PMDA 2006 Alex T. Makris, MD, CMD. INFLUENZA New Issues and New Challenges.

PMDA 2006PMDA 2006

Alex T. Makris, MD, CMDAlex T. Makris, MD, CMD

INFLUENZAINFLUENZA

New Issues and New New Issues and New ChallengesChallenges

Centers for Disease Control and Prevention. Influenza Prevention and Control. Influenza. Available at: http://www.cdc.gov/ncidod/diseases/flu/fluinfo.htm.

Clinically Relevant Influenza Clinically Relevant Influenza VirusesViruses

Type AType A Potentially severe illnessPotentially severe illness

Epidemics and pandemicsEpidemics and pandemics

Rapidly changingRapidly changing

Type BType B Usually less severe illnessUsually less severe illness

EpidemicsEpidemics

Genetically more stableGenetically more stable

Confirmed Influenza Isolates – Confirmed Influenza Isolates – Type A vs Type B (1992-1999)Type A vs Type B (1992-1999)

CDC MMWR Weekly. Update: Influenza activity (1992-94 to 1998-99 seasons). Available at: http://www.cdc.gov/epo/mmwr/preview/mmwrhtml.htm.

1992-93 93-94 94-95 95-96 96-97 97-98 98-99

Type B

Type A86%86%

Total =Total = 2,0872,087 3,9633,963 3,4233,423 4,1324,132 6,3446,344 11,43911,439 6,5296,529

14%14%

0.1%0.1%

99.9%99.9%

22%22% 19%19% 21%21%8%8%

0.3%0.3%

78%78% 92%92% 81%81% 99.7%99.7% 79%79%

Per

cent

age

of T

ype

A

Per

cent

age

of T

ype

A

and

B I

sola

tes

and

B I

sola

tes

00

2020

4040

6060

8080

100100

YearsYears FluFlu VirusVirus MortalityMortality

1918-191918-19 “Spanish”“Spanish” Type A (H1N1) Type A (H1N1) 20 million worldwide20 million worldwide550,000 US550,000 US

1957-581957-58 “Asian”“Asian” Type A (H2N2)Type A (H2N2) 70,000 US70,000 US

1968-691968-69 “Hong Kong”“Hong Kong” Type A (H3N2)Type A (H3N2) 34,000 US34,000 US

Glezen WP. Epidemiol Rev. 1996;18:65.Centers for Disease Control and Prevention. Influenza Prevention and Control. Influenza. Available at:http://www.cdc.gov/ncidod/diseases/flu/fluinfo.htm.

Influenza Pandemics in the 20th Influenza Pandemics in the 20th CenturyCentury

Pneumonia and Influenza Pneumonia and Influenza Mortality Mortality

Rates by AgeRates by Age

0

20

40

60

80

100

120

<5 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 ≥65Age (yr)

Pe

r 1

0,0

00

Glezen WP. Epidemiol Rev. 1996;18:73, with permission.

NeuraminidaseNeuraminidase

HemagglutininHemagglutinin

RNARNA

Influenza Surface ProteinsInfluenza Surface Proteins

MM22 protein protein

(only on type A)(only on type A)

INFLUENZAINFLUENZA

TransmissionTransmission

PathophysiologyPathophysiology

Clinical ManifestationsClinical Manifestations

InfluenzaInfluenzaTransmissionTransmission

Aerosolized droplet spreadAerosolized droplet spread

Incubation period 18 - 72 hoursIncubation period 18 - 72 hours

Attack rate 10% - 50%Attack rate 10% - 50%

Outbreaks generally begin in confined Outbreaks generally begin in confined locationslocations

After initial cases, numbers usually peak After initial cases, numbers usually peak over 2-3 weeksover 2-3 weeks

Usually occurs Dec - AprilUsually occurs Dec - April

Laver, WG, et. al. Scientific American: Disarming Flu Viruses: January 1999 Illustration: Bryan Christie

Adapted from the National Institute of Allergy and Infectious Diseases.

