Infectious Disease Part 1. I’m going to Jazz Fest this weekend! A. True B. False.

Board ReviewInfectious Disease Part 1

I’m going to Jazz Fest this weekend!A. TrueB. False

Test Question

HIV Infection in Children and Adolescents

Epidemiology, diagnosis, preventionand treatment of HIV/AIDS has changed dramatically over the past 25 years

Rates of new infections in infants hasplummeted

Effective screening and prevention strategiesChildren born with HIV are surviving into

young adulthoodAdolescents acquiring HIV at an alarming rate

An Introduction…

Worldwide:33.2 million people living with HIV

2.5 million are children younger than 15In 2007, 2.1 million AIDS deaths occurred

330,000 were children

In the US:In 2006, 2181 cases of AIDS were reported

among children and adolescents through age 24 Only 38 cases were in children <13yoPediatric burden of infection now rests in the

adolescent population!

Epidemiology

Lentivirus in the retrovirusFamilyInfection occurs when thevirus enters the body and binds to the CD4 receptorson host T lymphocytes

Pathogenesis

Binding fusion of HIV envelope with lymphocyte cell membrane viral RNA and enzymes (RT) enter host cell viral RNA reverse transcribed into DNA viral DNA enters host cell nucleus integration into host cell genome activation of host cell virion production and release spread to other cells

This viremic phase preceeds antibody response and is the period of HIGHESET INFECTIVITY!!

Pathogenesis

A 17 yo honor student comes to your office with a maculopapular rash on his face, trunk, palms, and soles. He also c/o a sore throat and fever. He states that he has been sexually active with women for 2 years and men for 6 months. He does not use condoms with either. He denies any sick contacts or substance abuse, including injection drug use. You are strongly considering early HIV infection in this patient. The most accurate test to confirm the diagnosis at this time would be:A. Western BlotB. EIAC. HIV RNA PCRD. Rapid test- bloodE. Rapid test- saliva

Question #1

Viremic phase corresponds with the acute retroviral syndrome:Fever, LAD, rash, myalgias/ arthralgias, HA,

diarrhea, oral ulcers, leukopenia/ thrombocytopenia, transaminitis

During this “window period” between host cell infection and antibody response:HIV antibody test negativeHIV RNA positive

Seroconversion occurs b/t 10-14 days and 6 months after infection

*Pathogenesis

All of the following are effective ways to decrease the risk of transmission of the HIV virus from mother to child EXCEPT:A. C/S before the onset of labor in persistently

viremic women B. ART during pregnancyC. Neonatal AZTD. Intrapartum AZTE. Breastfeeding the infant

Question #2

*Transmission by two principal modes*Mother-to-child

Antepartum: transplacental transferIntrapartum: exposure to maternal blood,

amniotic fluid or cervicovaginal secretions during delivery

Postpartum: BreastfeedingBehavioral

Unprotected sexTraumatic sexActive genital ulcer diseaseDouching before sex

Injection drug use

Preventing Transmission

So what do we do?!*Mother-to-child

ARTIntrapartum zidovudineNeonatal zidovudineSafe replacement feedingElective C/S before the onset of labor in women

with persistent viremiaBehavioral

*COUNSEL, COUNSEL, COUNSEL!!Abstinence Consistent and correct use of condoms

Preventing Transmission

A 20 mo F presents to your clinic, because her mother was recently diagnosed with HIV. Mom did not receive PNC during her pregnancy and is unsure if any HIV testing was performed at delivery. She is very concerned and would like the child tested. Of the following, the most appropriate test to order (on the child) would be:A. HIV DNA PCRB. HIV RNA PCRC. HIV antibody titerD. No testing is required in this patient

Question #3

*Remember that all infantsBorn to HIV-positive mothersWill test positive for the HIVAntibody due to maternalTransfer of Ig

Laboratory Testing

A 4 mo M presents to your office for a WCC. Past medical history includes HIV exposure in utero. Mom was treated with ART through the pregnancy and AZT at delivery. The child also received AZT and is formula fed. At his 2 week visit and 2 month visits, HIV DNA PCRs obtained were negative. Of the following, you are most likely to counsel Mom that: A. HIV is definitively excluded in her son B. An HIV antibody titer should be performed at this visit and if

negative, HIV is definitively excluded C. An HIV DNA PCR should be performed at this visit and if

negative, HIV is definitively excluded D. An HIV antibody titer should be performed at 18 mos to

definitively exclude HIV E. Even though the past 2 tests have been negative, there is still

a high likelihood her son is infected with HIV

Question #4

HIV-exposed infantsHIV DNA/RNA PCR at 2 weeks, 2 months, and

4 monthsDefinitive exclusion of infection

Negative results for two virologic tests First at age 1 month or olderSecond at 4 months of age or olderConfirmatory antibody test at 12-18 mos optional

