W4 Flashcards
Intensive vs Moderate vs No Infection control program
Intensive decreases infections
Moderate: NO CHANGE
none: increased infections
Bundles Concept in Infection control
A “bundle” is a collection of processes needed to effectively and safely care for patients undergoing particular treatments with inherent risks. Several interventions are “bundled” together and, when combined, significantly improve patient care outcomes.
- worked perfectly to reduce Catheter-Related Bloodstream Infection rates
CDAD
C. Difficile
Which infections INCREASED during covid, which DECREASED
INCREASE:
Catheter assoc. bloodstream infections
Ventilator assoc. pneumonia
MRSA bacteremia
- over worked staff, packed hosptials, harder for infection control
DECREASE:
Surgical site infections
C. Difficile diarrhea
- COVID related infection control maybe helped for these ones
Infectious Standard of care for all patients
Assumes “body substances” * from any patient could be infectious
- aims to prevent transmission from patients who are asymptomatic or have undiagnosed infections
Aims to prevent infections associated with invasive procedures
Practices based on nature of interaction with patient
- blood, body fluids, excretions, secretions, exudates
Hand washing vs Alcohol based hand rinses
Now considered method of choice for hand hygiene in health care
Effective, convenient, fast
Increased compliance with hand hygiene
Decreased infections rates
Respiratory Etiquette for Source control
PROMPTLY IDENTIFY patients with febrile respiratory illness
POST SIGNS instructing coughing patients to
- cover nose & mouth when coughing or sneezing
- dispose of tissues promptly
- clean hands after contact with respiratory secretions
- wear surgical mask if possible
SEPARATE coughing patient from others
PROVIDE tissues, masks, waste receptacles, hand hygiene product
When are CONTACT precautions used?
Skin and wound infections
Diarrhea
Colonization with selected multi-drug resistant organisms
Viral respiratory infections (with droplet)
Contact Precautions Include;
SINGLE ROOM or maintain spatial separation between patients
GLOVES to enter the patient’s room
GOWN if clothing or forearms will have direct contact with patient or contaminated items
Hand hygiene with ANTISEPTIC after removing gloves
Dedicated equipment (or DISINFECT before re-use)
DROPLET precautions for which infections?
Viral respiratory infections (with contact)
Meningococcus
Invasive Streptococcus group A infections
Pertussis, mumps, rubella, parvovirus
Droplet Precautions include
Single room or spatial separation of > 1-2 m
Surgical mask if < 1-2 m of patient
For viral respiratory infections, consider eye protection (mask with visor, face shield or goggles) *
Patient to wear surgical mask when out of room
Airborne Precautions
- more difficult to prevent
Single room
Special ventilation and negative pressure (air flows into room, not out)
High efficiency mask (N95)
- for contagious tuberculosis
- for measles, varicella if not immune
N 95 Mask
Originally designed for industry
(asbestos, other irritant particles)
Tight-fitting mask, built-in filter
Requires fit-testing and fit-check
Introduced for care of tuberculosis in 1994
- Recommended for varicella, measles in 1997
- Also used for SARS, Avian influenza,
Ebola
- Recommended if performing specific
procedures on patients with influenza
Antibiotic Resistant Organisms Infection Control
Use antibiotics wisely
Don’t use antibiotics as antipyretics !
Don’t substitute treatment for diagnosis
Prevent transmission of resistant organisms
Take appropriate Isolation Precautions
Physician Health in Infection Control
Have the appropriate immunizations:
- be immune to *hepatitis B, *measles, *mumps, *rubella, *varicella, *pertussis, polio, diphtheria
- get *influenza vaccine yearly
Have a PPD test if indicated
Have fit-test for N95 mask; know how to do a fit-check
Take appropriate precautions if working while ill with a contagious infection!
Students and Blood Borne Viruses
Carriers of BBV
- are not prohibited from patient-care activities solely on the basis of BBV infection
- are prohibited from performing selected high risk procedures which pose a risk to patients unless certain criteria are fulfilled
(low viral load, following advice from expert panel, routine medical follow-up & monitoring of viral load, adherence to specified infection control practices)
TRansmission of SARS, most transmission occured in…
Health Care settings!!
