Case discussion Michael Gardam University Health Network
Case 1
• 53 year old male presents with a 6 week history of cough, worsening malaise, weight loss, maybe low grade fever
• CXR shows a right upper lobe infiltrate
Things to think about
• Where is the patient from?• Where have they travelled?• Are they immunocompromised?• History of contact with an active case?• Occupation?• Smoker?• Homeless?
The medical team’s differential diagnosis is:
• Lung cancer• Community acquired pneumonia• Tuberculosis• Blastomycosis
• They order appropriate tests including sputum cytology and sputum for AFB
What else?
• Airborne isolation?• Wait for the sputum smear result and then put
in airborne isolation if positive?• Ask the team to plant a tuberculin skin test?• Collect additional sputum samples?
Results
• Patient is placed in airborne isolation• Sputum cytology pending• AFB smear negative• The team have started moxifloxacin to treat
community acquired pneumonia
• The team wants to discontinue airborne isolation.
What do you think?
• Stop isolation?– If not, why not?
• Await cytology result first?• Is Moxifloxacin a good choice in this setting?• Ask for molecular testing on the sputum
sample?
Update
• Patient still in airborne isolation• Sputum cytology comes back negative• Second AFB smear negative• Some improvement after 5 days of
moxifloxacin
• Team really wants to discontinue isolation.
What do you think?
• Discontinue airborne isolation now?– If not why not?– If not, when would you feel comfortable
discontinuing?• Can you review the case with someone?
Case 2
• A patient on your complex continuing care ward develops two episodes of loose stool.
• Chronically receives laxatives• Currently receiving Ancef for an infected heel
ulcer
Things to think about
• Any cases of C. difficile recently on that ward?• Patient history of C. difficile?• Other signs or symptoms beyond loose stool?– Abdominal pain– Fever– Increasing white count?
• Place in contact precautions now?
Update
• Stool sample using EIA is negative• Patient has another bought of loose stool• Patient has no other symptoms
• Patient has been placed in contact precautions• Physician has started flagyl
What now?
• Send another stool specimen?– How many until you are satisfied it is negative
• Continue contact precautions?
What if?
• Stool testing was done using PCR or culture instead of EIA?
• What if the result was positive but the patient’s diarrhea resolved after the first day?
• Can you have a positive test result but not be a C. difficile case?
Case 3
• You are called by the laboratory regarding a patient who has meropenem-resistant Klebsiella to isolated from a wound.
• The patient is currently in a 4-bedded room
What now?
• Do nothing?• Move the patient to a single room/institute
contact precautions?• Bedside contact precautions?• Screen roommates for carriage of the
organism?• Screen clinical isolates of roommates for the
organism?
What if?
• The patient is asymptomatically colonized?• The organism is sensitive to other classes of
antibiotics?• Resistance is due to – a klebsiella pneumonia carbapenemase?– Metallo beta-lactamase?– OXA carbapenemase?
PHAC recommendations
• Colonized or infected patients should be placed on contact precautions in institutional settings– Including prolonged contacts of known cases and
patients with suspected (but not yet confirmed) carbapenemase resistant organisms
• Colonized patients do not required contact precautions in the prehospital and homecare settings
In this case:
• Clinical screening of contacts and send clinically–relevant specimens– This does not mean surveillance for asymptomatic
colonization• Review laboratory records• Strongly consider active surveillance of contacts
if you find ≥ 2 clinical cases with the same strain• Do not screen family, staff, visitors or
environment in absence of a major outbreak
Other recommendations
• Clean your hands…• Single room or cohort with the same organism• Gloves ± gowns• Dedicated equipment• Twice daily cleaning with usual disinfectant• Normal laundry/waste management