HIV-positive mothers and BFTesting should continue throughout period of BF

and 6 months after

Laboratory Testing

Children and adolescentsAll children of HIV-positive mothers should be

screenedAdolescents should be screened as a part of

routine health careAge 13 and olderHigh-risk adolescents should be screened yearly!

Laboratory Testing

First step: referral to an HIV specialist!

Evaluation and Staging

Clinical Conditions (con't)

Antiretroviral therapyGoals: (maximize quality and longevity of life)

Complete suppression of viral replicationPreservation or restoration of immunologic

functionPrevention of or improvement in clinical disease

Treatment

AntiretroviralsWhat to start?

ART should be planned and monitored in collaboration with an HIV specialist

Triple-drug combination ART3 drugs from 2 categories: one non-nucleoside reverse

transcriptase inhibitor (NNRTI) OR protease inhibitor PLUS two nucleoside or nucleotide reverse transcriptase inhibitors

Viral load to monitor adherenceNon-detectable viral load within 3-6 monthsFailure to achieve this goal strongly suggests

suboptimal adherence rather than resistance

Treatment

Prevention of Opportunistic InfectionsPneumocystis jiroveci pneumonia (PCP)

Most common OIBactrim prophylaxis for:

All HIV-exposed infants until infection is reasonably excluded All HIV-infected infants <12mos All HIV-infected children and adolescents with severe immune

suppression CD4 percentage< 15% or CD4 count< 200 cells/mm3

Mycobacterium avium complexAzithromycin prophylaxis for:

Age≥ 6yo with CD4 count <50 cells/mm3 Ages 2-5yo with CD4 count <75 cells/mm3 Ages 1-2 yo with CD4 count <500 cells/mm3 Age< 1yo with CD4 count <750 cells/mm3

Treatment

Prevention of opportunistic infectionsToxoplasmosis

Less common in childrenBactrim prophylaxis in:

Toxoplasma IgG positive individuals with severe immunosuppression (CD4%< 15% or CD4 count < 100 cells/mm3)

Treatment

Immunization schedule same as for healthy children with a few small exceptions:CD4 percentage< 15% or CD4 count< 200

cells/mm3= NO VARICELLA OR MMROnly killed, injectible formulations of the

influenza vaccine

Immunizations

Coping with the diagnosis and prognosisOffer hope and reassurance about the availability of effective treatment

*Disclosure of HIV Infection statusPlanned disclosure to family and friends can

increase support for the HIV-positive personSexual partners can make informed decisions

about how to protect themselvesAdherence to Care and Treatment

Requires 90-100% adherence to drug regimens to avoid the development of resistance

Counseling and Support

School and sports participationHIV-infected children and adolescents can

participate fully in the educational and extracurricular activities at school

*No obligation to notify school personnel of student’s HIV infection status

Some experts advise athletes with a detectable viral load to avoid high-contact sports (boxing, wrestling)

Transition to adult health careComplete and coherent medical record

Advance care planning and palliative care

Counseling and Support

Epstein-Barr Virus

Which of the following statements regarding EBV epidemiology is TRUE?A. Immunocompetent persons who have been

infected shed more virus than immunosuppressed persons

B. Infectious mononucleosis caused by EBV occurs most commonly in infants and toddlers

C. Most people who become infected with EBV are symptomatic for life

D. The risk of transmission is highest from persons who have had recent infections

E. The virus is only transmitted through oral secretions

Question #5

EBV results in spectrum of diseasesInfectious MononucleosisAggressive non-malignant proliferations

Hemophagocytic syndromePost-transplant lymphoproliferative syndrome (PTLS)Lymphoid interstitial pneumonitisOral hairy leukoplakia

Human malignanciesNasopharyngeal carcinomaBurkitt lymphomaHodgkin diseaseLeiomyosarcoma

