentiates between lactose fermenting gram negatives
MacConkey Agar
Enterobacteriaceae- lactose fermenter that is motile
E. coli
Enterobacteriaceae- non-motile lactose fermenter
Klebsiella pneumoniae
Enterobacteriaceae- motile non-lactose fermenters
Salmonella
Proteus
Enterobacteriaceae- Non-motile non-lactose fermenters
Shigella
Yersinia
What types of HAIs are associated most often with Enterobacteracieae?
Pneumonias
SSIs
Bacteremia
UTIs
What are the most familiar species of Enterobacteriaceae recovered from extraintestinal diseases?
E. coli
Enterobacter cloacae
Klebsiella penumoniae
Serratia marcesens
Proteus mirabilis
Most common Enterobacteriaceae agents of gastroenteritis and colitis?
Salmonella
Shigella
E. coli
Two species of Salmonella for which humans are the only reservoir
Salmonella typhi
Salmonella paratyphi
How often to patients become chronic carriers of salmonella?
1-5%
Which virulence factor is associated with Enterobacteriaceae and septic shock and Disseminated intravascular coagulation (DIC)
LPS polysaccharides and Lipid A endotoxin
Common to all aerobic and some anaerobic, gram, negative bacteria, released upon death. Activates the macrophages, white blood cells, releases cytokines, and causes septic shock, necrosis, DIC, and death
LPS-polysaccharides and Lipid A endotoxin
What do LPS polysaccharides and Lipid A endotoxins cause?
- Septic Shock
- Necrosis
- DIC
- Death
Structure that facilitates motility and adherence to GI, and urinary epithelial cells. Also assists in invasion of mucosa
Flagellar H antigens
Structure that prevents phagocytosis, evades immune mechanisms
Capsule K antigen
Provides resistance to antibiotics, production of toxins, hemolysins, may be chromosomal or plasmid mediated
Pathogenic islands
Antigen that provides resistance to antibiotics, production of toxins, hemolysins, may be chromosomal or plasmid mediated
Pathogenic islands
Enterobacteriaceae with a symptom of red currant jelly sputum and penumonia
Klebsiella pneumoniae
Two most common HAIs caused by Klebisella, Enterbacter, and serratia
Pneumonia and UTIs
Concern with HAIs from Klebsiella, Enterobacter, and Serratia
Multi-drug resistance
What antibiotic for klebsiella, enterobacter, and serratia?
carbapenem
Do Klebsiella, enterobacter and serratia ferment lactose?
Yes
Motility for enterobacter?
motile
motility serratia?
motile
motility klebsiella?
not motile
what color are lactose fermenters on MacConkey agar?
Pink
What pigment does Serratia have on MacConkey agar?
Bright red
3 As of klebsiella
Alcoholics (common risk)
Abscesses (what they cause)
Aspiration (How it starts)
Enterobacteriaceae HAI that has a capsule
Klebsiella
Enterobacteriaceae that causes cavitation in chest imaging and may be mixed up with TB
Klebsiella
Which HAI most commonly produces urease?
Protease
What is the microbial resistance concern with Klebsiella?
Carbapenemase- producing strains
What is the most frequently isolated carbepenemase producing enterobacterales?
Carbapenem- resistant Klebsiella pneumoniae (CRKP)
Which enterobactericaeae is most often associated with blood stream infections?
Klebsiella
Enterobacteriaceae most often associated with CAUTIs
E Coli
What family was the leading cause of CAUTIs?
Enterobacteriaceae
What was the top pathogen recovered from CAUTIs?
E. Coli
Basic description of legionella
aerobic
Gram negative
Fastidious bacteria
Tests for legionella
Urinary antigen detection
Clinical manifestations legionella
Pneumonia (Legionnaires disease)
Flu-like illness (Pontiac fever)
CDC estimates that less than ___% of the legionella cases are dx’d and reported to the CDC
5%
Incubation periods Legionnaire’s disease
2-10 days
Associated symptoms Legionairre’s Disease
Nonproductive cough
fever (usually above 104)
shortness of breath
Malaise
Anorexia
Headache
Confusion
Watery diarrhea
Nausea
Vomiting
Abdominal pain
What will a legionnaire’s disease chest radiograph look like
infiltrates in the lungs
What is common lab result for legionnaire’s disease
Hyponatermia
low concentration of sodium in blood
Hyponatermia
Incubation for Pontiac fever
24-48 hours
Pontiac fever symptoms
High fevers
Chills
Myalgia
Headache
Symptom resolution with Pontiac fever
Typically resolve in 2-5 days without treatment
Risk factors for legionella
advanced age
male gender
cigarette smoking
alcohol abuse
chronic pulmonary disease
immunosuppressed hosts
renal failure
corticosteroid use
natural habitat of legionella
Water
Mode of transmission legionella
Direct inhalation or aspiration
does person to person transmission happen for legionella?
