Infectious Disease Public Health Lecture 3-Student copy PDF

INFECTIOUS DISEASE Shannon Layton DMSc, PA-C South College Where Dreams Find Direction  Objectives  List the most common nosocomial infections and describe their presentation, natural history, treatment, and prevention (LO 8). ...

INFECTIOUS DISEASE Shannon Layton DMSc, PA-C South College Where Dreams Find Direction  Objectives  List the most common nosocomial infections and describe their presentation, natural history, treatment, and prevention (LO 8).  Describe the presentation, signs, symptoms, work-up, and treatment of select infectious diseases (LO 8). o Bacterial Disease: Acute rheumatic fever, Bartonella, Botulism, Campylobacter Jejuni, Chlamydia, Cholera, Diphtheria, Gonococcal infections, MRSA, Salmonellosis, Shigellosis, Tetanus o Mycobacterial Disease: Atypical mycobacterial disease, o Spirochetal Disease Lyme disease, Rocky Mountain spotted fever, Syphilis  Case A 21 y/o female presents to your ER with the complaint of double vision, trouble swallowing, urinary retention and abdominal pain. Her partner states that normally she is healthy and spends her summer gardening and has canned several of her green beans this season. Case A 32-year-old healthy woman who lives in New England presents with fever to 101.5˚F A week ago, she scratched her leg behind the knee Underneath her fingernail, she noticed a “poppy seed” Patient/husband unsure what it was, as it was too small to see much However, when husband squeezed, it burst and had blood within it  A 45 y/o male presents to your clinic with a painless lesion on his genitals. He comments that it has been there for about three weeks. It does not itch.  A 6 y/o M is seen in your clinic with a 3 month history of intermittent fevers, fatigue, migratory joint pain and weight loss. 3 months ago mom reports that he had a sore throat that he stayed home from school for a week for. You notice a new systolic murmur with a thrill at the mitral area with radiation to the axilla. Left knee is mildly swollen and warm. Painless nodules are noted over his ankles and elbows. What is your suspected diagnosis?  Case You are seeing a 13 y/o female while on a medical mission trip to Syria. She has been having multiple episodes of watery diarrhea that they describe looks like rice water. She appears very dehydrated. What is she at risk for? BACTERIA: Overview HOW WE CHARACTERIZE BACTERIA: GRAM POSITIVE VS. GRAM NEGATIVE AEROBIC VS. ANAEROBIC ATYPICALS  BACTERIA: Gram Positive vs. Gram Negative GRAM NEGATIVE GRAM POSITIVE o 2 CELL o 1 CELL MEMBRANES MEMBRANE o THIN CELL WALL o THICK CELL WALL PINK ON GRAM STAIN PURPLE ON GRAM STAIN This actually matters for which antibiotics will work…  BACTERIA: Gram Positive vs. Gram Negative E. Coli Some common examples… Pseudomonas H. Influenzae GRAM Proteus N. Gonorrhea NEGATIVES Neisseria N. Meningitides Klebsiella Legionella Serratia H. Pylori  BACTERIA: Gram Positive vs. Gram Negative Staph aureus Staphylococcus Staph epidermidis Some common examples… Staph saprophyticus Strep pneumoniae Group A Strep (pyogenes) Streptococcus Group B Strep (agalactiae) GRAM Strep viridans POSITIVES Enterococcus Listeria C. difficile Clostridium C. perfringes C. tetani BACTERIA: Aerobic vs. Anaerobic AEROBIC Examples: Bacillus, oCAN ONLY SURVIVE IN mycobacterium and AerobicOF O2 THE PRESENCE pseudomonas ANAEROBIC oCAN ONLY SURVIVE IN THE ABSENCE OF O2 FACULTATIVE ANAEROBIC oCAN GO BOTH WAYS! BACTERIA: Aerobic vs. Anaerobic AEROBIC Gram (+)  Clostridium oCAN ONLY SURVIVE IN This is why C. Botulinum can AerobicOF O2 THE PRESENCE be obtained from canned food (anaerobic environment) ANAEROBIC oCAN ONLY SURVIVE IN THE ABSENCE OF O2 Gram ( - )  Bacteroides, FACULTATIVE Porphyromonas ANAEROBIC Found in the GI Tract oCAN GO BOTH WAYS! BACTERIA: Aerobic vs. Anaerobic AEROBIC oCAN