*Host immune response plays a key role in determining clinical manifestations

Introduction

Epidemiology*Know the epidemiology of EBV

*Mode of transmission: oral contact with salivaHandling of toysKissing among adolescentsAlso found in genital secretions

*Incubation period: 30 to 50 daysOnset of illness is insidious over 1

to 2 weeks*Period of communicability

Shed at high concentration for 6 months following acute infection, and then low concentration for life

HerpesvirusType 1 and Type 2

PathogenesisInfection of B cells in the lymphoid-rich areas

of the oropharynxDissemination throughout the lymphoreticular

system including the liver and spleenLike all herpesviruses, EBV establishes

persistent latent infection for the life of the hostMemory B-cellsReactivation is asymptomatic (second attacks

have not been documented)

Clinical Aspects*Classic infectious

mononucleosisFeverPharyngitisAdenopathy (90%)

Peaks in 1st weekFatigueHeadache

Nausea, vomiting, and anorexia are frequentReflect hepatitis

A 15-year-old male comes to the ER because he has had a sore throat and fever for the past week. On physical exam he has cervical lymphadenopathy, his spleen edge is palable 3cm below the costal margin, and he has a generalized maculopapular rash with several scratch marks. Upon further questioning, he tells you that his PCP gave him some antibiotics a few days ago but he can’t remember the name.

The MOST likely medication to cause the patient’s new symptom is:A. AmoxicillinB. CefdinirC. AmpicillinD. BactrimE. Ciprofloxacin

Question #6

Clinical AspectsSplenomegaly in 50 to 60%

Can cause upper quadrant discomfort2 to 3 cm below the costal margin

*Know the significance of rash following ampicillin in patients with mono3 to 15% of all patientsMaculopapularFollowing administration of ampicillin or

amoxicillin in 70 to 90%Immune mediatedDiscontinue antibiotic

Gianotti-Crosti syndromePapular acrodermatitis on cheeks, extremities,

and buttocksCan last for 15 to 50 days

*Know the range of clinical manifestations of EBV infection in children of various agesInfection in young children is usually

asymptomaticOr produces symptoms indistinguishable from other

febrile infectionsInfectious mononucleosis is rarely recognizable in

children under 4Among adolescents the clinical syndrome is

classicInfectious mononucleosis is rare in adults older

than 30 to 40, when most people are already infected with EBV

Clinical Aspects

DiagnosisHeme

Total WBC 12,000 to 18,000Lymphocytosis (>60%)Atypical lymphocytes (20-40%)Thrombocytopenia (usually self-limited)

Liver function testsElevated aminotransferases in 50% of patientsAsymptomatic without jaundice

You are evaluating a 3-year-old girl who has fever for 10 days, pharyngitis, and cervical lymphadenopathy. You suspect she has an infection caused by EBV. Which of the following tests is MOST likely to confirm your diagnosis?A. CBCB. Heterophile antibodyC. IgM early antigen testD. IgM viral capsid antigen testE. Viral culture

Question #7

DiagnosisHeterophile antibodies

Monospot is a latex agglutination assay using horse erythrocytesStays positive for 2 years after infectionDetects antibody in 90% of cases Does not have same specificity and sensitivity in young

childrenThey do not produce antibodies80% by age 4

Diagnostic choiceIf + monospot and compatible syndrome, no further

testingIf EBV infection still suspected, test for specific

antibodies

Diagnosis*Distinguish (by serologic tests) between

acute and past EBV infectionsEBV-specific antibodies

Viral capsid antigen (VCA)IgM and IgG are present at onsetIgM wanes over 3 months

Confirms the diagnosis of acute EBV infectionIgG persists for life

Nuclear antigen (EBNA)IgG to EBNA begins to appear 6 to 12 weeks after

onset of symptomsEarly antigen

IgG to EA present at onset of illness

Question #8You are seeing a long-time patient of yours who is a 16

year-old male with sore throat, fever, and fatigue for the past week. He is a varsity football player, but has felt too tired to practice this week. On physical exam he has mild hepatosplenomegaly. You do a Monospot in the office and it is positive.

