Module 6: Managing Common Infections

Question 1

Immune Senescence Risk Factors

Answer 1

1. Dysregulation of immune responses
   - Decrease in adaptive T cell responses
   - Decrease in naive t cells
   - Decrease in cytokine production
   - Decrease in cellular surface receptors
   - Supporessed t-cell responses

Question 2

Protein-Energy Malnutrition PEM

Answer 2

1. PEM is linked to CAP, nosocomial infection, and longer hospitalizations
2. Specific nutrient deficiencies related to poor immune function & Infection
   - B12 deficiency — inadequate pneumococcal vaccination response
   - Vit D deficiency — incnreased risk of TB and C. Diff infection

Question 3

Social/Environmental Risk Factors

Answer 3

1. Lower Socio-economic status — Associated w/ increased rates of CAP & invnasive pneumococcal infections
2. Long term Care
   - Residents frail, have multiple comorbidities and living in close proximity
   - Can lead to severe outbreaks & high mortality rates
   - Antibiotic resistance r/t high antibiotic use & poor infection control measures

Question 4

Common Presentation of infection in Older Adults

Answer 4

1. No fever or low-grade fever
2. Malaise
3. Sepsis w/out leukocytosis and fever
4. Falls
5. Anorexia
6. New onset of confusion
7. Acute mental status change
8. Acute decline in functional status

Question 5

COVID-19

-Illness Course

Answer 5

1. 85% mild illness
2. 14% severe disease requiring hospitalization (5% require ICU care)
3. Predictors of severe illness
   - Advanced age
   - BMI >30
   - Co-morbidities
   - Low 02 saturations
   - Lab findings — Lymphopenia, neutrophilia, hypoalbuminemia, leukocytosis, increased CRP, Increased D-Dimer, increased Transaminases, Increased lactate

Question 6

COVID-19

-Clinical Management

Answer 6

1. Monoclonal antibodies
2. Oral antiviral medications (5 day course)
   - Paxlovid — Many drug interactions **
   - Molnupiravir

Question 7

Herpes Zoster

Answer 7

1. Re-activation of the varicella-zoster virus
2. Localized — Rash in 1-2 adjacent dermatomes
3. Disseminated — rash affects 3+ dermatomes
4. Complications — Post-herpetic neuralgia 13%, blindness, bacterial superinfection of lesions

—Older adults can have confusion with infection

Question 8

Herpes Zoster — Treatment & Vacccination

Answer 8

1. Isolation
2. 7-10 day course of antiviral medicaiton
3. PHN can be treated with gabapentin, pregabalin — Use caution d/t risk of confusion/falls in older adults —

Vaccination

• Shingriz recommended over zostavax
• 2 doses — 2nd dose given 2-6 months after first dose
• Previous zostavax vaccination — shingrix recomended
• Previous zoster infection — Shingrix recommended

SHINGRIX is vaccination of choice ** — 2nd vaccine can cause sx’s — rest after vaccination
RENALLY dose acyclovir**

-Once rash has developed a crust — NO LONGER infectious

Question 9

Herpes Zoster

-Clinical information

Answer 9

1. Wash hands, cover rash with dressing, do not scratch
2. Zoster rash is NOT infectious once it is crusted over
3. Stay away from those with decreased immunity like children

Question 10

Sepsis/Bacteria

Answer 10

1. Most likely occurs from GI or GU source and most likely gram negative rod
2. High risk population — long term care
3. Antibiotic coverage similar to that of young adult
   - Broad coverage
   - High suspicion of resistant microbe — Cover MRSA, resistant gram negative rods, enterococci
4. IV fluids but monitor fluid status

Question 11

Sepsis Workup

Answer 11

1. Physical exam
   - Source of infection, lines prosthetic devices, hemodynamic stability
2. Labs/diagnostics
   - CBC w/ diff, BMP, UA w/ culture and sensitivity, Blood cultures x2 and chest xray

Question 12

C. Diff

Answer 12

1. Bacterial spores spread via fecal-oral route and thrive on toilets, hospital equipment, and door handles
2. Spores may survive for months
3. Outpatient incidences are rising
4. Risk factors — ANTIBIOTIC EXPOSURE, PPI use, advanced age, duration of hospitalization

Question 13

High risk antibiotics for C. Diff

Answer 13

1. High risk
   - Clindamycin, penicillin, quinolones, 2nd and 3rd generation cephalosporins
2. Medium risk
   - Macrolides
   - Tetracyclines
   - Aminoglycosides
3. Rare risk
   - Flagyl and vancomycin

Question 14

C. Diff Workup

Answer 14

1. Stool sample and Nucleic acid amplification test (NAAT)
2. Diagnosis requires — Stool test for cdiff toxins or C diff toxin gene **TEST
3. CBC w/ diff and a CMP
4. Up to 50% of patients have + C. Diff PCR for up to 6 weeks after completion of therapy TEST