ONLY SURVIVE IN Aerobic THE PRESENCE OF O2 ANAEROBIC oCAN ONLY SURVIVE IN THE ABSENCE OF O2 FACULTATIVE STAPH AUREUS! ANAEROBIC oCAN GO BOTH WAYS! BACTERIA: Atypicals MYCOPLASMA: o small organism, common cause of atypical pneumonia, tuberculosis RICKETTSIAL SPECIES: Rickettsia rickettsii o Obligate intracellular organism (can’t make own ATP) o Rickettsia rickettsii (Rocky Mountain Spotted Fever) CHLAMYDIA: o Obligate intracellular (also can’t make ATP), small o Chlamydia trachomatis (STD) and Chlamydophila pneumoniae SPIROCHETES: o Lyme disease (B. burgdorferi), syphilis (T. pallidum), MOA of Antibiotics Classes of Antibiotics Atypicals Mycobacterial Diseases  Atypicals: Mycobacterium Tuberculosis We already talked about this one!  Atypicals: Mycobacterium Marinum Pathophysiology: Causes Nodular Lymphangitis Exposure Risks: Fresh and saltwater exposure Fish handlers, swimming in lakes and oceans Signs and Symptoms Primary Lesion: 2–8-week incubation Secondary Lesions: Erythematous papules, nodules up lymph chain. Lesions ulcerate or form abscesses  Atypicals: Mycobacterium Marinum Diagnosis: Organisms rarely seen under microscope, culture of biopsied tissue requires special incubation temperatures PPD (purified protein derivative) Usually >10mm in active cases Treatment Apply warm compresses to lesions Antibiotics for 2-3 months Clarithromycin and Rifampin  Atypicals: Mycobacterium Avium Complex (MAC) Epidemiology Found in environment, rarely occurs if CD4 count >50 Dissemination MAC infection: 40% occurs in North American AIDS Signs and Symptoms Fever, fatigue, night sweats, wasting, GI upset, unilateral firm fluctuant lymphadenitis Imaging in MAC Lymphadenitis In MAC  Atypicals: Mycobacterium Avium Complex (MAC) Labs Alkaline Phosphatase increased, low Hgb, blood cultures, lymph node biopsy, PPD positive only 50% Diagnosis: pulmonary symptoms+ chest xray+ Sputum Treatment: Prophylaxis for HIV with CD4 cell count 50% of cats are infected (thanks to fleas) and transmit the infection via biting or clawing Self-Limited of immunocompetent host. May use antibiotics for moderate cases Signs and Symptoms Myalgias, arthralgias, malaise, anorexia, low-grade fever, Dermatitis at cat scratch/bite then painful ipsilateral lymphadenopathy, encephalopathy, neuroretinitis Tests: Serology, IgG titers Treatment: Azithromycin x 5 days or Bactrim (trimethoprim- sulfamethoxazole) x 10 days  Bartonella: Trench Fever Bartonella Quintana Affected millions in WWI Spread by Body Lice Seen in homeless patients Signs and Symptoms: Relapsing fever, headaches, back and leg pain, splenomegaly and sometimes rash. Can progress to endocarditis Treatment: Usually more than one combo of tetracyclines, aminoglycosides and macrolides Ie: Doxycyline orally for 4 weeks plus gentamicin IV for two weeks  Tetanus Etiology: Clostridium tetani. Gram- positive anaerobic rod Neurotoxin enters via puncture wounds. Produces tetanospasmin. Blocks the release of inhibitory neurotransmitters Epidemiology: rare due to vaccine (33 U.S. cases in 2017)  TETANUS Prevention: Active immunization: Td & booster q10yr (or time of major injury); Tdap with each pregnancy (27-36 wks) Passive immunization: TIG 250 units IM & concurrent active immunization Diarrheal Illnesses  Definition >3 loose or watery stools in 24 hours. Acute: Occurs for less than 14 days, usually infectious Persistent: 15-30 days, usually parasitic Chronic: Greater than 30 and is associated with chronic disease (IBS, IBD, Celiac Typhoid Fever Etiology: Salmonella typhi. Gram Negative bacteria Epidemiology: 11-20 million cases annually. 128,00- 161,000 cases of death per year 1-5% become chronic carriers Typhoid Fever Incidence  Typhoid Fever Most commonly seen in children and young adults. Incubation period 5-21 days. Fecal-oral route Signs and Symptoms : Pea-Soup diarrhea. Intractable fever, malaise, anorexia. Fever with relative bradycardia. “Rose spots”: faint pink colored macular rash that spreads from trunk to extremities. Peyer’s Patches. Delirium Peyer’s Patches.  