This is a recording of the recent lecture that I gave on West Nile virus in July of 2012.
This is a 48 minute recording of the Lyme disease presentation that was given on July 20th 2012.
This lecture focuses on the life cycle of the vector, the transmission and disease course. I also go in to the treatments and prevention of disease.
It may take minute or so to load, please be patient.
I have had a lot of questions about blood cultures. How many set? How many minutes apart? And so on. I put together this post to settle some of the questions.
This past week we reviewed some hospital data and found ongoing confusion with regards to classifying surgical wounds. I put together a quick cheat sheet to help with wound classification.
Under classifying the wound will produce a lower severity of illness making the provider and the institution appear worse for the same outcomes
Remember as more data is being collected for hospital report cards it is imperative to have accurate wound classification. The knee jerk reaction of many providers is to under classify the surgical wound. Outcomes are being compared to these data points. Under classifying the wound will produce a lower severity of illness making the provider and the institution appear worse for the same outcomes.
So lets all get the credit we deserve by making sure we classify wounds correctly.
Classification of surgical wounds
A lot of confusion about who gets vaccinated with the 23-valent pneumococcal vaccine. I put together this article to help clarify some of the common questions.
Invasive pneumococcal disease is the most common vaccine preventable disease worldwide
- There is no contraindication to give pneumovax at hospital admission.
- Invasive pneumococcal disease is the most common vaccine preventable disease worldwide. 40,000 deaths are attributable to invasive pneumococcal disease in the US annually.
- Current 23-valent polysaccharide vaccine covers 95% of the most common causes of invasive pneumococcal disease.
- Vaccination reduces rates of death from invasive pneumococcal disease. At least half of these deaths are preventable with vaccination.
- Pneumovax reduces duration of hospitalization for CAP. (see reference)
- Pneumovax reduces rates of death from myocardial infarction and strokes as shown in a recent prospective trial (see reference)
- The goal of pneumovax is to reduce death from invasive pneumococcal disease NOT to reduce the number of pneumonia cases.
- The current national average for patients 65 years of age and over is 65% coverage. This is too low.
- To address the issue of why only one dose after the age of 65 please see the attached algorithm that I put together. I hope that it better explains who needs to be vaccinated and how often. The recommendations are that EVERYONE get one dose of pneumovax after the age of 65. Anyone with additional risk factors will get the greater interval of vaccination per the higher risk group.
Chart showing who gets 23-valent pneumovax
- Fisman, David N, Elias Abrutyn, Kimberly A Spaude, Alex Kim, Cheryl Kirchner, and Jennifer Daley. 2006. Prior pneumococcal vaccination is associated with reduced death, complications, and length of stay among hospitalized adults with community-acquired pneumonia. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America 42, no. 8 (April): 1093-101. doi:10.1086/501354. http://www.ncbi.nlm.nih.gov/pubmed/16575726.
- Hung, Ivan F N, Angela Y M Leung, Daniel W S Chu, Doris Leung, Terence Cheung, Chi-Kuen Chan, Cindy L K Lam, et al. 2010. Prevention of acute myocardial infarction and stroke among elderly persons by dual pneumococcal and influenza vaccination: a prospective cohort study. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 51, no. 9 (November): 1007-16. doi:10.1086/656587. http://www.ncbi.nlm.nih.gov/pubmed/20887208.
- Dominguez, Angela, Lluis Salleras, David S Fedson, Conchita Izquierdo, Laura Ruiz, Pilar Ciruela, Asuncion Fenoll, and Julio Casal. 2005. Effectiveness of pneumococcal vaccination for elderly people in Catalonia, Spain: a case-control study. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 40, no. 9 (May): 1250-7. doi:10.1086/429236. http://www.ncbi.nlm.nih.gov/pubmed/15825026.