no
How can legionella be transmitted in healthcare settings?
Aerosolization by use of respiratory tract devices (humidifiers, nebulizers)
Legionella infections can be traced to …
Multi-species biofilms
What is the gold standard definitive test for legionella?
Culture
What is the limitation of urinary antigen tests for legionella?
only able to detect serotype 1
Treatment for legionella
Quinolones or macrolides
Prevention of Legionella
-Water safety plan
- Disinfection
What are the disinfection methods for legionella?
- Super heat and flush, hyperchlorination
- Copper silver ionization systems
- Chlorine dioxide
- Monochloramine
- Point of use water filters
Two organisms that are the waterborne pathogens that are most associated with outbreaks related to contaminated equipment. Tap water that is used to rinse instruments after disinfection and as a water source for medical instruments may be a source of these infections.
Pseudomonas and non-tuberculosis mycobacteria
What are the virulence factors for Klebsiella spp?
capsule
Endotoxins
What are common infections caused by Klebsiella spp?
CAP (alcoholics)
HAP (ventilator)
UTIs (indwelling catheters)
Incubation periods for ETEC
1-2 days
Symptoms of ETEC
Water diarrhea
Cramps
Nausea
Vomiting
Dehydration
Common name for ETEC
Traveler’s diarrhea
Transmission ETEC
fecal/ oral
Symptoms EIEC
Bloody/ mucoid stool
fever
cramps
watery diarrhea
Transmission EIEC
Travel
Contaminated H2O
Who is at risk for EPEC?
infants
Young children
Developing nations
Symptoms of EPEC
Watery diarrhea
Fever
Nausea
Vom
Muccoous in stool
Enteroaggressive E. Coli- where it’s a concern
Developing nations
Shigella virulence factors
neurotoxin
cytotoxin (B)
enterotoxin (A)
symptoms Shigella
cramps
diarrhea
fever
bloody stools
Can be asymptomatic
Transmission shigella
person to person
fecal oral
this organism cases 15-20% of pediatric cases of diarrhea in the U.S.
Shigella
Infective dose shigella (low/ medium/ high)
Low
How salmonella is transmitted
fecal oral or animal to person
Infective dose salmonella (low/ medium/ high)?
High infective dose
Who is at risk for salmonella?
kids under 5
>65
AIDS patients
Sickle cell
MSM
4 clinical manifestations of salmonella
Enteritis
Septicemia
Enteric Fever
Asymptomatic
Incubation for salmonella - GI
6-48 hours
Symptoms salmonella GI
nausea
vom
diarrhea
fever
ab cramps
myalgia
Treatment salmonella enteritidis
No treatment
Who is impacted by salmonella septicemia?
advanced age
HIV
Infections related to Salmonella septicemia (bloodstream infection)
osteomylitis
endocarditis
arthritis
Incubation period for salmonella enteric fever
10-14 days, lasts for weeks
What salmonella species cause asymptomatic Salmonella infections?
S. typhi
S. paratyphi
Where does salmonella live in the body during asymptomatic infections?
Gallbladder
Incubation period yersinia
3-7 days
Symptoms yersinia
fever
diarrhea
enterocolitis
acute mesenteric lymphadenitis
Source of nonenteric yersina bloodstream infections occur?
blood product
What are the two type of plague caused by yersinia pestis?
bobonic plague (most common)
pneumonic plague
Symptoms of bubonic plague
Buboes
Fever
Chills
sepsis
gangrene
What antigens are used on Enterobacteriaceae classification?