Of the following, the BEST way to manage this patient is:A. Start a course of corticosteroidsB. Supportive care and advise him to avoid contact sports

for 3 to 4 weeks and until his splenomegaly has resolvedC. Supportive care and advise him to avoid contact sports

for 6 monthsD. Supportive care and he can return to practice

immediatelyE. A 7 day course of Acycolvir

Managment *Plan the management of a patient with

uncomplicated infectious mononucleosisObservation and symptomatic treatment

Acetaminophen, NSAIDS, bed rest

Return to sportsWant to avoid splenic rupture

Most likely to occur within 2 to 21 days after onset of symptoms

Avoid sports in initial 2 to 3 weeks or while splenomegaly is present

All of the following are indications for corticosteroid use in the treatment of EBV infection EXCEPT:A. SeizuresB. Worsening fatigueC. Upper airway obstructionD. Hemolytic anemiaE. Thrombocytopenia with bleeding

Question #9

*Know the indications for the use of corticosteroids in treatment of infectious mononucleosisUpper airway obstructionThrombocytopenia complicated by bleedingAutoimmune hemolytic anemiaSeizuresMeningitis

Prednisone 1 mg/kg/day x 7 days then taper x 7 days

Should not be used on routine basis due to unknown hazards of immunosuppression for a virus that has oncogenic complications

Management

Uncommon in healthy personsSplenic rupture (<0.5% in adults)Tonsillar swelling that causes airway

obstructionDrooling, stridor, difficulty breathingIndication for hospitalizationIV hydration, humidified air, steroids

Headache (50%)Seizures and ataxia (1 to 5%)Meningitis, facial nerve palsy, transverse

myelitis, GBS“Alice-in-Wonderland synrome”

(metamorphopsia)

Complications

Hemolytic anemiaAplastic anemiaMyocarditisInterstitial pneumoniaPancreatitisParotitisOrchitisHLH

Complications

*Understand that host factors are important in the outcome of EBV infectionImmune response is essential for controlling

EBV replication during primary infection as well as latent infection

Immunocompromised people are at increased risk for EBV-associated malignanciesHIV, organ transplant anti-immune therapy,

congenital immunodeficiencies

Immunocompromised Persons

Excellent with symptoms typically lasting 2 to 4 weeksSome have debilatating fatigue and malaise

that can wax and wane for 6 monthsSecond attacks are not documented

Prognosis

TB

One of your patients recently had a positive TST. He was subsequently sent for a CXR which was normal. He is otherwise well and has no known TB contacts or travel. By definition, this patient has:A. Active TB diseaseB. No TB diseaseC. Latent TB infection (LTBI)D. Had the BCG vaccine

Question # 10

TB exposure: persons exposed to someone who has TB but whose status is not yet clear

*Latent TB (LTBI): positive TST without symptoms, physical findings, or radiologic anomalies c/w TB

*TB disease: positive TST with clinical or radiologic manifestations of TB disease

Multidrug-resistant (MDR) TB: TB resistant to 2 first-line TB meds (INH and rifampin)

First: Some TB lingo…

One third of the global population has LTBI (!)Of all persons with untreated LTBI, 5-10% will

ultimately develop TB disease90% of the burden of TB disease is in the developing

worldIn the US:

13,000 new cases of TB disease in 2007820 children <15yo

Control of TB in children has often been neglected b/c children are ineffective transmitters of the bacillusHowever, much of the morbidity and mortality occurs

during childhood!

Epidemiology

*Specific groups with high LTBI and disease rates include:ImmigrantsInternational adopteesTravelers to countries with endemic

infectionHomelessResidents of corrections facilitiesRefugees from high prevalence regions

Epidemiology

Increased risk of progression to TB disease:HIV co-infection (and other

immunocompromising conditions)Recent LTBIIV drug useMedical conditions

DMRenal failure

Epidemiology

*Mode of TransmissionTB is transmitted by expulsion of nasal droplets from an infected human individual to an uninfected one.

Nasal droplets, which contain tubercle bacilli and are no larger than 2 um in diameter, are able to penetrate to the alveoli of the respiratory tract of the uninfected individual.