Signs & SymptomsSigns & Symptoms FluFlu ColdColdOnsetOnset SuddenSudden GradualGradual

FeverFever Characteristic, high (over Characteristic, high (over RareRare101101F); lasting 3 to 4 daysF); lasting 3 to 4 days

CoughCough Nonproductive; canNonproductive; can HackingHackingbecome severebecome severe

HeadacheHeadache ProminentProminent Rare Rare

Myalgia (aches and pains)Myalgia (aches and pains) Usual; often severeUsual; often severe Slight Slight

Fatigue; weakness Fatigue; weakness Can last up to 2 to 3 weeksCan last up to 2 to 3 weeks Very mildVery mild

Extreme exhaustionExtreme exhaustion Early and prominentEarly and prominent NeverNever

Chest discomfortChest discomfort CommonCommon Mild to Mild to moderatemoderate

Stuffy noseStuffy nose SometimesSometimes CommonCommon

SneezingSneezing SometimesSometimes UsualUsual

Sore throat Sore throat SometimesSometimes CommonCommon

Flu vs. Cold SymptomsFlu vs. Cold Symptoms

Diagnostic ToolsDiagnostic Tools

Weekly CDC activity reportsWeekly CDC activity reports

Clinical suspicionClinical suspicion

Viral isolationViral isolation

SerologySerology

PCRPCR

Immunofluorescence assaysImmunofluorescence assays

Rapid diagnostic testsRapid diagnostic tests

MANAGEMENT OPTIONSMANAGEMENT OPTIONS

Early vaccinationEarly vaccination

Infection Control MeasuresInfection Control Measures

Anti-influenzal agentsAnti-influenzal agents

Prophylaxis with anti-influenzal Prophylaxis with anti-influenzal agentsagents

Influenza & Influenza & Pneumococcal Pneumococcal ImmunizationsImmunizations

Guidance TrainingGuidance TrainingCFR 483.25(n) F334CFR 483.25(n) F334

Effective October 1, 2006Effective October 1, 2006

CMS

Determination of ComplianceDetermination of ComplianceSynopsis of RegulationSynopsis of Regulation

The influenza & pneumococcal vaccination The influenza & pneumococcal vaccination requirement has five aspects:requirement has five aspects:

1.1. The resident is provided education regarding The resident is provided education regarding the benefits & potential side effects of the the benefits & potential side effects of the vaccinations;vaccinations;

2.2. The facility must determine if a resident is The facility must determine if a resident is eligibility to receive the vaccinations.eligibility to receive the vaccinations.

3.3. The resident, or the resident’s legal The resident, or the resident’s legal representative, has the right to refuse the representative, has the right to refuse the vaccinations.vaccinations.

CMS

Determination of ComplianceDetermination of ComplianceCriteria for ComplianceCriteria for Compliance

4.4. Each eligible resident is administered the Each eligible resident is administered the influenza & pneumococcal vaccine (unless influenza & pneumococcal vaccine (unless refused or contraindicated or the resident refused or contraindicated or the resident has already been immunized); and has already been immunized); and

5.5. The facility must document that education The facility must document that education was provided and that the resident either was provided and that the resident either received the vaccine(s) or, if not received, received the vaccine(s) or, if not received, that the vaccine(s) was (were) refused or that the vaccine(s) was (were) refused or medically contraindicated or the resident medically contraindicated or the resident had already been immunized. had already been immunized.

CMS

Vaccination ProgramVaccination Program

Generally, vaccinate in late September, Generally, vaccinate in late September, OctoberOctober

Vaccinate through March Vaccinate through March – New admissions should be offered vaccineNew admissions should be offered vaccine– Generally takes ~ 2 weeks for protectionGenerally takes ~ 2 weeks for protection– If vaccination occurs during high activity levels If vaccination occurs during high activity levels

may need to provide chemoprophylaxis during may need to provide chemoprophylaxis during the 2 weeks after vaccination the 2 weeks after vaccination

MMWR. 1999;48:4.

