Schoenwald: Infections of GI tract-Hepatitis: slide 30 on Flashcards
Hepatitis B Vaccine: is a ___ dose series
3 dose series
Hepatitis B vaccine: 3 dose series schedule?
-typical schedule 0, 1-2, 4-6 months - no maximum time between doses (no need to repeat missed doses or restart) -FDA approved in **newborns and above -Engerix and Recombivax
Hepatitis B vaccine protection: -which demographic is the vaccine less protective for?
~30-50% dose 1; 75% - 2; 96% - 3; lower in older, immunosuppressive illnesses (e.g., HIV, chronic liver diseases, diabetes), obese, smokers
Hepatitis B vaccine: adults?
-2 dose series (adult dose) –licensed by FDA for 18 years and older –Heplisav-2 doses given Day 0 and at 1 month -TwinRix- see Hep A vaccine slides
Hepatitis B Vaccination ACIP Recommendations: which groups should be vaccinated?
-Routine infant -Ages 11-15 “catch up”, and through age 18(VFC eligible) -**Over 18 – high risk: –Occupational risk (HCWs) –Hemodyalisis patients –All STD clinic clients –Multiple sex partners or prior STD –Inmates in Correctional settings –MSM (males sex w males) -IDU -Institution for developmental disability -Pre-vaccination testing – if cost effective -Post-vaccination testing: 1-2 months after last shot, if establishing response critical (HCW)
Hepatitis C: infection is ___x as widespread when compared to HIV
5x
Hepatitis C: is the leading cause of ____ cancer and liver transplantation in the US
liver cancer
Hepatitis C: Vaccine?
no vaccine available (but it can be cured wihth newer meds)
Hepatitis C: risk for infection after a needle stick exposure is ___%
2%
Hep C virus infection: incubation period?
6-7 weeks (range of 2-26 weeks) -usually pts are asymptomatic
Hep C virus infection: acute illness (jaundice) (what % of Pts have jaundice)?
mild (<20%)
Hep C virus infection: case fatality rate?
low
Hep C virus infection: chronic infection?
60-80%
Hep C virus infection: Chronic hepatitis?
10-70% (most asymptomatic)
Hepatitis C virus infection: Cirrhosis ___%?
<5-20%
Hep C virus infection: mortality from CLD (chronic liver dz?
1-5%
Chronic Hepatitis C: list factors that promote progression or severity
-increased alcohol intake -Age >40 yo at time of infection -HIV co-infection -Other (male gender or chronic HBV co-infection)
Exposures known to be assoc. with HCV infection in the US
-injecting drug users -Transfusion, transplant from infected donor -Occupational exposure to blood (needle sticks) -Iatrogenic (unsafe injections) -Birth to HCV-infected mother -sex with infected partner -Multiple sex partners
Exposures known to be assoc. with HCV infection in the US
-injecting drug users (60%) -Transfusion, transplant from infected donor -Occupational exposure to blood (needle sticks) -Iatrogenic (unsafe injections) -Birth to HCV-infected mother -sex with infected partner -Multiple sex partners
Hepatitis C 2016 all age groups US: highest % in which age groups?
-25-34 yo -35-44 yo -15-24 yo
alcohol and hepatitis C are exponential risk factors for ______
cirrhosis
Hepatitis C Labs:
-Hepatitis C Antibody (if +, they may have hep C, but you will want to confirm with PCR test) -HCV (Hepatitis C Virus) PCR= **Confirmatory test -Genotype –1-6 –Genotype 1 is MC in US(80%) followed by type 2 and 3. 4-6 more common in Asian countries.
HCV testing is routinely recommended based on (2 things)?
-Based on increased risk for infection -Based on need for exposure management
HCV testing: describe the need for testing based on increased risk for infection
-ever injected illegal drugs -Pt received clotting factors made before 1987 - Received vlood/organs before 1992 -Ever on chronic hemodialysis - Evidence of liver dz
HCV testing: describe the need for testing based on the need for exposure management
-healthcare, emergency, public safety workers after needle-stick/mucosal exposures to HCV- positive blood -Children born to HCV-positive women
CDC recommendation for HCV testing:
-Anyone born from 1945 to 1965 -People in this age group are 5 times more likely to be infected
Treatment: Hepatitis A
supportive
Treatment: hepatitis B
-difficult, -Adefovir, entecavir,tenofivir
Treatment: Hepatitis C
-Pegylated interferon -Ribaviron -Protease inhibitors released May of 2011, obsolete -Polymerase inhibitors released Dec 2013, obsolete -Combination therapy- non interferon based released late 2014.