*Clinical Manifestations

PULMONARY TB

Includes intrathoracic LAD and parenchymal disease

Most common site of TB infectionIncubation period 4-12 mosThree time frames for pulmonary

involvement with TBPrimary parenchymalProgressive primaryReactivation disease

Pulmonary TB

One of the most common manifestations of disease

Infants and adolescents more likely to be symptomatic than 5-10 yo children

Become symptomatic when enlarging LN compress adjacent airways collapse consolidation pattern

Radiographic features: hilar/mediastinal LAD

Primary Parenchymal

Extensive Primary TB in a ToddlerRight –sided hilar LAD, narrowing of the right mainstem bronchus

and

collapse-consolidation of the RLL

*Courtesy of UTD*

Results from poor containment of the initial infectionYoung infant or

immunocompromised hostLN erosion into the airways

aspiration of bacilliDevelopment of adult-type cavitary

disease in children >10yoAssociated with lung tissue

destruction and cavity formation

Progressive Primary Disease

Progressive Primary TB in a toddler

Extensive hilar

LAD with

collapse-

consolidation in

the left lung and

miliary-like

presentation of

the right lung

*Courtesy of

UTD*

More common in adolescents, especially in areas that have high rates of co-infection with HIV

Reactivation disease more common in the apices of lungs in adults (while primary disease occurs in the bases)- NOT SO FOR CHILDREN

Radiographic findings in reactivation overlap considerably with the other two types of pulmonary disease

Reactivation Disease

Cavitary TBInfiltrate and cavity along R horizontal fissure. Absent

hilar LAD c/w adult-type or reactivation TB in adolescents.

*Courtesy of UTD*

Symptom Infants Children Adolescents

Fever Common Uncommon Common

Night sweats Rare Rare Uncommon

Cough Common Common Common

Productive cough Rare Rare Common

Hemoptysis Never Rare Rare

Dyspnea Common Rare Rare

Sign

Rales Common Uncommon Rare

Wheezing Common Uncommon Uncommon

Decreased BS Common Rare Uncommon

Location of diseasePulmonary Common Common Common

Pulmonary+Extrapulmonary

Common Uncommon Uncommon

Signs and Symptoms of Pulmonary TB

Lymphatic TB Disease

Most common extrapulmonary form of TBHematogenous spread

Incubation period: 4-12 mosLN involvement: anterior cervical >

posterior triangle > submandibular > supraclavicularUsually measure 2-4 cm and lack the classic

inflammatory findings of a pyogenic nodeMay be overlying violaceous skin

discoloration

Lymphatic TB

Untreated lymph nodes: may caseate, spread to contiguous structures and lead to formation of a sinus tract

Surgical node excision not curative but may be necessary to establish the diagnosis

Lymphatic TB

CNS Disease

RareDevelops in fewer than 2% of all cases of

TB50% of all patients are younger than 2

years of ageIncubation period: 2-6 mos(In parts of the developing world, TB is

the primary cause of subacute meningitis and tuberculomas are common causes of mass occupying CNS lesions)

CNS TB

TuberculomasConglomerate caseous foci within the brain that

develop from deep seated tubercles acquired during recent or remote hematogenous bacillemia

Single rim enhancing lesions ranging from 1-5cm.

TB MeningitisWhen a subependymal tubercle progresses

and ruptures into the subarachnoid spaceCSF : lymphocytes, low glucose, and high

proteinHighest morbidity and mortality rate

CNS TB

Miliary Disease

Due to lymphohematogenous spreadSo, it can pretty much go ANYWHERE!

Disease of the younger or immunocompromised child

Clinical presentation highly variableAcute disease: may be fulminant including

multiorgan system failure, septic shock, or ARDS

Subacute or chronic disease: may present with FTT without fever, fever of unknown origin, or with dysfunction of one organ system

Miliary TB

Clinical manifestations Fever, constitutional symptomsHSM on examCNS involvement in 20%

A child with miliary TB should ALWAYS be evaluated for meningitis

Miliary TB

Extensive miliary pulmonary lesions

*Courtesy of

UTD*

Skeletal diseaseDisease of the older childSpondylitis (Pott’s disease), arthritis,

osteomyelitisPleural disease

Also a disease of the older childCan occur in isolation from or

concomitantly with pulmonary diseaseSx: CP, fever, dyspnea, cough, anorexia

Other Clinical Manifestations…

Congenital diseaseOccurs in infants born to mothers

with endometrial or disseminated TBAbdominal diseaseRenal diseaseCutaneous disease

Other Clinical Manifestations…

Diagnosis

Who to screen?Screening tests

TSTIGRAs

Confirmatory testsSequential sputum samplingEarly AM gastric aspiratesSpecimens from an extrapulmonary siteCT scan

Initial Approach

Who to Test?

