Norovirus, MRSA, C. diff, Hepatitis, Common Infections in the elderly Flashcards
what is norovirus
- A nonenveloped single strand RNA virus
- Previously known as Norwalk virus
- The most common cause of gastroenteritis in the United States
- Particularly likely to affect elders: On cruise ships, In long-term care facilities
virology
- Six genotype groups
- Most common: GI, GII, GIV
- GII.4 is the most common cause of outbreaks
symptoms… severe
- Acute onset of nausea and vomiting
- Diarrhea: Nonbloody, Watery
- Abdominal cramps
transmission
o Highly contagious o Food and water borne o Close person to person contact o Contact with contaminated surfaces o Aerosolized vomit
epidemiology
o Causes >20,000,000 cases annually o Contributes to >70,000 hospitalizations o 16% of all gastroenteritis o Most common in the winter o Increases mortality of 90+ patients
definition of an outbreak
o An outbreak of norovirus is defined as an occurrence of two or more similar illnesses resulting from a common exposure that is either suspected or laboratory-confirmed to be caused by norovirus
how to report norovirus
- Clinicians: Report to County/State/Territorial Health Departments
- NORS: National Outbreak Reporting System
- Calicinet: National Norovirus Reporting Network
- NoroSTAT
what is MRSA
o Methicillin (Naficillin) Resistant Staph Aureus
methicillin resistance
-A group of antibiotics no longer able to cure infections caused by Staph: Methicillin, Amoxicillin, Oxacillin, Cephalosporins (Keflex) – this used to be the standard for any type of skin infection (Now, Keflex is no longer considered sufficient if you suspect MRSA, If you are treating prophylactically, you can start with Keflex)
where do we find staph bacteria
o 30% of the population carry Staph in the nose or on the skin
o They, however, are not ill
o If you are a carrier, this does not mean that you are infected by it! You can be just a carrier
community acquired MRSA
o Schools
o Athletic Centers
o Correctional Facilities
hospital acquired MRSA
o Surgeries
o IV Tubing
o Artificial Joints – the worst cases he sees are almost always in artificial joints
long-term care facilities MRSA
o Frail
o Debilitated
o Open wounds/pressure ulcers
o Malnourished
who is at high risk MRSA
o Underlying Health Conditions – diabetes, CHF, etc.
o Prior Antibiotic Use
o Body Implants: Pacemakers, Hip and Knee Replacements
o Prior Hospital or Nursing Home Admission
who is at risk MRSA
o Wrestlers
o Child Care Workers
o People who Live in Crowded, Unclean Conditions
prevention of MRSA
o If you do not see your health care providers clean their hands, please ask them to do so.
o Center for Disease Control
o WASH YOUR HANDS!!!!
o Keep your hands clean by washing thoroughly with soap and water or using an alcohol-based hand rub
o Avoid contact with other people’s wounds or bandages.
o Cover cuts or scrapes until healed
o Avoid contact with other people’s wounds
o Carry disposable gloves with you
prevention of transmitting MRSA
o Cover Your Wound o Clean Your Hands o Do Not Share Personal Items o Talk to Your Doctor o Maintain a Clean Environment: Establish special cleaning procedures for any area that has contact with your skin
prevention of MRSA in a health care setting
o Hand Hygiene
o Gloving: Change gloves between patients, Do Not Wash Gloves for Reuse
o Mouth, Nose, Eye Protection
o Gowning
o Patient Equipment Cleaning: Beds/Rails, Wheelchairs, Gurneys
o Gowning
o Isolation
treatment of MRSA
o Bactrim DS: 1 tab po bid x 10 days
o Doxycycline: 100mg po bid x 10 days: If you are treating with Bactrim but youre not sure if its MRSA, you have to give keflex and Bactrim which is a lot to remember; You can treat strep and staph with doxy so it’s a lot easier
o Clindamycin: Serious infection: 150 to 300 mg orally every 6 hours; More severe infection: 300 to 450 mg orally every 6 hours; Can be given orally or IV – has more of a sliding scale dosing regimen
What is C. diff
o A bacterial infection that causes mild to severe diarrhea
o C. Diff spreads when people touch contaminated surfaces…then touch their own nose or mouth
how does C. diff spread
o C. Diff spreads when people touch contaminated surfaces…then touch their own nose or mouth
o Health care workers can accidentally spread the bacteria to patients or contaminate surfaces that patients touch.
