Norovirus, MRSA, C. diff, Hepatitis, Common Infections in the elderly

Question 1

what is norovirus

Answer 1

• 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

Question 2

virology

Answer 2

• Six genotype groups
• Most common: GI, GII, GIV
• GII.4 is the most common cause of outbreaks

Question 3

symptoms… severe

Answer 3

• Acute onset of nausea and vomiting
• Diarrhea: Nonbloody, Watery
• Abdominal cramps

Question 4

transmission

Answer 4

o	Highly contagious
o	Food and water borne
o	Close person to person contact
o	Contact with contaminated surfaces
o	Aerosolized vomit

Question 5

epidemiology

Answer 5

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

Question 6

definition of an outbreak

Answer 6

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

Question 7

how to report norovirus

Answer 7

• Clinicians: Report to County/State/Territorial Health Departments
• NORS: National Outbreak Reporting System
• Calicinet: National Norovirus Reporting Network
• NoroSTAT

Question 8

what is MRSA

Answer 8

o Methicillin (Naficillin) Resistant Staph Aureus

Question 9

methicillin resistance

Answer 9

-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)

Question 10

where do we find staph bacteria

Answer 10

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

Question 11

community acquired MRSA

Answer 11

o Schools
o Athletic Centers
o Correctional Facilities

Question 12

hospital acquired MRSA

Answer 12

o Surgeries
o IV Tubing
o Artificial Joints – the worst cases he sees are almost always in artificial joints

Question 13

long-term care facilities MRSA

Answer 13

o Frail
o Debilitated
o Open wounds/pressure ulcers
o Malnourished

Question 14

who is at high risk MRSA

Answer 14

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

Question 15

who is at risk MRSA

Answer 15

o Wrestlers
o Child Care Workers
o People who Live in Crowded, Unclean Conditions

Question 16

prevention of MRSA

Answer 16

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

Question 17

prevention of transmitting MRSA

Answer 17

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

Question 18

prevention of MRSA in a health care setting

Answer 18

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

Question 19

treatment of MRSA

Answer 19

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

Question 20

What is C. diff

Answer 20

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

Question 21

how does C. diff spread

Answer 21

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.

Question 22

what are the symptoms of C. diff

Answer 22

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

Question 23

which clients are at risk for C. diff

Answer 23

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)

Question 24

infection in the facility C. diff

Answer 24

o Strict hand-washing
o No hand cleaner!
o Gloves and disposable gowns
o Disciplined toilet/incontinent cleanliness procedures

Question 25

Treatment of C. diff

Answer 25

o PO VANCO IS IV, IT IS NOT ABSORBED SYSTEMICALLY
o Discontinue antibiotics if possible
o Start treatment: Rx: Metronidazole (Flagyl), Rx: Vancomycin

Question 26

+ cdiff test or +cdiff toxin

Answer 26

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.

Question 27

Alternative treatment for C. diff

Answer 27

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!!

Question 28

Recurrent C. diff

Answer 28

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

Question 29

what is hepatitis

Answer 29

o Liver inflamation
o Caused by a virus
o Contagious
o Multiple subgroups: A, B, C, D etc etc

Question 30

hepatitis A

Answer 30

fecal/oral

o Food sources

Question 31

Hepatitis B

Answer 31

o Blood sources

o Immunization available

Question 32

Hepatitis C

Answer 32

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.

Question 33

Who is at risk for hepatitis

Answer 33

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

Question 34

who is not at risk for hepatitis

Answer 34

o Healthcare workers
o Pregnant women
o Household non-sexual contacts of HCV+ persons

Question 35

who is maybe at risk for hepatitis C

Answer 35

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

Question 36

symptoms of hepatitis C

Answer 36

o	NONE
o	Nausea, vomiting
o	Fever, fatigue
o	Dark urine
o	Jaundice
o	Fever
o	Pruritis

Question 37

Acute hepatitis C

Answer 37

o Symptoms occur (if they occur) typically 6-8 weeks after exposure
o Disease can be spread even if you have no symptoms

Question 38

chronic hepatitis c

Answer 38

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

Question 39

hepatitis and baby boomers

Answer 39

o New Guidelines: test all people born between 1945 and 1965
o Estimate 1 in 30 baby boomers unknowingly infected

Question 40

why screen baby boomers

Answer 40

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

Question 41

cure for hepatitis C

Answer 41

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

Question 42

management of hep C

Answer 42

o	AFP (alphafetaprotein) q 3 mo x 2 then q 6 mo
o	High AFP? Get Liver ULS eval for lesions

Question 43

alerting your clients

Answer 43

o CDC Basic Fact Sheet

o Take the disease “Out of the Closet”

Question 44

UTI

Answer 44

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

Question 45

managing PNA

Answer 45

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

Question 46

TB and elderly

Answer 46

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