O antigen
K antigen (capsule)
H antigen (Flagella)
What increases the risk level for enterobacteriaceae?
medical intervention
disruption to normal GI microbiome
Exposed to contaminated H2O
Very young, old, debilitated
Resistance mechanisms for enterobacteriaceae
most common is beta lactamase- ESBLS
Enterobacteraceae most common MDROs
Enterobacter
Klebsiella
Serratia
Plasmid carrying
KPC
VIM
IMP
NDM
OXA-48
are resistant to what antibiotic?
Carbepenem
Most common carbapenem resistant bacteria
Klebsiella
Most common organism isolated from CAUTIs
E. coli
Most common organism isolated from SSIs
Enterobacter
Most common species isolated from bacteremias
Klebsiella spp
Common pathophysiology of enterbacteriaceae bloodstream infection
spreads from UTI, lungs, or GI tract to blood
Releases endotoxins
Enterobacteriaceae in top 10 CLABSI list
Klebsiella
Enterobacter
E. Coli
What enterobacteriaceae cause HAP?
Enterobacter
Klebsiella
E. Coli
What Enterobacteraceae organism most commonly casess VAP?
Klebsiella
What are the top 5 organisms for CAUTIs?
1) e. coli
2) Kelbsiella
3) Proteus
4) enterobacter
5) seratia
What is a risk for an SSI infection with enterbacteriaceae, esp e. coli
Antibiotic PEP with a 3rd gen cephalosporin
Who is at risk for a CNS infection with enterobacteriaceae?
premature babies
low birth weight in infants
What 2 Enterobacteriaceae organisms typically cause CNS infections?
E. coli
Klebsiella pneumonia
E. Coli is in the Top 10 organism list for which HAIs?
1 CAUTI
#3 SSI
#6 VAP
#9CLABSI
E. coli is not a common ________ pneumonia but is a common ________ pneumonia
community acquired pneumonia
healthcare acquired pneumonia
Enterobacteriaceae that cause oppurtunistic infections in immunocompromised patients, especially those on ventilators, and prolonged antimicrobials.
enterobacter
Enterobacter can cause the following infections
lower resp infections
UTI
wounds infections
septecemia
MDRO concern for enterobacter
carbapenemase + EBSL producer
Most dangerous type of EHEC that can cause HUS
O157: H7
Incubation period for EHEC
1-9 days
Incubation period for ETEC
3-14 days
Incubation period for EPEC
3-6 days
Epi of EPEC
Diarrhea for >2 weeks in children
Precautions for E. coli
Contact
Clinical symptoms for EHEC
Ab pain
Myalgia
headache
vom
hemorrhagic colitis
Key difference between ETEC and EHEC
No leukocytes in stool of ETEC, just watery diarrhea
Systemic complications of EHECt
HUS
Culture for EHEC
macConkey agar (lactose fermenter)
Is EIEC common in the U.S.
no, very rare
How many serotypes of Salmonella enterica are there? based on what?
2400
O, Vi, and H antigen
Where are Salmonella Typhi and Salmonella paratyphi prevalent
India and Asia
Incubation period Salmonella typhi
5-21 days
Symptoms Salmonella typhi
diarrhea
headache
anorexia
myalgia
general weakness
rose spots
hepatosplenomegaly
Antibiotic for salmonella typhi
Fluloroquinolones
Who is at highest risk for non-typhoid Salmonella
HIV
Infants
Season for non-typhoid salmonella
summer, early fall
Most common cause of salmonella outbreaks
Salmonella enteritidis
Transmission non-typhoid salmonella
Ingestion of undercooked meat (esp poultry, eggs, dairy products)
Exotic pets
Incubation of non-typhoid salmonella
6-48 hours
Symptoms non-typhoid salmonella
Diarrhea
ab cramps
bacteremia (infants, elderly, immunocompromised, sickle cell)
Extraintestinal infections Salmonella
UTI
Osteomyelitis
Joint infections
Dx for salmonella
Stool culture
Very virulent form of EnterobacteriaceaeEnterobacteriaceae with only humans as the host
shigella
Are non-typhoid salmonella patients typically treated?