Question 15

C. DIff Tx and Management

Answer 15

1. Contact Isolation — Private Room and dedicated equipment
2. Use soap and water for handwashing
3. Fluid replacement — Oral or IV
4. Low residue diet
5. D/C offending antibiotic if indicated
6. NO ANTIDIRRHEALS
7. VANCOMYCIN is now 1st line treatment
8. Alternative first line agnet — Dificid - fidaxomicin

Question 16

C. Diff Recurrence

Answer 16

1. Treat similar as original episode if uncomplicated
2. may require pulse-dose or tapered vancomycin
3. Fecal microbiota transplants indicated after 3rd recurrence** Poop transplant

Question 17

C. Diff Prevention

Answer 17

1. Clean equipment w/ bleach
2. Concomitant probiotic use while on antibiotics?
3. Taper and D/C PPI if indicated

Question 18

Influenza

-Info

Answer 18

1. Influenza is an RNA virus and has A, B and C subtypes that impact humans
2. Influenza D primarily affects cattle and isn’t known to infect humans

Question 19

Influenza A

-Info

Answer 19

1. Divided into subtypes based on 2 proteins on the surface of the virus
   - Hemagglutinin (H) 18 subtypes
   - Neuraminidase (N) 11 subtypes
2. This is further broken down into strains
   - Current subtypes of influenza A found in people — H1N1 and H3N2 — These are both included in the vaccination

Question 20

Influenza B

-Info

Answer 20

1. Not divided into subyptes
   - Broken down to lineages and strains
2. Current influenza B viruses — one of the following lineages:
   -B/Yamagata
   -B/Victoria
   —Both of these are included in vaccination every year

Question 21

Influenza C

Answer 21

1. Milder respiratory sx’s
2. Not thought to cause epidemics
3. Seasonal flu vaccine does NOT cover influenza C

Question 22

First Flu Vaccine?

Answer 22

1. First flu vaccine was given in the US in 1938.

Question 23

Flu Vaccination for Senior Citizens

Answer 23

1. FLUAD
   - approved over age 65 yrs
   - egg based
   - + adjuvant (MF59)
2. FLUZONE High Dose
   - Approved over age 65 yrs
   - egg based
   - Has 4x amount of antigen

NO RCTs comparing FLUAD to FLUZONE High Dose

Question 24

Influenza

-Am I contagious?

Answer 24

1. Typical incubation period is 1-4 days (Average 2 days)
2. Adults shed influenza virus from the day before sx’s begin through 5-10 days after illness onset
3. Virus shed declines rapidly by 3-5 days onset
4. Severely immunocompromised can shed virus for weeks or months **

Question 25

Influenza Rapid Flu Test

Answer 25

1. Advantages - Easy and quick results <15 minutes 2. Disadvantages - False negative results common - Not all tests distinguish between A & B - None of the tests differentiate between specific strains (H1N1 vs H3N2) 3. If rapid is (-) but flu-like sx’s — Treat w/ antiviral medication - If flu is documented in your community, do not have to perform a rapid flu test — clinical presentation of flu is sufficient for diagnosis

Question 26

Pharm management antiviral meds

Answer 26

1. Neuraminidase inhibitors - Tamiflu — Oral — renal dosing - Relenza — Inhaled — Contraindicated in asthma or COPD 2. Endonuclease inhibitors - baloxavir (Xofluza) — One time dose

Question 27

Oseltamivir (Tamiflu) | -Info

Answer 27

1. Effective against influenza A or B 2. Start w/in 48 hr window after sx’s begin 3. Oral (pill or liquid) 75mg BID x 5 days 4. Prophylaxis 75 mg Qd x 7-14 days A/E’s — N/V, reports of transient neuropsychiatric events (self injury or delirium), especially in children/adolescents

Question 28

Baloxavir (Xofluza)

Answer 28

1. Endonuclease Inhibitor - 12 years old and up - Uncomplicated influenza - Patients w/ High risk of developing influenza-related complications 2. Start w/in 48 hrs of sx’s onset 3. Single dose 40-80 mg — Dose dependent A/E — Nausea *

Question 29

Pneumonia Stats

Answer 29

1. 8th leading cause of death in US older adults 2. Cumulative 2 year risk for nursing home resident to develop PNA is 30% 3. Baseline incidence in those 75+ - Community dwelling elsders = 12/1000 - NH residents = 33/1000 4. PNA mortality in older adults 3-5x greater than young adults

Question 30

PNA | -Mortality

Answer 30

1. Co-morbidities — STRONGEST predictor) 2. Age >65 3. Debility 4. CRI (Creatinine >1.5) 5. Leukocytosis, leukopneia, and/or anemia 6. Multi-lobar PNA on radiograph

Question 31

CAP | -Atypical PNA

Answer 31

1. Mycoplasma Pneumonia Hallmark sign is a NAGGING COUGH** - More common in persons 20-40 yrs - Incubation 2 weeks - requires close contact w/ infected person

Question 32

35 minutes

Answer 32

35 minutes