TSTComprises antigens not all specific

to M. tuberculosis Antigens trigger a delayed

hypersensitivity reaction to persons who have come in contact with TB bacilli

Becomes positive 3 weeks to 3 months after infection and should remain positive for life

Screening Tests

One of the nurses on the 5th floor asks you to read her TST that was placed ~60h ago. You appreciate an area of induration approximately 11 mm in diameter. What is the most appropriate next step for this nurse?A. INH for 9 mosB. CXR to screen for active TB diseaseC. ReassuranceD. Repeat TST in 3 mosE. RIPE therapy for 6 mos

Question #11

*Positive TST

You are doing a WCC on a 7 yo F who recently moved to the US from India. Since there were 2 positive responses on the TB risk factor-based questionnaire (+lived out of the US, +BCG vaccine), you place a TST. When the patient returns in 48h, the TST is positive with a 12 mm area of induration. The mother asks you what needs to be done next. You respond:A. Nothing, the TST was likely positive because she

received the BCG vaccineB. Induced sputum for AFB gram stain and cultureC. INH therapyD. CXRE. RIPE therapy

Question #12

False Positive ResultsChildren exposed to

nontuberculosis mycobacteria

Recent administration of the BCG vaccine**

Improper administration or interpretation of TST

Age<6mosDisseminated forms

of TB can induce anergy (miliary and meningitis)

Recent measles infection

High-dose corticosteroid treatment (or other forms of immunosuppression)

Irradiation

*Drawbacks to TST False Negative Results

Measures patient’s ability to produce interferon gamma after their lymphocytes are stimulated by 2 or 3 antigens on M. tuberculosis

Greater specificity than TST but similar sensitivity

Interferon Gamma Release Assay(IGRA, Quantiferon Test)

Latent or Active TB

Detailed contact and symptom

history

CXR Physical Exam

What do I do with a positive TST or IGRA?

• Induced vs. Expectorated vs. BAL

• 3 samples collected on different days before the child eats or ambulates

• If CXR findings are equivocal

• Pleural fluid, CSF, lymph node biopsy, etc…

Sequential sputum sampling

Gastric aspirates of early

AM secretions

CT scan

Specimens from an

extra-pulmonar

y site

Confirmatory Testing

*Management

*Healthcare worker:+TST (≥10mm) CXR

CXR negative offer to treat for LTBI weighing risks and benefits

CXR positive further evaluation and RxContact investigations

*Child with an adult household contact with TB disease:TST and CXR for ALL children in the householdChildren <4yo (or immunocompromised)

empiric INH

Specific Clinical Scenarios…

The mother of a 2 mo breastfed infant comes to your clinic very concerned, because she recently had a positive TST. She reports that her doctor sent her for a CXR, which was normal, and then put her on a single medication. She asks you what needs to be done to keep her baby from contracting the illness?A. No intervention is required for the infantB. Cessation of breastfeedingC. Separation of mother and babyD. Empiric INH in the infantE. Multidrug therapy in Mom

Question #13

Infant whose mother has TB: Mom with +TST, -CXR (LTBI) no

intervention for infantMom with +TST, +CXR (TB disease)

evaluation for congenital TB; separation from Mom until infant is receiving INH and Mom is on multidrug therapy

Specific Clinical Scenarios…

Children who have TB should be seen monthly while receiving therapyMedication tolerance and adherenceWeight gainAchieving appropriate milestones (esp with TB

meningitis)Look for disease spread

Pulmonary TBRepeat CXR after 1-2 months of therapy

TB meningitis:Often require sequential CNS imaging by CT scan

or MRI

Follow-up

TB Prevention and Control

Appropriate chemoprophylaxis of children who have been exposed to TB or have LTBI

BCG vaccinationShould only be considered for children who

are HIV negative, have a negative TST and who are continually exposed, and cannot be separated from, adults who:Are untreated or ineffectively treated for TB

disease (if the child cannot be given long-term treatment for infection)

Have TB caused by strains resistant to isoniazid and rifampin

TB Prevention and Control

Infection control and contact investigationHospital infection control

Most younger children do not have a sufficiently forceful cough or high enough organism burden in the airways to be infectious EXCEPT FOR children with: Cavitary or extensive pulmonary involvementAFB smear-positive TBLaryngeal TBProcedures with high risk of aerosolization of bacteria (BAL,

entubation)If any of the above criteria met personally fitted

and sealed particulate respirators should be used by all patient contacts and patient should be placed in airborne infection isolation