Efficacy of the Influenza Efficacy of the Influenza VaccineVaccine

Most effective (70%-90%) in preventing Most effective (70%-90%) in preventing illness in persons aged <65 yrsillness in persons aged <65 yrs

30%-70% in preventing P/I hospitalization in 30%-70% in preventing P/I hospitalization in elderly not in chronic care facilityelderly not in chronic care facility

30%-40% in preventing illness in frail elderly30%-40% in preventing illness in frail elderly

50%-60% in preventing P/I hospitalization in 50%-60% in preventing P/I hospitalization in nursing home elderlynursing home elderly

80% in preventing death in nursing home 80% in preventing death in nursing home elderlyelderly

TypeType HemagglutininHemagglutinin NeuraminidaseNeuraminidase OriginOrigin Yr Yr

A (H1N1)/Sydney/5/93A (H1N1)/Sydney/5/93

B/Beijing/B/Beijing/184/93184/93

Naming Influenza VirusesNaming Influenza Viruses

Strain Strain Sequence Sequence

No.No.

2006 – 2007 Vaccine Composition2006 – 2007 Vaccine Composition

A/New Caledonia/20/1999 (H1N1)-likeA/New Caledonia/20/1999 (H1N1)-like

A/Wisconsin/67/2005 (H3N2)-likeA/Wisconsin/67/2005 (H3N2)-like

B/Malaysia/2506/2004-like antigensB/Malaysia/2506/2004-like antigens

Inactivated vaccineInactivated vaccine

Live, Attenuated Influenza Vaccine (LAIV)Live, Attenuated Influenza Vaccine (LAIV)

Characteristics of Influenza Characteristics of Influenza VaccinesVaccines

CharacteristicCharacteristic InactivatedInactivated LAIV (FluMistLAIV (FluMist™)™)

Route of Route of administrationadministration

Intramuscularly - Intramuscularly - annuallyannually

Intranasally - annuallyIntranasally - annually

CompositionComposition Killed virus:Killed virus:

Same antigenic Same antigenic makeupmakeup

Live, attenuatedLive, attenuated

Same antigenic Same antigenic makeupmakeup

IndicationIndication ≥≥ 6 months6 months 5 – 49 years5 – 49 years

Clinical IllnessClinical Illness Mild, localMild, local Mild signs/symptoms Mild signs/symptoms of influenzaof influenza

MMWR July 28, 2006/55(RR10); 1-42 Prevention and Control of Influenza

Avian InfluenzaAvian Influenza

H5N1 epizootic H5N1 epizootic

Human infections from direct contact with Human infections from direct contact with infected poultry/wild birdsinfected poultry/wild birds

Person Person → person transmission→ person transmission– Rare, Limited, UnsustainedRare, Limited, Unsustained

If sustained transmission, pandemic may If sustained transmission, pandemic may resultresult

Little pre-existing immunityLittle pre-existing immunity

CDC August 9, 2006 Avian Influenza: Current Situation

Avian InfluenzaAvian Influenza

No available vaccineNo available vaccineSx & Sx similar to circulating strainsSx & Sx similar to circulating strainsCases/deaths 2003 through August 2006Cases/deaths 2003 through August 2006– 241/141241/141

Cases/deaths 2006Cases/deaths 2006– 96/6496/64

Oseltamivir and Zanamivir are currently Oseltamivir and Zanamivir are currently effective for treatment and effective for treatment and chemoprophylaxischemoprophylaxiswww.who.int/csr/disease/avianinfluenza/en

Infection ControlInfection Control

AndAnd

Outbreak ManagementOutbreak Management

Outbreak ControlOutbreak Control

Recognize when a potential outbreak Recognize when a potential outbreak existsexists– Any activity above the usual for the FacilityAny activity above the usual for the Facility

Manage the active residentsManage the active residentsPrevent transmission to other residents Prevent transmission to other residents and staffand staff– Infection Control MeasuresInfection Control Measures– Treatment of active residentsTreatment of active residents– Chemoprophylaxis of uninfected residentsChemoprophylaxis of uninfected residents

Mode of TransmissionMode of Transmission

DropletsDroplets– Person Person → person→ person– Generated via cough, sneezing ( 3 feet)Generated via cough, sneezing ( 3 feet)

