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2438405706745Infection Control00Infection Control15525755706745Modes of infection control should take into account mode of transmissionHealth care associated infection: affects 5-10% hospitalised patients; mostly preventable by good infection control practices; major cause of patient harm; ? need for isolation; ? hospital LOS by 4/7Disinfecting agents: alcohol and iodine good for everything; chlorhexidine good for bacteria and virus, not for mycobacteria and fungi; phenols good for G+ive onlyUniversal precautions: avoiding contact with bodily fluids; strict adherance to this is single most important thing Hand hygeine: most effective method to reduce infection transmission, gloves for any contact with body fluids, hand washing (when visibly soiled, after toilet, when likely resistant MO); alcohol hand rub (more effective against most MO than soap, rapid, less skin irritation, more availability, more cost effective; less effective against spores, parasites, C difficile) Others: gloves, masks, gowns etc… cover cuts, protect MM and gown if spattering of fluids possible, ready availability of PPE, update staff on infectious disease outbreaks; have 12 sets of high level PPE suitsOthers: sterilising, isolation, asceptic techniques, avoidance of invasive procedures, immunisation, educate and train employees, vaccinate employees, monitor antibiotics use and resistance, feedback to physicians and staff, reportable diseases list on public displayStrict isolation: highly contagious / virulent MO (SARS, avian flu, Diptheria, viral haemorrhagic fever, dissemiated Herpes Zoster and Varicella, bioterrorism) single room, appropriate air flow, N95 masks, gowns, glovesContact spread: bacteria, Hepatitis A, Staph, HSV; highly transmissible infections not transmitted by airborne droplets (eg. Paediatric URTI and pneumonia, Gonococcal conjunctivitis, Herpes Simplex, Staph skin infections, cutaneous diptheria, MRSA) contact isolation universal precautions, single room, gowns, gloves, hand hygieneAirborne precautions: TB, zoster, measles respiratory precautions universal precautions + single negative pressure room (air cycled 6-12x/hr, discharged to outside or put through filter), mask if patient contact necessary, make patient wear mask if leaves room, use spacers rather than nebs, do NPA in negative pressure room, keep 1m away from others, designate stethoscope, N95 duckbill mask and eyeshield if manipulate airway, admit to ward ASAP00Modes of infection control should take into account mode of transmissionHealth care associated infection: affects 5-10% hospitalised patients; mostly preventable by good infection control practices; major cause of patient harm; ? need for isolation; ? hospital LOS by 4/7Disinfecting agents: alcohol and iodine good for everything; chlorhexidine good for bacteria and virus, not for mycobacteria and fungi; phenols good for G+ive onlyUniversal precautions: avoiding contact with bodily fluids; strict adherance to this is single most important thing Hand hygeine: most effective method to reduce infection transmission, gloves for any contact with body fluids, hand washing (when visibly soiled, after toilet, when likely resistant MO); alcohol hand rub (more effective against most MO than soap, rapid, less skin irritation, more availability, more cost effective; less effective against spores, parasites, C difficile) Others: gloves, masks, gowns etc… cover cuts, protect MM and gown if spattering of fluids possible, ready availability of PPE, update staff on infectious disease outbreaks; have 12 sets of high level PPE suitsOthers: sterilising, isolation, asceptic techniques, avoidance of invasive procedures, immunisation, educate and train employees, vaccinate employees, monitor antibiotics use and resistance, feedback to physicians and staff, reportable diseases list on public displayStrict isolation: highly contagious / virulent MO (SARS, avian flu, Diptheria, viral haemorrhagic fever, dissemiated Herpes Zoster and Varicella, bioterrorism) single room, appropriate air flow, N95 masks, gowns, glovesContact spread: bacteria, Hepatitis A, Staph, HSV; highly transmissible infections not transmitted by airborne droplets (eg. Paediatric URTI and pneumonia, Gonococcal conjunctivitis, Herpes Simplex, Staph skin infections, cutaneous diptheria, MRSA) contact isolation universal