Types of infections–bacterial, fungal, viral, site specific and mechanisms of resistance

 Laurl at ONS 

Welcome to the ONS Hot Topic Chats! Today’s expert is Brenda Shelton, who will be talking with us about Types of Infections . Welcome Brenda!

 sheltbr 

Welcome everyone! I am happy to be here to chat about a topic so common in our practice. What questions do you have?

 sheltbr 

What settings do some of work in? Ambulatory? Inpatient?

 akite428 

I work inpatient oncology in CT.

 sheltbr 

My practice goes over inpt and outpt units. Let's start with how everyone is handling H1N1?

 steph199 

Inpatient med/oncology

 akite428 

How any of you expirienced al ot of aspergillus in the lungs of your AML pts?

 akite428 

No H1N1 cases at my hospital.

 sheltbr 

Aspergillus is especially common I think if there is nearby construction and with some certain highly suppressive regimens, such as those with fludarabine. Agree?

 akite428 

We actually had closed off one of our rooms because so many of our AML pts were suffering from it.

 sheltbr 

About H1N1- we discontinued flu precautions, then when H1N1 cases went up, we reinstituted patient screening, droplet precautions until culture negative and masks with immunocompromised pts.

 akite428 

The room was cleared, but still odd. We had about 4 cases at the same time.

 sheltbr 

About aspergillus- we routinely room culture, air culture etc. and found aspergillus coming through stairwells that exited to outside- they are now closed and cases down. Pts also wearing N95 masks to/ from hospital.

 kkaiser 

We would like to know about BSI monitoring. (blood stream infection).

 kkaiser 

Regarding BSI monitoring, what types of BSI data do you get from your infection Control Department?

 sheltbr 

RE: BSI: We have a highly defined process of monitoring BSI that is unique to oncology with all the variables such as type of line, pt access at home, etc.

 kkaiser 

Who keeps track of the lines? BSI= Blood stream infection

 sheltbr 

More about BSI.... Our BSI criteria and data to collect were determined  by collaboration with our nurses. BSI = blood stream infections. Complex in oncology due to central lines as outpatients.

 sheltbr 

Mikaela is the expert on this and we will address on Monday.

 Laurl at ONS 

Actually, folks, we are going to talk ALL about lines and BSI, etc with Mikaela Olsen on on Monday (Jun 29), and should be able to give lots of very detailed information about this then. Today we hope to focus on types of infections.

 kkaiser 

Ok, we will sign in on Monday

 Laurl at ONS 

Please don't hesitate to continue today with types of infections questions!

 sheltbr 

Back to aspergillus- were your concerns addressed?

 rarmbrust 

What are the most common types of infections being seen in the last 30 days?

 akite428 

Well I am curious if other institutions struggle with it

 sheltbr 

Please explain last 30 days.

 steph199 

MRSA

 akite428 

Aspergillus: it is extremely hard to get rid of in our immunocompromised patients.

 sheltbr 

In my practice here we have seen plenty of MRSA, VRE, but also a complex pseudomonas refractory to typical antibiotics and recurrent fungal infection.

 rarmbrust 

30 days in the past month i.e. Month of May what were the most common infections being seen and needing to be treated? Were  they related to the oncology treatment plan?

 sheltbr 

Just this week a nurse noted recurrent sputum changes and we discovered the pseudomonas had become resistant to meropenem.

 sheltbr 

We have had a large group of new leukemia pts and so several fungal infections. We also have a few cord blood transplant patients, so some unusual polymicrobials.

 akite428 

Wow, the pseudomonas is also common for us.

 amkeenan 

What is your experience with using posaconazole when patients are not eating?

 rarmbrust 

What guidelines are followed when new clusters of infections are found?

 kkaiser 

We are seeing very resistant psuedomonas in MD (Maryland).

 akite428 

Very hard to fight-multiple bags of antifungal (drugs) plus blood products makes for a crazy night.

 sheltbr 

Most of our infections are a combination of disease risk profile and treatment plan. A few are community- we have certainly seen RSV and Influenza late this spring.

 sheltbr 

Re Posaconazole. It is challenging to give if patients are unable to tolerate a high fat diet.

 sheltbr 

More on posaconazole. We have been conscientious on monitoring intake and will change to other antifungals if necessary.

 akite428 

Anyone still using amphotericin? We seems to be on a run of it with all the aspergillus.

 amkeenan 

Re; Posaconazole: That’s true, but is there any absorption of the drug? Is it worth administering?

 juniemoon_48@yahoo.com 

Posaconazole: We use it once in a while, but not very often; often we find it last choice.

 rarmbrust 

What precautions are being followed with the N1H1?

 sheltbr 

Re: clusters: We have a specialty transplant/ immunocompromised ID ( Infectious Disease) service that helps monitor clusters and we discuss at a open meeting to determine if these are community-patient based or transmitted iatrogenically. Great discussions and consensus decisions. That was how we altered H1N1 guidelines.

 amkeenan 

Very infrequent use of amphotericin-AmBisome® is our choice.

 sheltbr 

Posaconazole- a good drug- but requires careful monitoring. I think I should ask Amy who will be on tomorrow's chat if there are times when it is not worth the trouble.

 amkeenan 

I will ask the question tomorrow-thanks.

 olsenmi 

This is Mikaela...For H1N1 our institutions is screening all patients upon admission (inpt and outpt), as well as visitors. If they have a fever > or equal to 100 + a cough or sore throat then they get a nasopharygeal wash and...