Mucosal surfacesMucosal surfaces

Inanimate surfaces laden with virusInanimate surfaces laden with virus

– Transmission from 24 hours prior and 5 days Transmission from 24 hours prior and 5 days after onsetafter onset

CDC December 23, 2005. Infection Control Measures for Preventing and Controlling Influenza Transmission in Long-Term Care Facilities

General Infection Control MeasuresGeneral Infection Control Measures

Annual influenza vaccinationAnnual influenza vaccinationStandard and Droplet PrecautionsStandard and Droplet PrecautionsPrivate room if possiblePrivate room if possibleCohort when possibleCohort when possibleActive surveillanceActive surveillanceTesting for new casesTesting for new casesLimit visitation Limit visitation Limit communal activitiesLimit communal activitiesLimit admissionsLimit admissionsProphylactic antiviralsProphylactic antiviralsCDC December 23, 2005. Infection Control Measures for Preventing and Controlling Influenza Transmission in Long-Term Care Facilities

Infection Control MeasuresInfection Control MeasuresStaff ManagementStaff Management

Reinforce hand washing importanceReinforce hand washing importanceProvide alcohol based hand gelsProvide alcohol based hand gelsDo not allow ill employees to workDo not allow ill employees to workIf outbreak confined to one unit; limit staff If outbreak confined to one unit; limit staff cross over to other unitscross over to other unitsIf possible, assign care givers to only ill or If possible, assign care givers to only ill or well residentswell residentsIf not, care for well residents first, then ill If not, care for well residents first, then ill residents residents

Influenza TreatmentInfluenza Treatment

Antiviral Agents for InfluenzaAntiviral Agents for Influenza

Amantadine, RimantadineAmantadine, Rimantadine– Only active against influenza AOnly active against influenza A– Significant CNS adverse effectsSignificant CNS adverse effects– Rapid, high levels of resistanceRapid, high levels of resistance

192/209 (92%) influenza A, 26 States192/209 (92%) influenza A, 26 States

– No longer recommended for treatment or No longer recommended for treatment or chemoprophylaxis of influenzachemoprophylaxis of influenza

MMWR July 28, 2006/55(RR10); 1-42 Prevention and Control of Influenza

Antiviral Agents for InfluenzaAntiviral Agents for Influenza

Zanamivir, Oseltamivir phosphateZanamivir, Oseltamivir phosphate– Neuraminidase inhibitorsNeuraminidase inhibitors– Treatment initiated within 48 hours of onset Treatment initiated within 48 hours of onset – Active against A, BActive against A, B– Approved for treatment of acute illnessApproved for treatment of acute illness– Approved for prophylaxisApproved for prophylaxis

Oseltamivir Oseltamivir ≥ 1yr≥ 1yr

Zanamivir ≥ 5 yrsZanamivir ≥ 5 yrs

– Zanamivir – inhalationZanamivir – inhalation– Oseltamivir – oral Oseltamivir – oral

Neuraminidase InhibitionNeuraminidase Inhibition

Influenza TreatmentInfluenza Treatment

Zanamivir (Relenza)Zanamivir (Relenza)– Delivery via inhalationDelivery via inhalation

Diskhaler deviceDiskhaler device

10 mg BID X 5 days10 mg BID X 5 days

Begin within 48 hours of onsetBegin within 48 hours of onset

Oseltamivir phosphate (Tamiflu)Oseltamivir phosphate (Tamiflu)– Delivery via oral route (suspension available)Delivery via oral route (suspension available)

75mg BID X 5days75mg BID X 5days

Begin within 48 hours of onsetBegin within 48 hours of onset

Influenza ProphylaxisInfluenza Prophylaxis

CDC CDC encouragesencourages the use of oseltamivir for the use of oseltamivir for chemoprophylaxischemoprophylaxis– 75 mg daily75 mg daily

Vaccinated elderly in aggregate living Vaccinated elderly in aggregate living settings may develop influenza or be settings may develop influenza or be susceptible to influenzasusceptible to influenza

www. cdc.gov/flu/professionals/treatment/0506antiviralguide.htm. CDC Influenza Antiviral Medications: 2005-06 Interim Chemoprophylaxis and Treatment Guidelines.