Typhoid Fever Diagnosis: Stool culture, Blood culture Treatment: Oral rehydration and electrolyte replacement. 1st line management. If Severe: Ciprofloxacin 750mg BID x 7-10 days or Azithromycin 1g PO daily) and Ceftriaxone (2gIV daily) x7-10 days What is she at risk for?  Nontyphoidal Salmonella Etiology: Salmonella bongori, Salmonella enterica, Salmonella typhimurium Epidemiology: 1million cases per year in the US Incubation period: 8-72 Hours Sources: Facultative anaerobes Undercooked or raw poultry, eggs, milk, fresh produce Contact with reptiles (esp turtles)  Nontyphoidal Samonella Clinical Manifestation Inflammatory diarrhea (+/- blood) with vomiting Dx: Stool culture Tx: Oral rehydration and electrolyte replacement Severe: Fluroquinolones  SALMONELLOSIS Bacteremia Clinical features: RF: older age, immunosuppression, chronic liver disease, malaria Prolonged or recurrent fevers, bacteremia, local infections (bone, joints, pleura, pericardium, lungs, urinary tract, or other sites), non-typhoidal isolates most common Management: same as for enteric fever (fluoroquinolone) including abscess drainage & debridement; HIV may require lifelong suppressive therapy (relapse common)  Reportable Diseases Novel influenza A virus infections Severe acute respiratory syndrome- Typhoid fever associated coronavirus disease Pertussis Vancomycin intermediate (SARS CoV-2) Staphylococcus aureus (VISA) Pesticide-related illnesses and Shiga toxin-producing Escherichia injuries Vancomycin resistant Staphylococcus coli (STEC) aureus (VRSA) Plague Shigellosis Vibriosis Poliomyelitis Smallpox Viral hemorrhagic fever (including Poliovirus infection, nonparalytic Syphilis, including congenital Ebola virus, Lassa virus, among Psittacosis syphilis others) Q-fever Tetanus Waterborne disease outbreak Rabies (human and animal cases) Toxic shock syndrome (other than Yellow fever streptococcal) Rubella (including congenital Zika virus disease and infection syndrome) Trichinellosis (including congenital) Salmonella paratyphi and typhi Tuberculosis Salmonellosis Tularemia  Kiyoshi Shiga Japanese Physician 1897 “Sekiri” outbreak >91,000 Japanese people Mortality rate >20%  Shigellosis Etiology: Shigella dysenteriae. S. flexneri, S. boydii, S. sonnei. Shiga toxin: neurotoxic, cytotoxic and enterotoxic Epidemiology: 188 M cases worldwide, mainly affects children in U.S Sources Fecal-oral route Raw Vegetables  Shigellosis Clinical Features: Abrupt onset of explosive, watery diarrhea that becomes progressively bloody Tenesmus Abdominal pain +/- systemic symptoms (fever, anorexia, malaise Dx: Stool culture Fecal WBC/RBC CBC WBC>50,000 Sigmoidoscopy  Punctate areas of ulceration Tx: Oral rehydration and electrolyte replacement If Severe: Fluroquinolones  Reportable Diseases Novel influenza A virus infections Severe acute respiratory syndrome- Typhoid fever associated coronavirus disease Pertussis Vancomycin intermediate (SARS CoV-2) Staphylococcus aureus (VISA) Pesticide-related illnesses and Shiga toxin-producing Escherichia injuries Vancomycin resistant Staphylococcus coli (STEC) aureus (VRSA) Plague Shigellosis Vibriosis Poliomyelitis Smallpox Viral hemorrhagic fever (including Poliovirus infection, nonparalytic Syphilis, including congenital Ebola virus, Lassa virus, among Psittacosis syphilis others) Q-fever Tetanus Waterborne disease outbreak Rabies (human and animal cases) Toxic shock syndrome (other than Yellow fever streptococcal) Rubella (including congenital Zika virus disease and infection syndrome) Trichinellosis (including congenital) Salmonella paratyphi and typhi Tuberculosis Salmonellosis Tularemia  Campylobacter