List ex’s of Hepatitis C Polymerase Inhibitors
-Simeprevir (Olysio) -Sofosbovir (Sovaldi) -Released December of 2013 -Used with pegylated interferon and ribavirin
Hepatitis C treatment:
-Harvoni: Sofosbovir/Ledipasvir (harvoni is a combo pill with both sofosbivir/Ledipasvir) (this one is commonly used!!) KNOW (also know harvoni is an 8 week treatment) -Viekira pak: ombitasvir,paritaprevir and ritonavir, dasabuvir tabs (these are used more for genotype 2 or 3)
Hepatitis C: current treatment- (list 3)
-Zepatier-elbasvir/grazoprevir (2016): –NS5A inhibitor/NS3/4A inhibitor –**Need to test for NS5A resistance in Genotype 1a (dont use this med in pts with this resistant gene) -Epclusa: sofosbuvir/velpatasvir (2016) –NS5B inhibitor/NS5A inhibitor –**No resistance testing needed –FDA approved for all genotypes –**12 week treatment -Mavyret(glecaprevir/pibrentasvir) 2017: –NS34A protease inhibitor/NS5A inhibitor –Approved for all genotypes –8 week treatment (this is usually preferred on medicare)
Recent black box warning for Hepatitis C treatment
-Risk of hepatitis B reactivation in patients co infected with hepatitis C and B -Routine testing for Hep B reactivation during and post treatment. What tests?
HCV antibody nonreactive=
No HCV antibody detected, no further action required
HCV antibody reactive & HCV RNA NOT detected=
-NO current HCV infection, so they either had a false + test or cleared the infection. No further action required
HSV antibody reactive=
presumptive HCV infection, confirm with HCV RNA test
HCV antibody reactive AND HCV RNA detected=
CURRENT HCV infection, link person to care with ID and GI
Hep C about ____% go onto have chronic infection
80%
Infectious Esophagitis: -MC organism? -MC demographic
-Candida albicans MC -CMV or Herpes virus also common -MC in immunosuppression -HIV/Diabetes
Infectious Esophagitis: clinical sx? -diagnosed by?
-Dyspahgia, odynophagia, retrosternal chest pain -Diagnosed by endoscopy
Infectious Esophagitis: -management is dependent on ?
-Depends on pathogen -C albicans–>diflucan -CMV–>ganciclovir -HSV–>acycolvir
Helicobacter pylori= gram ____ rod residing in ..
Gram negative rod residing in mucous gel coating of epithelial cells of stomach
Helicobacter pylori: 1 in ___ Pts with peptic ulcer disease
1 in 6
Helicobacter Pylori: ___x increase risk of gastric carcinoma
20 fold
Helicobacter pylori is associated with _____
MALT cell lymphoma
Helicobacter Pylori Diagnosis: -sx? -tests?
Sx: Nausea, abdominal pain Tests: -Stool Ag for H pylori -Urea breath tests -Endoscopy
Helicobacter pylori tx
-Combination of PPI and 2 antibiotic agents: clarithromycin and amoxicillin+PPI -Smoking cessation
Diverticulitis: sx
-LLQ pain -Tenderness, bloody stools, fever
Diverticulitis- tx?
combination of metronidazole and fluoroquinolone
Botulism: -organism?
clostridium botulinum= Gram positive rod with spore production
Botulism: describe the toxin and sx associated
*Toxin production–>toxin prevents release of acetylcholine at neuro-muscular junction -**Flaccid paralysis
Botulism: clinical sx
-Rapid onset of symptoms following ingestion of contaminated food -**Symmetric impairment of cranial nerves followed by weakness/paralysis of muscles of extremities and trunk (descending paralysis) -Dysphagia, dry mouth, diplopia, dysarthria, fatigue, upper extremity weakness, constipation, lower extremity weakess, dyspnea, vomiting and dizziness
Botulism: Physical exam findings
-Ophthalmoplegia and ptosis of eyelids -Decreased gag reflex -Facial weakness with normal mental status -Descending paralysis
Miscellaneous: botulism -hx of eating ______?
-wound botulism stems from ______?
- History of eating home canned food or honey (infants)
- Wound botulism–> IV drug usage**
Botulism: tx
-ICU management -Induce vomiting -**Antitoxin=mainstay of treatment -ABX controversial: +/- penicillin IV