TB Prevention and Control (con’t)

Infection control and contact investigationHospital infection control (con’t)

Major concern is household contacts that may be the source caseVisitation should be limited to those who have had a CXR

that excludes contagious TBReturn to child care and school

Children with TB disease can attend school or child care if:Effective therapy has been institutedAdherence to therapy has been documentedClinical Sx have diminshed substantially

Children with LTBI can participate in all activities whether they are receiving treatment or not

TB Prevention and Control (con’t)

Children with a positive TST should be a “starting point for epidemiologic investigation by the local health department”Reporting of suspected and confirmed cases

of TB is mandated by law in all statesPhysicians should assist local health

department in the search for the source case and others infected by the source caseNew Orleans Health Department 504-658-2500

TB Prevention and Control (con’t)

LTBI •100% effective in preventing TB disease•Adherence must be EXCELLENT!

TB Disease •95-100% cure in drug-susceptible disease•Overall mortality low

TB meningitis •Highest rates of mortality and long-term sequelae•33% die and 50% have residual defecits

Prognosis

Isolation Precautions

Designed to prevent the spread of microorganisms among patients, health-care personnel, and visitors

Standard precautions and “cough etiquette” should be used for all persons in and out of the health-care setting

Isolation Precautions

3 componentsSource

Patient, health-care worker, visitorAcutely ill with symptomsColonized/infected but no symptomsInanimate objects and toys

Susceptible hostMeans of transmission

Direct contact (infected person to host)Indirect contact (fomite)Droplet (large particles going < 3 feet)Airborne (small particles suspended in air and

dispersed)

Transmission

*Know the recommendations for standard precautions

All patientsHand hygiene before and after each patient contact

Single most important practice to reduce transmission of microorganisms

Alcohol-based preferred (superior activity and adherence)

Soap and water if visible soil or with spore-forming organisms (C. diff)

No artificial nails for workers in ICU, OR, or oncology)Assoc. with gram-neg bacillary and candidal infections

Use of protective equipment when needed

Standard Precautions

Respiratory Hygiene“Cough etiquette”

For staff, patients, families (everyone!)Covering one’s mouth and nose during a cough or

sneezeDispose of tissuesFollow with hand hygiene

If no hand hygiene available → direct cough into antecubital fossa

Those with respiratory illness who cannot be separated from others by 3 feet, should wear a mask

Standard Precautions

You are on night float for Purple team and a 7 month old male comes in with rhinorrhea, cough, and increased work of breathing. The viral panel comes back positive for RSV.

Which of the following will you include in your order set?A. Droplet precautionsB. No precautions necessaryC. Airborne precautionsD. Standard precautionsE. Contact precautions

Question #14

*Know the recommendations for contact precautionsGloves and gown when direct patient contactPatients in single rooms or cohorted*Identify when contact precautions are required

OrganismsC. diffEnterovirusesRSVMultidrug-resistant organisms

Draining abscesses, cellulitis, decubitus ulcersSupplies should be available outside the patient

rooms

Contact Precautions

A few hours later, you are admitting a 4-year-old male for Silver team who is a know asthmatic with symptoms of cough, fatigue, and increased work of breathing. His viral panel comes back positive for influenza. Being the stellar resident that you are, you order droplet precautions prior to sending this patient to the floor.

Which of the following BEST describes droplet precautions?A. Single room and surgical mask requiredB. Shared room and no personal protective equipment

requiredC. Single room and gown and gloves requiredD. Cohort room and good hand hygeineE. Negative pressure room and surgical mask required

Question #15

*Know the recommendations for droplet precautionsA surgical mask is requiredSingle room or cohort (with 3 feet and curtain) for

patientsWhen patients leave the room → mask, cough etiquette

*Identify when droplet precautions are required InfluenzaRhinovirusBordetella pertussisNeisseria meningitidisStrep pyogenes

Keep precautions in place until pt. has been receiving antimicrobial therapy long enough to prevent transmission

Droplet Precautions

*Know the recommendations for airborne precautionsNegative pressure airborne infection isolation

roomBefore entering the room, clinicians should use

a fit-tested N95 or similar sealing mask*Identify when airborne precautions are

requiredTBMeaslesVaricella

Airborne Precautions

Flu shot*Understand that office and hospital staff

should receive an annual influenza immunization

THE END!!Have a great weekend!