Baby boy: Presents to your office with three days of fever to 40C, irritability, poor sleep and clawing at his face/pulling his ears
On exam, you note a febrile, crying baby with a bright red and bulging tympanic membrane
- Diagnosis
Acute Otitis Media
What is the most common pathogen identified in acute otitis media
Viral pathogens!
what are common bacterial pathogens for Acute Otitis Media
Common bacterial pathogens include:
*Streptococcus pneumoniae
Haemophilus influenza Moraxella catarrhalis Streptococcus pyogenes
Most complications of AOM (mastoiditis, perforation) happen in the context of a S. pneumoniae infection
Acute otitis media
Risk factors for resistant streptococcus pneumoniae strains:
Daycare
Children <2 years
Recent hospitalization
Recent antibiotic use (within 30 days) Frequent history of AOM
Presentation of Acute Otitis Media
Recent and often abrupt onset of fever and ear pain, often accompanied by congestion
Presence of the following features:
- Evidence of middle ear inflammation (an erythematous TM)
- Evidence of mucopurulent effusion in the middle ear (a TM that bulges)4
TReatment for Acute Otitis Media
Amoxicilin
Advice to parents of kids with ear infection within 24 hours
likely a viral infection - which resolves within 24-48 hours
better to AVOID antibiotics if not needed
with a family you can give them an walk out prescription, if they don’t get better after two days then take meds.
Savannah is a healthy 7 year old girl with no past medical history She presents to care with: • Sudden onset 48h of fever • • • • Extreme throat pain Vomiting x 1, poor appetite Absence of cough or congestion • Tender anterior lymphadenopathy Tonsillar and pharyngeal inflammation with exudate on her tonsils Petechiae on palate No rash On exam, you notice: • • • •
Diagnosis
Pharyngitis
- can be caused by many things: most common pathogen is VIRAL
Pharyngitis
common pathogens:
What is the most common pathogen identified in acute pharyngitis?
Viral pathogens!
If a bacterial cause is identified, it is usually group A beta-hemolytic
streptococcus (GABHS): streptococcus pyogenes
- 5-15% of pharyngitis/tonsillitis in children
- 20-305 of pharyngitis/tonsillitis in adults
The diagnostic challenge is identifying which cases are in fact bacterial and require antibiotic treatment
Pharyngitis
- Important DDX
Viral: Epstein-Barr virus, coxsackie, adenovirus, herpes simplex virus
Peritonsillar or retropharyngeal abscess
Thrush
N. gonorrhoeae (in sexually active patients)
Foreign body
Kawasaki disease
Key Management Principles for Pharyngitis
Don’t treat viral pharyngitis with antibiotics
Analgesia is very much recommended in the first few days (very painful so you wanna relieve symptoms)
Do not initiate treatment in the absence of a positive rapid test or a positive culture of the throat, unless:
- Very severe symptoms
- Clinical signs of Scarlet fever
- Complications (i.e. evidence of tonsillar abscess)
- A history of acute rheumatic fever (complication of strep)
Scarlet fever
Complications of infection by GABHS; “strep throat with a rash”
Scarlatiniform rash is characterized by:
Diffuse erythema that blanches with pressure
Starts usually in groin and armpits; accompanied by circumoral pallor and strawberry tongue
Rash progresses to trunk, then to extremities, then desquamates; palms and soles are often spared
Most MARKED in the inguinal, axillary, antecubital and abdominal areas
- Axillary and antecubital: Linear petechial pattern called PASTIA’S LINES
Scarlet fever
- cause
- Management
Rash usually occurs because of a delayed-type skin reaction to pyogenic exotoxin
Untreated scarlet fever with pharyngitis can predispose to acute rheumatic fever
- Management of scarlet fever is the same as management of pharyngitis/tonsillitis
- Children may return to daycare 24 hours after antibiotics
- No specific monitoring of these patients is needed
Pharyngitis and scarlet fever: treatment
Why treat
Reduces symptoms
Reduces risk of complications as well as person-to-person transmission
Will prevent acute rheumatic fever if treatment is started within 9 days of initial onset of symptoms
so you use treatment to PREVENT complications*
Mono is a high DDX for….