No, not unless high risk
Epi- risk factors for shigella
daycare
migrant workers
international travel
custodial institution
MSM
Can you have shigella twice?
no, infection confers immunity
Clinical symptoms shigella
FEVER
Bloody diarrhea (20+ stools per day)
severe abdominal cramps
tenesmus
Pathogenicity shigella
multiply and cause cell death and inflammation
Treatment for shigella
Rehydration therapy
Antimicrobials
Gram negative cocobacillus enterbacteriaceae that is invasive and cases disease in humans
Yersinia
Where is yersinia common?
Europe
What is a common source of yersinia?
chitterlings
High risk populations yersinia
infants
African americans
iron chealtor
receive blood
What animal is yersinia associated with?
pigs
What is the incubation period for yersinia?
1-4 days
Symptoms yersinia
- enterocolitis
-mesenteric adenitis (right lower quadrant pain) - terminalilitis
- septicemia
- reactive arthritis
What antibiotics is yersinia resistant to?
macrolides
Infection control for yersinia
-safe food handling, esp pork
- Test blood products
-treat H2O
Very common enteric- gram negative, non spore forming rod, but not in enterobacteriaceae family
Campylobacter
Reservoir for campy
intestines of cows and poultry animals
Transmission of campylobacter
Undercooked meat
Unpasteurized dairy
Unchlorinated water
contact with sick pet
Incubation campylobacter
1-7 days
symptoms of campylobacter
Prodome- fever, headache, malaise, myalgia
1-2 days later- tenesmus, diarrhea, ab pain, lower right quadrant pain
Is campylobacter common in healthcare?
No, very rare in healthcare\
Gram negative bacteria that are transmitted via fish (aquarium to wounds, fishers, eating fish)
Edwardsiella tarda
Aeromonas speicies
Pleisiomonas Shigelloides
Aeromonas species are rare except in ___ therapy
leech therapy
Spore forming, gram+ enteric
Bacillus cereus
Most common foods bacillus cereus
Rice, noodles, pastries
Incubation period Bacillus cereus
8-12 hours
What are the caliciviruses?
Norovirus and Sapprolike viruses
Transmission
of caliciviruses
Fecal/oral
aersolized vom
Person to person
Season for calciviruses
winter
Where caliciviruses are the biggest risk
nursing homes
*cruise ships
*Schools
*camp
*military
*restaurants
*airplanes
Incubation period for caliciviruses
12-48 hours
Symptoms calicivirus
vomit
ab cramps
diarrhea
How long can a patient shed norovirus?
3 weeks
incubation 24-48 hours
illness 12-60 hours
more than 50% vom
no bacteria in stool
Kaplan criteria for noro
Control norovirus
Wash hands soap and water
Exclude sick staff
No new admits
Disinfect
Most common viral GI infenction
Rotavirus
Transmission rotavirus
Fecal oral
P2P close contact within household
How long can rotavirus survive on the hands?
60 minutes
What age group most commonly is infected with rotavirus?
children
Symptoms rotavirus
may have cough/ coryza
followed by fever and vomitting
followed by bloody diarrhea 2-3 days later
Are there protective antibodies for rotavirus?
No
Describe diarrhea for rotavirus
20x per day
non bloody diarrhea
Treatment for rotavirus
Oral rehydration
Prevention rotavirus
Vaccinate babies
Virus that causes watery diarrhea from shell fish, H2O and fomites
astroviruses
Describe symptoms of astroviruses
Watery diarrhea
nausea
headache
malaise
low-grade fever
**asymptomatic (most common)
Which is more mild, rotavirus or astrovirus?
rotavirus
Age effected by astroviruses
<9 years
how long astroviral shedding last in stool
up to 35 days
High risk age for enteric adenoviruses
Children <4
transmission enteric adenoviruses
fecal/ oral
droplet
transplant
NOT FOOD
Incubation period for enteric adenoviruses
8-10 days
Does infection with enteric adenoviruses confer immunity?
Yes, lifelong
symptoms adenoviruses
Protracted diarrhea
asymptomatic
What organism causes amoebiasis?
Entamoeba histolytica
Transmission amoebiasis
fecal oral
High risks for amoebiasis transmission
Travel
Nursing homes
Immigrants
Institutionalized
MSM with HIV
Symptoms amoebiasis
90% asymptomatic
otherwise- blood diarrhea, fever, dehydration, weight loss
More severe symptoms of amoebiasis
Colon ulcers
invasive hepatic abcesses
Dx amoebiasis
wet mount or serology
This parasetic diarrheal diseases causes diarrhea, stomach pain, flatulence, and anoerexia, or asymptomatic colonization. It is unclear how it is transmitted.