Chemoprophylaxis ManagementChemoprophylaxis Management

If confined to one unitIf confined to one unit– Implement infection control measuresImplement infection control measures– Provide chemoprophylaxis to unvaccinated Provide chemoprophylaxis to unvaccinated

staff and uninfected, unvaccinated residents staff and uninfected, unvaccinated residents on the uniton the unit

– If vaccinated residents have Sx & Sx provide If vaccinated residents have Sx & Sx provide chemoprophylaxischemoprophylaxis

– Continue prophylaxis for at least two weeks Continue prophylaxis for at least two weeks and for as long as one week after the last and for as long as one week after the last resident case occurredresident case occurred


Chemoprophylaxis ManagementChemoprophylaxis Management

If active cases occur on several unitsIf active cases occur on several units– Implement infection control measuresImplement infection control measures– Provide chemoprophylaxis to all unvaccinated Provide chemoprophylaxis to all unvaccinated

staff and uninfected, unvaccinated residents staff and uninfected, unvaccinated residents – If vaccinated residents have Sx & Sx provide If vaccinated residents have Sx & Sx provide

chemoprophylaxischemoprophylaxis– Continue prophylaxis for at least two weeks Continue prophylaxis for at least two weeks

and for as long as one week after the last and for as long as one week after the last resident case occurredresident case occurred


Clostridium difficile InfectionClostridium difficile Infection

New StrainNew Strain

New ChallengesNew Challenges

Clostridium difficileClostridium difficilePrevalencePrevalence

4% - 20% - LTCF without outbreak4% - 20% - LTCF without outbreak¹¹

10% - 20% may acquire during their stay²10% - 20% may acquire during their stay²

Rate of acquisition – 1 yr. follow up Rate of acquisition – 1 yr. follow up 0.52/1,000 rcds³0.52/1,000 rcds³

Incidence - AADIncidence - AAD– 1,600 per 1,000 resident years1,600 per 1,000 resident years¹¹

¹Gerding DN, et al. Infect Control Hosp Epidemiol 1995;16:459. ²Monsieur I, et al. Arch Gerontol Geriatr 1991;13:255. ³Simor AE, et al. Clin Infect Dis 1993;17:672

Clostridium difficileClostridium difficilePrinciples of Treatment - CDAD Principles of Treatment - CDAD Discontinue antimicrobial therapy if Discontinue antimicrobial therapy if possiblepossibleFluids and electrolytesFluids and electrolytesAvoid anti – peristaltic agentsAvoid anti – peristaltic agentsAvoid opiates Avoid opiates Mild casesMild cases– 15% - 20% will resolve with above measures15% - 20% will resolve with above measures¹¹

¹Olson MM et al. Infect Control Hosp Epidemiol 1994;15:371

Clostridium difficileClostridium difficilePrinciples of Treatment - CDADPrinciples of Treatment - CDAD

Specific therapy should be given orally Specific therapy should be given orally when possiblewhen possibleSpecific therapy should be continued for Specific therapy should be continued for 10 days10 daysTest of Cure cultures or toxin assays Test of Cure cultures or toxin assays should not be done in asymptomatic should not be done in asymptomatic patients¹patients¹– Does not predict clinical relapseDoes not predict clinical relapse

¹Fiengold SM Academic Press 1988:341

Clostridium difficileClostridium difficileTreatment Options - CDADTreatment Options - CDAD

Metronidazole Metronidazole

VancomycinVancomycin

Vancomycin + RifampinVancomycin + Rifampin

Probiotics Probiotics – Lactobacillus Lactobacillus – Saccharomyces boulardiiSaccharomyces boulardii

Ion-exchange resins - colestipolIon-exchange resins - colestipol

Clostridium difficile Current Clostridium difficile Current Guidelines forGuidelines for

Treatment - CDADTreatment - CDAD

Initial therapyInitial therapy– Metronidazole PO – 10 days Metronidazole PO – 10 days