- what organism is it caused by?
high DDX for strep throat
mono is caused by EBV
Madeleine is a 35 year old previously healthy woman presenting with dysuria, urgency and increased urinary frequency, as well as ‘funky-smelling urine’
She takes no medications
She is sexually active with her monogamous partner of 10 years, and has no history of STI
She denies fever, nausea, vomiting or low back pain
Her last menstrual period was 2 weeks ago, and she has an IUD for contraception
Her physical exam is normal except for mild suprapubic tenderness. She has no costovertebral angle tenderness
Diagnosis?
UTI!
Cystitis vs Pyelonephritis
Cystitis vs Pyelonephritis
Pyelonephritis
Symptoms of cystitis Fever/chills
Nausea and vomiting
CVA tenderness (positive renal punch)
Cystitis
Dysuria
Urinary frequency Burning/pain during urination Hematuria
Suprapubic pain
Cloudy or foul-smelling urine
Absence of temperature/change in vital signs
DDX for UTI
Consider an alternate diagnosis if the following symptoms are present
Women: Vaginal discharge, vulvar itch, symptoms of pregnancy
Men: Pain elicited by prostatic or testicular examination
DDX
Women: Vaginal or pelvic infection, pregnancy, gynecological pathology (PID, ruptured ovarian cyst, ectopic pregnancy)
Men: Prostatitis, epididymo-orchitis
All: STI, urolithiasis, abdominal infection (diverticulitis, appendicitis)
Common Bacteria for UTI
E. coli
Klebsiella Pneumoniae
Staph saprophyticus
Enterococcus
staph aureus is RARE
Urinanalysis
Urinalysis
A simple, low cost, reliable test
The presence of leukocytes, nitrites and new onset of symptoms** has a 90% positive predictive value (PPV)
The absence of leukocytes and nitrites in a newly symptomatic patient has a 90% negative predictive value (NPV)
Urine culture: Helpful to identify bacteria
UTI treatment
DONT MEMORIZE
Simple cystitis:
NITROFURATOIN*** , 100 mg po bid x 7 days
Trimethoprim-sulfamethoxazole (TMP-SMX) 160/800 mg po bid x 3 days (shorthand: Septra DS 1 tab bid x 3 days)
Fosfomycin 3g x1
Failure of first line, Second line:
Fluoroquinolone (i.e. ciprofloxacin XL, 500 mg po bid x 3 days) - don’t wanna waste this, save it for when they come back resistant
Jaxon is a 40 year old male presenting to care with congestion and facial pain
He is a PhD student defending his thesis in 2 days and is worried that he won’t be well enough to do so
His past medical history is significant for tonsillectomy/adenoidectomy as a child He smokes a half pack of cigarettes per day
He had a bad cold one week ago which he expected was going to improve on its own. Instead, his secretions became thicker and dark green, he began to cough more, and he began to experience pain on the right side of his face and his teeth
His exam is notable for purulent secretions observed in the right nasal cavity and draining down the back of his throat. He is tender to palpation of the right maxillary and frontal sinuses.
Clear Diagnosis?
Sinusitis
MOST cases are viral; only a small percentage of cases are complicated by a bacterial infection
Most cases are self-limiting and will resolve in 10-14 days
It is important to be judicious in the prescription and use of antibiotics; even in some cases of acute bacterial rhinosinusitis, antibiotics are not needed
Increased antibiotic resistance is seen due to increased (and sometimes inappropriate) prescription of antibiotics
Pathogens that cause Sinusitis
Pathogens are similar to those in acute otitis media
S. pneumoniae H. influenza M. catarrhalis S. aureus S. pyogene
smoking is a risk too
Acute Rhinosinusitis Diagnosis
Main symptoms: unilateral dental or facial pain
Nasal Obstruction or congestions
Coloured anterior or posterior Rhinorrhea
Other symp to consider:
headache
Hyposmia
Cough
+ symptoms persist for 10-14 days without improvement; or Symptoms worsen 5-7 days after initial infection (biphasic infection)
Antibiotic treatment depends on severity of symptoms and how impactful they are to the patient
ABX for viral infection is NOT going to help, so much education patient that treating with ABX will NOT help with their symptoms
Sinusitis: Conservative management
NSAIDs/acetaminophen
Nasal irrigation (especially important in children who cannot manage their own secretions)
Short term topical decongestant
Consideration of intranasal corticosteroid
Proceed to antibiotics if evidence of moderate-severe infection