Blastocytis heminis
This is the most common parasite in the U.S.
Giardia (lamblia) deodenalis
Transmission giardia
contaminated H2O
animals
diapers
MSM
fecal oral
Size of inoculum giardia
low
Most common clinical presentation giardia
asymptomatic
When symptoms are present for giardia, what are the symptoms
foul smelling, profuse watery diarrhea
Dx giardia
wet mountw
treatment giardia
Metronidazole
Tridazole
Transmission of cryptosporidum parvum
contaminated H2O (drinking and recreational)
P2P *handwashing MSM
What is unique about crytosporidium parvum?
resistant to chlorine
What type of organism is cryptosporidium parvum?
parasite
incubation period cryptosporidium
5-28 days
symptoms cryptosporidium
profuse, watery diarrhea
ab pain
fever
fatigue
Type of agent of cyclospora cayetanesis
parasite
Transmission of cyclospora cayetanesis
tropical climates
foodborne
Incubation time cyclospora
1-7 days
Symptoms cyclospora
Profuse, watery diarrhea
nausea
vom
appetite loss
Dx cyclospora
modified acid fast stain
Treatment cyclospora
TMP-SMP
What are the most common legionella pneumophila serogroups?
1*, 4, and 6
Virulence factors of legionella
LPS
Flagella
Pili
Exoproteases
cytotoxins
Outter membrane proteins
Mortality rate legionella
1/10
Risk for legionella
Advanced age
male gender
smoking
alcohol abuse
COPD
Who is at biggest risk for HAI legionella
organ transplants
Where do people typically get legionella CAP?
hotel
fountain
cruise ship
spas
4th leading cause of CAP
legionella
What makes a probable case of legionella healthcare acquired pneumo?
in setting <10 days before onset
What makes a definite case of HC acquired pneumo due to legionella?
in hc setting for 10+ days b4 onset
When to investigate legionella
2+ cases
Where does legionella grow?
Drinking water dist systems
whirlpools and spas
decorative fountains
industrial equip
Transmission of legionella
1) aersolization
2) aspiration
3) direct deposit from medical procedure
Incubation period of legionairre’s disease
2-10 days
Incubation period pontaic fever
24-48 hours
what mental change is common in legionairre’s disease patients?
confusion
Does legionella grow easily in culture?
No, fastidious
Antibiotics for legionella
quinolones and macrolides
Water safety plan steps
1) Describe the water system
2) Assess risk
3) control risk
4) Audit
When do you need to culture the water system for legionella?
1 case- where patient was, high risk patient areas
2 cases- facility wide
is superheating a flushing a long term solution for legionella?
No, will grow back
Non-toxic chemical method to kill legionella
Chlorine dioxide
Kills legionella and biofilm
monochloromine
Where to use point of use filters for legionella
high-risk units
Concerns with hyperchlorination for legionella
short term
carcinogens
To prevent legionella use ___ water to rinse respiratory equipment, naso/ oro trach probes, CPAPS
sterile
To prevent legionella, clean and disinfect these machines
ice machines
baths
Should portable humidfyers be allowed in the room?
No, allow for legionella to grow
Who should drink bottled water during a legionella outbreak?
immunocompromised patients
What are the CAP- core quality measures?
-oxygen assessment within 24 hours or hosp arrival
- pts over 65 screened for pneumo vax
- blood cultures in ED b4 abx administered
- abx timing (within 6 hrs of arrival)
- Abx selection
- adult smoking cessation advise
-influenza vax
What type of virus is Hep A
RNA
transmission route Hep A
Fecal/ oral
Primary modes of transmission for Hep A
Intimate contact
Poor hygiene
unsanitary conditions
contaminated food and water
People at risk for Hep A
Children
MSM
IV Drug users
Occupation (sewage)
travel
incubation for Hep A
15-50 days
typically hep a symptom for children under 6
asymptomatic
Typical symptom for adults and older children in prodromal phase
Fever
Ab discomfort
arthralgia
malaise
fatigue
nausea/ vomit
Hep A symptoms iciteric phase
jaundice
dark urine
pale stool
pruritis
Infection control for Hep A
Vax PEP within 2 weeks <40 years old
-IG within 2 weeks >40
- standard precautions
Best prevention Hep A
Childhood vax
Vax high risk adults
Type of virus Hep B
DNA virus
Transmission of Hep B
blood
sexual
perinatal
These fluids contain which type of Hep?