precautions, single room, gowns, gloves, hand hygieneAirborne precautions: TB, zoster, measles respiratory precautions universal precautions + single negative pressure room (air cycled 6-12x/hr, discharged to outside or put through filter), mask if patient contact necessary, make patient wear mask if leaves room, use spacers rather than nebs, do NPA in negative pressure room, keep 1m away from others, designate stethoscope, N95 duckbill mask and eyeshield if manipulate airway, admit to ward ASAP2438402586990Blood Cultures00Blood Cultures15513052586356Volume of blood collected is primary determinant to sensitivity (? yield by 3%/ml); use anaerobic culture bottle when intra-abdominal / pelvic source suspected; best taken at onset of feverindications: bacterial origin suspected / no other more direct specimen possible / inpatient treatment likely (eg. Septicaemia, endocarditis, febrile neutropenia, PUO, febrile traveller)Cons: delay to results (median 30 hours); expensive; 9% yield; 5% contamination rate; impacts treatment in 1.5% cases; 20% will be missed if only 1 culture taken In pneumonia: Blood culture: not needed if immunocompetent non-hospitalised community acquired pneumonia; 1/500 change management; up to 14% +ive, mostly strep pneumoniae Sputum culture indicated if: requires admission and atypical micro-organism suspected; only 1/3 can produce sputum, 1/3 of these take 24 hours to do so, 50% of these take >24hrs to process, 50% of these are “valid”, 20% G stain +ive; 4x ? yield if prior antibiotics; 1/100 change management In UTI: Blood culture: if urinary obstruction / severe renal disease / pregnant pyelonephritis; rarely +ive if urine –ive; rarely changes management Urine culture: 1/20 (5%) cause change in management In cellulitis: rarely indicated; up to 4% +iveContamination: coag neg staph / corynbacterium / P acne / multiple bacteria isolated (<10% true bacteraemia due to multiple micro-organisms) / different micro-organism to that identified from source of infection (eg. Urine) / not found in later cultures / isolated only after prolonged incubation 00Volume of blood collected is primary determinant to sensitivity (? yield by 3%/ml); use anaerobic culture bottle when intra-abdominal / pelvic source suspected; best taken at onset of feverindications: bacterial origin suspected / no other more direct specimen possible / inpatient treatment likely (eg. Septicaemia, endocarditis, febrile neutropenia, PUO, febrile traveller)Cons: delay to results (median 30 hours); expensive; 9% yield; 5% contamination rate; impacts treatment in 1.5% cases; 20% will be missed if only 1 culture taken In pneumonia: Blood culture: not needed if immunocompetent non-hospitalised community acquired pneumonia; 1/500 change management; up to 14% +ive, mostly strep pneumoniae Sputum culture indicated if: requires admission and atypical micro-organism suspected; only 1/3 can produce sputum, 1/3 of these take 24 hours to do so, 50% of these take >24hrs to process, 50% of these are “valid”, 20% G stain +ive; 4x ? yield if prior antibiotics; 1/100 change management In UTI: Blood culture: if urinary obstruction / severe renal disease / pregnant pyelonephritis; rarely +ive if urine –ive; rarely changes management Urine culture: 1/20 (5%) cause change in management In cellulitis: rarely indicated; up to 4% +iveContamination: coag neg staph / corynbacterium / P acne / multiple bacteria isolated (<10% true bacteraemia due to multiple micro-organisms) / different micro-organism to that identified from source of infection (eg. Urine) / not found in later cultures / isolated only after prolonged incubation 15525752157730Fever absent in 20-30%00Fever absent in 20-30%2438402157730In Elderly00In Elderly2438401672590Epidemiology00Epidemiology15513051671955Fever reason for 5% ED presentations; 85% cause found, 15% no cause found; if no cause found after 3/7, likely bacterial; only 40% meningococcal diseases present with rash00Fever reason for 5% ED presentations; 85% cause found, 15% no cause found; if no cause found after 3/7, likely bacterial; only 40% meningococcal diseases present with rash243840964565Pyrexia00Pyrexia1551305963295Drugs causing fever: aspirin, isoniazid, methyldopa, phenytoin, serotonin syndrome, neuroleptic malignant syndromeCancer causing fever: Hodgkin’s disease, lymphoma, renal cancer, leukaemia, hepatoma, atrial myxoma00Drugs causing fever: aspirin, isoniazid, methyldopa, phenytoin, serotonin syndrome, neuroleptic malignant syndromeCancer causing fever: Hodgkin’s disease, lymphoma, renal cancer, leukaemia, hepatoma, atrial myxoma246380330200General Infectious Diseases00General Infectious Diseases2463802883535Immunisation00Immunisation155130528829000015513055905500Passive: using preformed immunological effectors (eg. IgG); indicated in prevention of disease following exposure, treatment of disease usually prevented by vaccine, where active immunisation not possible; complications rare; used in hepatitis A, polio, measles, tetanus, HepB IgActive: give antigen to host; used in DPT, MMR, Hib, Hepatitis B, pneumococcus, N meningitidis, cholera, typhoid, TB, yellow fever, salmonella, VZV, rabies, plagueADT: given if >8yrs old; boosted every 10 yearsBCG: live attentuated (don’t give if immunocompromised); 90% effective; no longer standard, given to indigenous people, health care workers with contact with TB patients, neonates with recent travel to endemic countries, <16 exposed to active TB; do Mantoux / tuberculin test before vaccination (contra- indicated if previously strong +ive, previous TB, recent live vaccine; measure at 72hrs; negative if <5mm)DTP: efficacy 85%; 50% soreness and swelling at injection site, 30% low grade feverHib: 90-100% effective; HIB and Hepatitis B combined; mild swelling and redness in 5%Hepatitis B: given to all babies at birth; 3 doses in 1st year; 90-97% effective; side effects mostly minorHepatitis A: 100% efficacy in 1 year; given to travellers, childcare personnel, intellectually impaired, health care providers, homosexuals, IVDU, chronic liver disease, haemophiliacsHPV: females 10-45yrs oldFlu: inactivated virion; >65yrs, indigenous people etc…, chronic co-morbidities, health care providers; ? mortality and morbidity by >50%; herd immunity of 50% prevents pandemicsMMR: >95% effective; attentuated live; at 1yr, 4yrs; may get parotitis 3/52 laterMeningococcal: C >B in Australia (usually other way round in developed countries)Pneumococcal: do if traumatic splenectomy, sickle cell diseaseVZV: attentuated livePolio: attentuated live00Passive: using preformed immunological effectors (eg. IgG); indicated in prevention of disease following exposure, treatment of disease usually prevented by vaccine, where active immunisation not possible; complications rare; used in hepatitis A, polio, measles, tetanus, HepB IgActive: give antigen to host; used in DPT, MMR, Hib, Hepatitis B, pneumococcus, N meningitidis, cholera, typhoid, TB, yellow fever, salmonella, VZV, rabies, plagueADT: given if >8yrs old; boosted every 10 yearsBCG: live attentuated (don’t give if immunocompromised); 90% effective; no longer standard, given to indigenous people, health care workers with contact with TB patients, neonates with recent travel to endemic countries, <16 exposed to active TB; do Mantoux / tuberculin test before vaccination (contra- indicated if previously strong +ive, previous TB, recent live vaccine; measure at 72hrs; negative if <5mm)DTP: efficacy 85%; 50% soreness and swelling at injection site, 30% low grade feverHib: 90-100% effective; HIB and Hepatitis B combined; mild swelling and redness in 5%Hepatitis B: given to all babies at birth; 3 doses in 1st year; 90-97% effective; side effects mostly minorHepatitis A: 100% efficacy in 1 year; given to travellers, childcare personnel, intellectually impaired, health care providers, homosexuals, IVDU, chronic liver disease, haemophiliacsHPV: females 10-45yrs oldFlu: inactivated virion; >65yrs, indigenous people etc…, chronic co-morbidities, health care providers; ? mortality and morbidity by >50%; herd immunity of 50% prevents pandemicsMMR: >95% effective; attentuated live; at 1yr, 4yrs; may get parotitis 3/52 laterMeningococcal: C >B in Australia (usually other way round in developed countries)Pneumococcal: do if traumatic splenectomy, sickle cell diseaseVZV: attentuated livePolio: attentuated live23260053211830Hepatitis BHepatitis B, DTP, Hib, polio, pneumococcal, rotavirusHepatitis B, DTP, Hib, polio, pneumococcal, rotavirusHepatitis B, DTP, Hib, polio, pneumococcal, rotavirusHepatitis B, Hib, MMR, meningococcal CHepatitis A, pneumococcal for AboriginalsVZVHepatitis A, pneumococcalDTP, MMR, polioHepatitis B, VZVHPVDTPFlu, pneumococcalPneumococcal for Aboriginals Q5yrPneumococcal Q5yrs, influenza Q1yr00Hepatitis BHepatitis