- Vila-Córcoles, Angel, Olga Ochoa-Gondar, Imma Hospital, Xabier Ansa, Angels Vilanova, Teresa Rodríguez, and Carl Llor. 2006. Protective effects of the 23-valent pneumococcal polysaccharide vaccine in the elderly population: the EVAN-65 study. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 43, no. 7 (October): 860-8. doi:10.1086/507340. http://www.ncbi.nlm.nih.gov/pubmed/16941367.
- Johnstone, Jennie, Thomas J Marrie, Dean T Eurich, and Sumit R Majumdar. 2007. Effect of pneumococcal vaccination in hospitalized… [Arch Intern Med. 2007] – PubMed result. Archives of internal medicine 167, no. 18 (October): 1938-43. doi:10.1001/archinte.167.18.1938. http://www.ncbi.nlm.nih.gov/pubmed/17923592.
- Jackson, Lisa a, and Edward N Janoff. 2008. Pneumococcal vaccination of elderly adults: new paradigms for protection. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 47, no. 10 (November): 1328-38. doi:10.1086/592691. http://www.ncbi.nlm.nih.gov/pubmed/18844484.
Drug Safety and Availability > FDA Drug Safety Communication: Increased risk of death with Tygacil (tigecycline) compared to other antibiotics used to treat similar infections.
A must read notice published by the FDA. It appears that there is a trend towards statistical inferiority of tigecycline when compared to standard therapy with regards to ventilator associated pneumonia. It is also notable that it did not show better outcomes in any category when compared to standard therapy.
This by no means indicates that tigecycline is an inferior drug but merely that it is about as good as other standard therapy on the market. Yes; it is a broader coverage drug similar to imipenem. But contrary to popular belief among my fellow colleagues, broader coverage drug not always equate with better drug or even a better outcome.
Keeping the coverage appropriate to the condition being treated using a drug that achieves appropriate serum levels at the site of the infection under the conditions currently present (pH, low O2 concentrations, neutropenia) will achieve optimal results.
Spring break is here many Americans will go on vacation and some will take a cruise.
Cruises have become increasingly popular over the years as a form of vacation. Cruise lines have responded to the increased demand by adding larger ships to meet the demand. On the darker side cruise ships have been plagues by risk of infection outbreaks due to the over crowding aboard ships. The cruise lines have appropriately responded to this fear of outbreaks by instituting appropriate precautions without interfering with the vacation mood. In fact we just got back from our own spring break cruise in the Caribbean sea on Royal Caribbean’s Oasis of the Seas, their newest and currently largest cruise ship. I noticed several precautions since the last time we took a cruise several years ago. (BTW:The cruise was fabulous. I highly recommend it!)
From an infectious disease perspective I not only have to congratulate the cruise line on a phenomenal job with the accommodations and entertainment but also the attention to infection control issues.
Most dreaded infection issues are the ones transmitted by either droplet leading to respiratory infections or by contact leading to diarrheal illnesses like norovirus outbreaks that often get media attention that the cruise lines dread.
With regard to respiratory infections the few obvious changes in newer ships is the larger airspaces in common areas. The dining halls, the theaters and the promenade all had higher ceilings than on older cruise ships allowing for greater air exchanges. There was information posted daily about respiratory infections, H1N1 precautions etc.
Diarrheal outbreaks can quickly turn a vacation cruise into a nightmare adventure at sea, especially with the greater number of older persons on cruise ships who may be very susceptible to become very ill. If an effort to control this the cruise ships installed waterless hand sanitizer at the entry points to the ship and to the dining halls. They had staff reminding guests to use them. I was pleasantly surprised to see (non scientific observation) that the compliance rate among passengers was very high. I did not see the opposition from anyone that usually accompanies this kind of added inconvenience. Children, adults all seemed to participate and understand why this is needed. Of course the usual buffet controls were also in place such as sneeze guards, single use of plates and flatware etc.
It is very easy for corporations to go overboard (pun intended) with precautions in a knee jerk effort to control outbreaks at sea. These kind of measures prove to be counter productive in the long run. They create more inconvenience, greater cost, greater customer dissatisfaction without much hard science that they are getting anything for it. I did not see any of these problems on this particular cruise. Whoever is advising them is doing a good job.