what are the symptoms of C. diff
o Diarrhea: 3 watery bowel movements daily for 2 or more days (He thinks more like 4 or 5 or 7)
o Fever, nausea, abdominal pain
o Complications: Colitis, Sepsis, Death
which clients are at risk for C. diff
o Hospitalized o Nursing Homes o Assisted Living o RCFE (residential care for elderly) o Community Care Facilities o The Elderly o The Ill o Immunocompromised: HIV, Chemotherapy, Chronic steroid use (COPD, Arthritis) o Recent Antibiotic Use, especially: Ampicillin, amoxicillin, Cephalosporin (e.g. Keflex), Fluoroquinolones (eg Levaquin)
infection in the facility C. diff
o Strict hand-washing
o No hand cleaner!
o Gloves and disposable gowns
o Disciplined toilet/incontinent cleanliness procedures
Treatment of C. diff
o PO VANCO IS IV, IT IS NOT ABSORBED SYSTEMICALLY
o Discontinue antibiotics if possible
o Start treatment: Rx: Metronidazole (Flagyl), Rx: Vancomycin
+ cdiff test or +cdiff toxin
o Vancomycin 10 mg/kg/dose (up to 125 mg) PO Q6 hours for 10 days.
If no clinical improvement is noted by day 4 - 6 of vancomycin treatment, consider adding rifampin 10 mg/kg/dose
o (up to 300 mg) PO Q12 hours to the vancomycin treatment. Continue combined therapy with vancomycin and rifampin for a total of 10 – 14 days from the start of initial antibiotic therapy. REVIEW DRUG INTERACTIONS BETWEEN RIFAMPIN AND THE PATIENT’S OTHER MEDICATIONS PRIOR TO INITIATING RIFAMPIN.
o If no improvement is noted by day 4 - 6 of vancomycin + rifampin treatment, consider obtaining GI, infectious disease, and/or surgical consultation and increasing to high dose vancomycin 40 mg/kg/dose (up to 500 mg) PO Q6 hours. Also consider donor stool transplant.
Alternative treatment for C. diff
o suspected C. difficile and ileus (vomiting, abdominal pain, abdominal distention) or with known or suspected C. difficile and toxic megacolon (vomiting, abdominal pain, abdominal distention, fever, tachycardia, hypotension):
o Obtain GI, infectious disease, and/or surgical consultation.
Metronidazole 7.5 mg/kg/dose (up to 500 mg) IV Q6 hours for 10 days. DO NOT ADMINISTER METRONIDAZOLE TO PREGNANT WOMEN.
Consider intracolonic vancomycin.
o DO NOT GIVE IMMODIUM TO C. DIFF PTS BECAUSE YOU CAN CREATE TOXIC MEGACOLON!!
Recurrent C. diff
o After a second relapse within one year or if the patient worsens significantly after treatment is discontinued, consider:
o Vancomycin taper:
o Week 1: 10 mg/kg/dose (up to 125 mg) PO Q6 hours Week 2: 10 mg/kg/dose (up to 125 mg) PO Q12 hours Week 3: 10 mg/kg/dose (up to 125 mg) PO QD
Week 4: 10 mg/kg/dose (up to 125 mg) PO QOD
Week 5 and 6: 10 mg/kg/dose (up to 125 mg) PO Q3 days
o OR
Vancomycin pulse therapy: 10 – 40 mg/kg/dose (up to 125 – 500 mg) PO Q 2-3 days for 3 weeks
what is hepatitis
o Liver inflamation
o Caused by a virus
o Contagious
o Multiple subgroups: A, B, C, D etc etc
hepatitis A
fecal/oral
o Food sources
Hepatitis B
o Blood sources
o Immunization available
Hepatitis C
o 2.7-4 million people infected in U.S.
