Case discussion

Michael GardamUniversity Health Network

Do you have any cases you would like to discuss?

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

You are worried about TB

What information would help you?

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?

Resolution

• Smear grows MTB after 17 days

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

You are worried about C. difficile

What information would help you?

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

Other recommendations

• Discontinuing contact precautions– Unknown, likely continue for whole hospitalization– If readmitted within 1 year, consider re-isolation

• Oh yeah, you should have an antimicrobial stewardship program in place