1.0 – 1.5 gm/day for 10 days1.0 – 1.5 gm/day for 10 days¹ ¹

– Vancomycin PO – 10 daysVancomycin PO – 10 days500 – 1,000 mg/day for 10 days500 – 1,000 mg/day for 10 days²²

RelapseRelapse– Retreat with initial agentRetreat with initial agent³³

Cures 90% of recurrences Cures 90% of recurrences

¹Peterson LR et al. Verlog 1990:115 ²Gerding DN Infect Control Hosp Epidemiol 1995;15:8:459

3Simor et al Infect Control Hosp Epidemiol 2002;23:696

Clostridium difficileClostridium difficileTreatment Outcomes - CDADTreatment Outcomes - CDAD

Clinical improvement 2 – 4 daysClinical improvement 2 – 4 days

Symptoms remit 7 – 10 daysSymptoms remit 7 – 10 days

Relapse rates 10% - 20%Relapse rates 10% - 20%¹¹ ³³׳׳²²׳׳– Metronidazole – 7%Metronidazole – 7%²²,16%,16%³³– Vancomycin – 10%², 16%³Vancomycin – 10%², 16%³

¹Teasley DG et al. Lancet 1983;5: 1043 ²Olson MM et al. Infect Control Hosp Epidemiol 1994;15:371 ³Wenisch C et al. Clin Infect Dis 1996;22:813

Clostridium difficileClostridium difficileAsymptomatic Carriers Asymptomatic Carriers

No increased risk of CDAD in No increased risk of CDAD in asymptomatic carriers vs. non colonized asymptomatic carriers vs. non colonized patientspatients¹¹

Treatment of colonization does not reduce Treatment of colonization does not reduce risk of CDADrisk of CDAD²²

Metronidazole ineffective in eliminating the Metronidazole ineffective in eliminating the carrier statecarrier state³³

Vancomycin may prolong carrier stateVancomycin may prolong carrier state

¹Johnson S et al. Lancet 1990;336:97 ²Bender BS et al. Lancet 1986;ii:11 ³Johnson S et al. Ann Int Med 1992;117:297

Epidemic Strain

New strainNew strain – Appears to produce greater quantities of Appears to produce greater quantities of

toxins A and Btoxins A and B1,21,2

– Is more resistant to fluoroquinolonesIs more resistant to fluoroquinolones3,43,4

– Has a Has a tcdCtcdC gene deletion gene deletion22

– Binary toxin genes are presentBinary toxin genes are present

1. CDC Fact Sheet, July 2005. 2. Warny M, et al. Lancet. 2005;366:1079-1084.3. McDonald LC, et al. 42nd Annual Meeting of the Infectious Diseases Society

of America (IDSA); 2004. Abstract LB-2.4. McDonald LC, et al. N Engl J Med. 2005;353:2433-2441.

Markers of Severe DiseaseMarkers of Severe Disease

Decreased mental statusDecreased mental status

Severe abdominal distension, pain Severe abdominal distension, pain

Marked increase in white blood cell countMarked increase in white blood cell count

Hemodynamic instabilityHemodynamic instability


Jacques Pepin et al. Clin Inf Dis 2005;40:1591Jacques Pepin et al. Clin Inf Dis 2005;40:1591– Retrospective review 1991-2004Retrospective review 1991-2004

Clinical diagnosis + toxin assayClinical diagnosis + toxin assay

Metronidazole therapyMetronidazole therapy– 250 mg QID – 500 mg TID250 mg QID – 500 mg TID

Relapse ratesRelapse rates

Metronidazole Metronidazole → Vancomycin → Vancomycin – Clinical failure Clinical failure


1991-20021991-2002– Treatment failure with MetronidazoleTreatment failure with Metronidazole

9.6% (66/688)9.6% (66/688)

– Recurrence rate Recurrence rate < 60 days< 60 days15.2%15.2%

2003-20042003-2004– Treatment failure with MetronidazoleTreatment failure with Metronidazole

25.7% (112/435)25.7% (112/435)

– Recurrence rate Recurrence rate < 60 days< 60 days47.2%47.2%


Daniel M Musher et al. Clin Infect Dis Daniel M Musher et al. Clin Infect Dis 2005;40:15862005;40:1586– 207 patients treated with Metronidazole207 patients treated with Metronidazole