B, DTP, Hib, polio, pneumococcal, rotavirusHepatitis B, DTP, Hib, polio, pneumococcal, rotavirusHepatitis B, DTP, Hib, polio, pneumococcal, rotavirusHepatitis B, Hib, MMR, meningococcal CHepatitis A, pneumococcal for AboriginalsVZVHepatitis A, pneumococcalDTP, MMR, polioHepatitis B, VZVHPVDTPFlu, pneumococcalPneumococcal for Aboriginals Q5yrPneumococcal Q5yrs, influenza Q1yr23260052883535Australia00Australia50539653211830Hepatitis B, DTP, Hib, pneumococcal, IPVHepatitis B, DTP, Hib, pneumococcal, IPVHepatitis B, DTP, Hib, pneumococcal, IPVHib, MMR, pneumococcalDTP, MMR, IPVDTPHPVDiptheria, tetanusDiptheria, tetanus, influenza00Hepatitis B, DTP, Hib, pneumococcal, IPVHepatitis B, DTP, Hib, pneumococcal, IPVHepatitis B, DTP, Hib, pneumococcal, IPVHib, MMR, pneumococcalDTP, MMR, IPVDTPHPVDiptheria, tetanusDiptheria, tetanus, influenza15519403211830Birth6/522/123/124/125/126/121 year15/1218/122 years4 year11 years12 years16 years45 years>50 years>65 years00Birth6/522/123/124/125/126/121 year15/1218/122 years4 year11 years12 years16 years45 years>50 years>65 years50546002883535New Zealand00New Zealand2463801273175MRSA00MRSA15525751272540Pathogenesis: modified cell wall protein beta-lactams can’t bind; CA-MRSA has not had contact with health care system in 1 year and not in long term care facility (often skin and soft tissue, may cause more serious illness eg. Necrotising fasciitis, septic arthritis, otitis media); PVL (produces exotoxin lethal to leucocytess; aggressive but sensitive to moreManagement: if staph aureus, treat with flucloxicillin / cephalexin unless documented CA-MRSA in family; consider IV vancomycin if critically ill If HA-MRSA: sensitive to vancomycin If CA-MRSA: sensitive to narrow spectrum antibiotics (eg. Clindamycin, co-trimoxazole, tetracyclines, doxycycline, bactrim)00Pathogenesis: modified cell wall protein beta-lactams can’t bind; CA-MRSA has not had contact with health care system in 1 year and not in long term care facility (often skin and soft tissue, may cause more serious illness eg. Necrotising fasciitis, septic arthritis, otitis media); PVL (produces exotoxin lethal to leucocytess; aggressive but sensitive to moreManagement: if staph aureus, treat with flucloxicillin / cephalexin unless documented CA-MRSA in family; consider IV vancomycin if critically ill If HA-MRSA: sensitive to vancomycin If CA-MRSA: sensitive to narrow spectrum antibiotics (eg. Clindamycin, co-trimoxazole, tetracyclines, doxycycline, bactrim)246380413385Infection Control(cntd)00Infection Control(cntd)1552575393065Droplet spread: N meningitidis, H influenzae, influenza, diptheria, pertussis; can travel <1m universal precautions + isolation nursing; mask if moving patient or within 1m of other patientsEnteric precautions: prevent transmission of diseases with fecal materials (eg. Hepatitis A, gastroenteritis, enteric virus infection, parasitic enteric infection) single room, toilet, gowns, gloves00Droplet spread: N meningitidis, H influenzae, influenza, diptheria, pertussis; can travel <1m universal precautions + isolation nursing; mask if moving patient or within 1m of other patientsEnteric precautions: prevent transmission of diseases with fecal materials (eg. Hepatitis A, gastroenteritis, enteric virus infection, parasitic enteric infection) single room, toilet, gowns, gloves246380441325Notifiable Diseases00Notifiable Diseases1552575440691AIDS, anthrax, arbovirusBotulism, brucellosisCampylobacter, chlamydia (3rd most common reportable disease in Aussie), cholera, CJD, cryptosporidiosisDiptheriaGonorrhoeaHUS, invasive Hib, hepatitis A-E, HIVFluLegionellaLeprosy, leptospirosis, listeriaMalaria, measles, meningococcus, mumpsPertussis, plague, invasive pneumococcal, polioQ feverRabies, rubellaSalmonella, SARS, shiga E coli, smallpox, syphilisTetanus, TB, typhoidVZV, viral haemorrhagic feversYellow fever00AIDS, anthrax, arbovirusBotulism, brucellosisCampylobacter, chlamydia (3rd most common reportable disease in Aussie), cholera, CJD, cryptosporidiosisDiptheriaGonorrhoeaHUS, invasive Hib, hepatitis A-E, HIVFluLegionellaLeprosy, leptospirosis, listeriaMalaria, measles, meningococcus, mumpsPertussis, plague, invasive pneumococcal, polioQ feverRabies, rubellaSalmonella, SARS, shiga E coli, smallpox, syphilisTetanus, TB, typhoidVZV, viral haemorrhagic feversYellow fever ................
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