Enteritis Etiology: Campylobacter jejuni Most common cause of bacterial enteritis in the US Typically affects children and young adults Incubation period 3 days Sources Raw or undercooked poultry Raw milk Puppies  Campylobacter Enteritis Clinical Manifestations Inflammatory diarrhea with cramping periumbilical pain Bloody Diarrhea Diagnosis: Stool culture: Gram negative, may appear S or comma shaped PCR Treatment: Fluid and electrolyte replacement If severe: Azithromycin  Reportable Diseases Anthrax Gonorrhea West Nile virus Haemophilus influenza, invasive disease Eastern and Western Equine Encephalitis Hantavirus pulmonary syndrome Babesiosis Hemolytic uremic syndrome, post-diarrheal Botulism Hepatitis A, B, C Brucellosis HIV Campylobacteriosis Influenza-related infant deaths Chancroid Invasive pneumococcal disease Chickenpox Lead, elevated blood level Chlamydia Legionnaire disease (legionellosis) Cholera Leprosy Coccidioidomycosis Leptospirosis Cryptosporidiosis Listeriosis Cyclosporiasis Lyme disease Dengue virus infections Malaria Diphtheria Measles Ehrlichiosis Meningitis (meningococcal disease) Foodborne disease outbreak Mumps Giardiasis  Case You are seeing a 13 y/o female while on a medical mission trip to Syria. She has been having multiple episodes of watery diarrhea that they describe looks like rice water. She appears very dehydrated.  Cholera Etiology: Vibrio cholerae. Produces exotoxin Epidemiology: 3 million cases & 100K deaths annually worldwide, most cases in Africa & Asia Sources: Contaminated food and water, Outbreaks with poor sanitation and overcrowding  Cholera Clinical Manifestations: Copious watery diarrhea. “Rice water stools” Diagnosis: Stool culture: Gram negative, comma shaped rods, PCR Treatment: Rehydration (lactated ringers) and electrolyte replacement. If severe: Tetracyclines Prevention: Bottled water in endemic areas, washing hands with soap.  Reportable Diseases Anthrax Gonorrhea West Nile virus Haemophilus influenza, invasive disease Eastern and Western Equine Encephalitis Hantavirus pulmonary syndrome Babesiosis Hemolytic uremic syndrome, post-diarrheal Botulism Hepatitis A, B, C Brucellosis HIV Campylobacteriosis Influenza-related infant deaths Chancroid Invasive pneumococcal disease Chickenpox Lead, elevated blood level Chlamydia Legionnaire disease (legionellosis) Cholera Leprosy Coccidioidomycosis Leptospirosis Cryptosporidiosis Listeriosis Cyclosporiasis Lyme disease Dengue virus infections Malaria Diphtheria Measles Ehrlichiosis Meningitis (meningococcal disease) Foodborne disease outbreak Mumps Giardiasis  Clostridiodes Difficile First Recognized in 1978 as “antibiotic-associated diarrhea” Epidemiology US Adults: 14 cases per 1000 persons Most common nosocomial infection in the US Mortality: 6% Pathophysiology: Obligate, anaerobic, gram positive, spore-forming bacillus Toxins produced  C. Diff Risk Factors: Older patients >70 years old, immunocompromised, steroid use, cystic fibrosis, obesity, female, CKD, IBD, Cirrhosis, Acid suppression (omeprazole highest risk) RECENT ABX USE Broad-spectrum highest risk Clindamycin, fluoroquinolones, Cephalosporins Symptoms (Can be asymptomatic carriers), 20-30 stools a day, mucous and blood often present, pain, Can progress to Toxic Megacolon  C. Diff Labs Contraindications: Formed stool, recent laxative use in prior 48 hours, testing for cure in asymptomatic patients, children 1.5. WBC >15,000. Imaging If severe abdominal pain or h/o ulcerative colitis/crohns disease CT Abdomen Target sign or double halo sign. C. Diff Treatment x10 days Fidaxomicin (Dificid) Macrolid (new), very expensive ($3,000) Vancomycin HAS to be oral. Not IV Needs serum level monitoring esp in Kidney disease Preventing spore spread Resistant to Alcohol/ Antiseptics Chlorhexidine and Soap are effective Contact Isolation of the patient