Clinical cure - 50% (103/207)Clinical cure - 50% (103/207)Persistent symptoms – 22% (46/207)Persistent symptoms – 22% (46/207)Recurrence – 28% (58/207)Recurrence – 28% (58/207)


Jacques Pepin et al. Clin Inf Dis Jacques Pepin et al. Clin Inf Dis 2005;41:12542005;41:1254– 1/1/03 – 6/30/041/1/03 – 6/30/04– All hospital admissionsAll hospital admissions– Clinical CDADClinical CDAD


293 incident cases CDAD293 incident cases CDAD– 50.5% (148/293) in patients > 80 y.o.50.5% (148/293) in patients > 80 y.o.– 63.5% (186/293) received Fluoroquinolones 63.5% (186/293) received Fluoroquinolones – 21.8% (64/293) mortality < 30 d of diagnosis21.8% (64/293) mortality < 30 d of diagnosis

SummarySummaryExpanding spectrum of diseaseExpanding spectrum of disease

Epidemic strain has been identifiedEpidemic strain has been identified

Await updated guidelines (Spring 2007)Await updated guidelines (Spring 2007)

Role of vancomycin may be re-definedRole of vancomycin may be re-defined

Prevention is key!Prevention is key!– Infection control measuresInfection control measures– Judicious use of antibioticsJudicious use of antibiotics

Treatment – Complicated Treatment – Complicated InfectionsInfections

Vancomycin + Vancomycin + – Saccharomyces boulardiiSaccharomyces boulardii¹¹– Rifampin²Rifampin²– Lactobacillis³Lactobacillis³– Colestipol¹Colestipol¹

¹Feckety R Am J Gastroenterol 1997;92:739 ²Buggy BE J Clin Gastroenterol 1987;9:155 Gorbach SL Lancet 1987;ii:1519

Infection Control

Clostridium difficileClostridium difficileMode of TransmissionMode of Transmission

Direct ContactDirect Contact– Hand carriage - HCWHand carriage - HCW¹¹ ²²׳׳

Most likely plays major roleMost likely plays major role

– Environmental surfacesEnvironmental surfacesSpores – weeks or monthsSpores – weeks or months

Commodes, rectal thermometers Commodes, rectal thermometers

¹McFarland LV et al. N Engl J Med 1989;320:204 ²Fekety R et al. Am J Med1981;70:906

Clostridium difficileClostridium difficileInfection ControlInfection Control

Two major potential reservoirsTwo major potential reservoirs– Infected humansInfected humans

SymptomaticSymptomatic

ColonizedColonized

– Inanimate objectsInanimate objects

Nosocomial acquisition – 20%Nosocomial acquisition – 20%¹¹– Most asymptomaticMost asymptomatic

¹McFarland LV et al. N Engl J Med 1989;320:204


Patients with CDAD and incontinence Patients with CDAD and incontinence should be in private roomsshould be in private rooms

Contact isolationContact isolation– Barriers with direct contactBarriers with direct contact– Barriers when contact with environmentBarriers when contact with environment

Dedicated equipment when possibleDedicated equipment when possible

Simor AE et al. SHEA Position Paper. Clostridium difficile in Long-Term Care Facilities for the Elderly 2002;23:696


Meticulous hand hygieneMeticulous hand hygiene– Alcohol based hand gels are not sporocidal Alcohol based hand gels are not sporocidal

Environmental cleaning with sporocidal Environmental cleaning with sporocidal agents agents

Discontinuation of isolation when diarrhea Discontinuation of isolation when diarrhea subsidessubsides

Do not treat asymptomatic carriersDo not treat asymptomatic carriers

Simor AE et al. SHEA Position Paper. Clostridium difficile in Long-Term Care Facilities for the Elderly 2002;23:696

PMDA 2006 Alex T. Makris, MD, CMD. INFLUENZA New Issues and New Challenges.

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Transcript of PMDA 2006 Alex T. Makris, MD, CMD. INFLUENZA New Issues and New Challenges.