Blood
semen
vag secretions
saliva
tears
csf
ascites
serous fluids
Hep B
Incubation period for Hep B
60-150 days
How long before symptoms of hep B does the HbsAg, HBeAg, and HBV DNA start to convert to positive?
2-7 weeks
Symptoms of Hep B in young children
asymptomatic
Symptoms for adult prodromal acute infection with Hep B
uticarical rash
arthritis
fever
Symptoms acute HBV
Fever
fatigue
loss of appetite
nausea
vom
ab pain
dark urine
jaundice
How long does acute HBV last?
6 months
What labs are elevated during acute Hep B?
IgM
ALT/ AST
Bilirubin
What percentage of children with acute Hep B will develop chronic Hep B?
90%
What percentage of adults with acute Hep B will develop chronic Hep B?
5%
Outcomes chronic HBV
liver damage
cirrhosis
hepatocellular carcinoma
When does HBsAg appear? test results mean?
1-10 weeks after exposure
Pt has Hep B
What doe HBeAg test results mean?
patient is infectious
What does a positive HBV test mean?
patient is infectious
What does it mean if the HBsAg stays positive for 6+ months
Chronic case
What does it mean if the HBsAg is positive and the DNA and HBeAg are negative
The person is a carrier
What to do after HBV exposure
Test anti-HBC
if <10 miu/mL, single dose of HBIG + booster vax within 7 days
What to do for HBsAg+
check viral loads
>1000, no non-emergency exposure prone surgeries until viral loads decrease
Prevention hemodialysis hep b
Test patients total anti-HBC annually and revax if needed
- do not share med equip
- cleaning and disinfection
Partners and infants of HBV patient
should get HBIG
Most common Hepatits
Hep C
who is at highest risk for Hep C?
-Born 1945-1965
- IV drug users
- multiple sex partners
- HIV
- hemophiliacs with blood before 1987
- blood products before 1992
Transmission of Hep C
-Blood injection
- organ transplant
- transfusion HCV blood/ blood products
- sex (much less efficient)
How long is the incubation period for Hep C for blood products?
4 weeks
How long is the incubation period for Hep C
15-160 days
Acute symptoms of Hep C
Asymptomatic*
Fatigue
Ab Pain
Hepatomegaly
jaundice (25%)
How many individuals with acute Hep C will continue to have a chronic infcetion?
85%
Outcomes of chronic Hep C
Cirrhosis
Hepatic carcinoma
How long after exposure does anti-HCV become positive?
6-8 weeks
How long after exposure can the PCR for HCV show an infection?
1-2 weeks
Treatment for HCV
pegylated interferon +ribdavarin (PR)
protease inhibitors
Infection prevention for HCV
-Screen blood, organs and tissue
- counsel patients with HCV
- Needle exchange
What can inactivate HCV in blood products?
Heat
This is an RNA virus that requires a Hep B infection
Hep D
Where is Hep D prevalent?
Mediterranean- Italy
hemophiliacs
IV drug users
Transmission of Hep D
Percutaneous only
Not sex or perinatal
incubation period Hep D
30-180 days
Acute symptoms Hep D
Fever
Fatigue
Loss of appetite
Nausea
vom
ab pain
dark urine
jaundice
This is when Hep D infection occurs at the same time as a Hep B infection, which causes a slower moving pathogenesis
Coinfection
This is when a Hep D infection occurs after a Hep B infection, and causes a quickly moving infections with chronic symptoms in 1-2 years
Superinfection
Chronic symptoms Hep D
Cirrhosis
Hepatic carcinoma
This hepatitis causes high mortality in pregnant women
Hep E
This hepatitis is spread by the fecal oral route, but is not common in the US
Hep E
Which is more severe in the Iceteric phase- Hep A or Hep E?
Hep E
Precautions for Hep E
Standard precautions