All these precautions go a long way in making a successful vacation.
Hats off to Royal Caribbean cruise lines for the effort. We do appreciate it.
The topic of varicella zoster vaccination has come up several times this week. Probably time for a summary.
Varicella zoster, commonly called shingles is caused by the reactivation (reawakening) of chickenpox virus also called varicella zoster virus (VZV) in the distribution of a nerve root that results in a localized single-sided rash that later blisters (vesicles). The rash itself is not the problem, the pain that occurs due to nerve damage called post herpetic neuralgia can be. Post herpetic neuralgia can be very difficult to manage. This can therefore be very debilitating in the sufferer. The idea of vaccination with the shingles vaccine is to prevent or at least minimize the pain and suffering that goes along with shingles.
One does not acquire shingles from another patient with shingles. As mentioned above. Shingles is the reawakening of the chickenpox that occurred many years ago. In other words the bugs causing shingles are your own. One cannot get shingles from shingles either. But one can get chickenpox from a case of shingles.
Prior to the introduction of chickenpox vaccination, 95.5% of people 20-29 yrs of age and more than 99.6% of people 40 years of age or greater have evidence of previous chickenpox (VZV) infection. All of these persons are at risk of later developing shingles. Once one has recovered from chickenpox the virus does not leave the body. It can remain contained in parts of the nervous tissue called doral nerve root ganglia. As long as our immune system is healthy, the virus remains dormant and contained. However, if our immune system is no longer capable of watching over these prisoners, they can reawaken and lead to shingles. And through that considerable pain and suffering. Shingles develops in about 30% of people over their lifetime. The likelihood of shingles rises with every decade of life over 50. By the time we are in our 80s one in two persons may suffer from shingles. This correlates with the gradual decline in antibodies to varicella. Therefore adequate boosting of anti-varicella antibodies should help reduce the incidence of varicella reactivation.
The varicella vaccine for chickenpox is very effective in preventing primary or initial infection with varicella in children and has become part of the standard vaccination schedule. It is a live attenuated (weakened) vaccine. However when this same vaccine was used in older adults it was found to not stimulate the immune response enough to prevent shingles. Hence the zoster preparation of the vaccine though containing the same weakened live varicella virus is in 14x greater quantity that was found necessary to bring antibody response to protective levels.
Trials from zoster vaccination appear to result in a 51% reduction in the incidence of zoster with a 67% reduction in the incidence of post-herpetic neuralgia (the pain). Those that did have pain despite being vaccinated wen compared to non vaccinated did so for 21 days on average compared to 24 days respectively. The severity of pain was also less in the vaccinated group.
The vaccine is currently indicated in adults aged 60 or over and are not receiving any immunosuppressive therapy such as steroids, chemotherapy. This is a currently recommended as a one time vaccination. This is not to be used to treat active shingles or the pain from recent shingles. Some experts do recommend vaccinating persons with zoster vaccine 12 months after recovering from an episode of zoster.
Most common side effects include pain at the site of injection and occasionally vesicles can develop. No cases of transmission of live virus to other individuals has been seen.
Centers for disease control and prevention (CDC) updated their H1N1 infection control measures for healthcare workers. This does differ though just slightly from the position of The Society for Healthcare Epidemiology of America (SHEA) in that CDC does recommend continuing use of N95 particulate masks when caring for patients with H1N1. Whereas SHEA supports the more traditional use of surgical masks as has been for seasonal influenza.
A study from Ontario, Canada published in the Oct 1, 2009 edition of Journal of American Medical Association (JAMA) did show equivalence of N95 with surgical masks. link
This does put hospitals in a bit of a difficult position. I do agree that considering the volume of patients with suspected H1N1 that are coming into the hospitals that it would not be practical to use our N95 for all patients, we would simply run out.