o 8,000-10,000 deaths each year
o 17,000 new cases in 2007
o 75% of deaths occur in the baby boomer generation
o Hepatocellular carcinoma (HCC) is the fifth most common cancer, the third most common cause for cancer death in the world.
Who is at risk for hepatitis
o IVDU o Hemophiliacs who received clotting factors before 1987 o Received blood/organs before 1992 o Hemodialysis o Medical workers who had needle sticks o Children of HCV+ women
who is not at risk for hepatitis
o Healthcare workers
o Pregnant women
o Household non-sexual contacts of HCV+ persons
who is maybe at risk for hepatitis C
o Transplant recipients before 1992 o Cocaine abusers o Tattoos o Multiple sexual partners o Long-term steady sexual partners of HCV+ persons o HIV + persons
symptoms of hepatitis C
o NONE o Nausea, vomiting o Fever, fatigue o Dark urine o Jaundice o Fever o Pruritis
Acute hepatitis C
o Symptoms occur (if they occur) typically 6-8 weeks after exposure
o Disease can be spread even if you have no symptoms
chronic hepatitis c
o May be undetected for years
o Symptoms – YOU DON’T HAVE TO HAVE SYMPTOMS TO COMMUNICATE HEP C: Arthritis, Itching, Numbness
o Leads to: Hepatocellular carcinoma
o Evidence of Liver Failure: Jaundice, Cirrhosis -> Ascites, Breast enlargement (Gynecomastia)
o Fibromyalgia-like symptoms: Malaise, Joint pain, Muscle inflammation
hepatitis and baby boomers
o New Guidelines: test all people born between 1945 and 1965
o Estimate 1 in 30 baby boomers unknowingly infected
why screen baby boomers
o Chronic Hepatitis C affects 75% of those who have Acute Hepatitis C
o Hepatitis C is Silent until Deadly
o Baby boomers are 5 times more likely to suffer from Hepatitis C than the general population
o Just because you get acute Hep C does not mean that you will get chronic Hep C
cure for hepatitis C
o Interferon
o Ribaviran
o New: Epclusa, combines the older Sovaldi medication with the newer velpatasvir, and costs $74,760 for a 12-week course of treatment
o He treats symptoms and then refers to a hepatitis clinic
management of hep C
o AFP (alphafetaprotein) q 3 mo x 2 then q 6 mo o High AFP? Get Liver ULS eval for lesions
alerting your clients
o CDC Basic Fact Sheet
o Take the disease “Out of the Closet”
UTI
o Very Common among female residents
o Don’t treat dirty urine, wait for culture
o Only treat if >100k colonies on culture
o Cultures often contaminated, don’t treat
o Male UTI’s are always complicated
o UTI with dsyuria/fever is symptomatic, +SPT usually not enough in SNF
o Don’t always treat if colonized, eg, recurrent and asymptomatic, esp if have chronic indwelling foley
managing PNA
o Bronchitis: Zpack: Azithromycin 500mg po x 1 then 250mg po x 4 d, can’t call it bronchitis anymore, call it atypical PNA
o HAP: Levofloxacin 500mg po qd x 7 d
o Aspiration:
o Augmentin 870mg po bid x 10 d
o Often Levofloxacin with addition of Flagyl 40mg po qid x 7d
TB and elderly
o Common, especially in long-term care
o Seek history of prior disease and
o immune limitations
o Screening: PPD x Two, Blood: Quantiferon Gold
o CXR
o Check for weight loss, fever, nightsweats