 Laurl at ONS 

Just FYI to the group - Both Mikaela Olsen and Brenda Shelton are here, so Mikaela may be answering some questions as well!

 sheltbr 

Amphotericin still has a place. I have to look it up, but there are certain subtypes of candida I think and refractory fungal infection where we still use it- maybe mucor.

 sheltbr 

Wait- I interpreted the amphotericin question perhaps wrong- we use the liposomal form, not standard amphotericin.

 olsenmi 

For inpts we place them on droplet precautions for a minimum of 7 days or until discharge. Our infection control department has seen quite a few early antigens come back negative but the cultures have ended up being positive so we keep them on precautions until the specimen is finalized.

 sheltbr 

Has anyone seen much RSV or influenza this past winter? How do you screen and monitor?

 olsenmi 

For any aerosolizing procedure we have our staff wear N-95 masks or paprs (Powered Air Purifying Respirators) (e.g. aspirate, wash, nebulizers, suctions etc.)

 rarmbrust 

How often does your the ID committee meet to discuss the N1H1? And have guidelines needed to be altered much?

 becky04 

Are there standards as to when antibiotics should be changed? (i.e. persistent fever).

 olsenmi 

Our infection control department has reported an increase in H1N1 in the past month so we are on full Flu precautions here. No children visiting under age 12 in the cancer center and all staff are wearing masks in patient rooms.

 akite428 

Where is that?

 sheltbr 

Regarding H1N1 monitoring- our ID department discusses this daily and evaluates the effectiveness of strategies. (We are in Maryland).

 olsenmi 

Guidelines have gotten more strict because of the increase in cases recently

 sheltbr 

Changing standards: Antibiotic changes are well defined in the NCCN guidelines. If the patient is stable and no culture positive results occur- 72 hrs is recommended before changing antibiotics. If the patient becomes very sick- shock-like, add the kitchen sink.

 rarmbrust 

RE: N1H1 How long does it take to get culture results and are employees sent home once suspected?

 olsenmi 

Yes, they (employees)  are cultured in occupational health, sent home if suspected and we await the results. All staff have to come back through occupational health prior to coming back to their units.

 rarmbrust 

Where can the NCCN guidelines be found?

 sheltbr 

The National Comprehensive Cancer Network guidelines are at www.nccn.org

 rarmbrust 

What is the first line treatment for H1N1?

 olsenmi 

NCCN: The guideline is called "Prevention and Treatment of Cancer Related Infections"

 sheltbr 

The NCCN guideline is endorsed by several other key agencies and replaces the old BMT ( bone marrow transplant) infection prevention document from 2001 and covers more info about prevention of infection, fever and then specific infections.

 sheltbr 

Mikaela is answering treatment  question re:  H1N1 – please wait…

 sheltbr 

Have any of you used more than one antifungal at a time? I think this practice has been controversial.

 olsenmi 

Treatment for H1N1: We are seeing the novel influenza A H1N1 and this is most sensitive to Oseltamivir® (tablet) and Zanmivir® (inhaled). We treat all inpts for 5 days and outpts who are in the first 48 hours of their onset of symptoms and who are considered high risk get treated with the same drugs/course.

 amkeenan 

Sorry I have to go to another meeting; I'll read the transcript.

 sheltbr 

Combination treatment: In refractory fungal infection, there has been some evidence that combination agents (e.g. caspofungin and voriconazole) can be synergistic.

 olsenmi 

RE: Treatment: We consider high risk to include immunocompromised patients, those <6 months to 18 months, pulmonary or cardiac disease, those in nursing homes, pregnant women, and those with diabetes.

 Laurl at ONS 

Mikaela and Brenda, what are the organisms that you are normally seeing w./ pneumonia?

 rarmbrust 

Sorry I have to go to another meeting- Thanks for the info today.

 sheltbr 

Pneumonias are often disease or risk-specific. For instance, we know that patients post-transplant, on steroids, or with low lymphocytes can get pneumocystis.

 Laurl at ONS 

Glad you could make it! Please come to  the other chats!

 sheltbr 

Pneumonia can often involve oral organisms- both aerobic and anaerobic, so heavier broader antibiotics are needed.

 sheltbr 

Does anyone have some tips about symptoms of different infecting organisms in pneumonia?

 kkaiser 

Has anyone seen acinetobacter in their patients? Do you do anything other than conventional contact precautions?

 sheltbr 

Sputum colors- staph is purulent, strep is white, pseudomas green, pleural rub with aspergillus, any other tips?

 sheltbr 

Acinetobacter used to be strict isolation, and now less worry about resistance, so we use contact isolation.

 kkaiser 

Why less worry? We see pan-resistant sometimes.

 olsenmi 

We have cases of acinetobacter now but not resistant acinetobacter.

 sheltbr 

In pan-resistant acinetobacter, especially around immunocompromised pts, we will institute strict isolation. We have not seen many cases so are relaxed, but maybe you should have higher concerns.

 sheltbr 

Amy Seung just came in and is helping Mikaela answer the posaconazole question earlier.

 kkaiser 

We use some additional rules: care when pairing, because we have seen an upsurge with transmission. We don't have a "strict" category. Please define "Strict".

 olsenmi 

Regarding posaconazole...per Amy Seung..posaconazole is used in our area as maintenance and it is well tolerated; however, in our BMT and leukemic patients receiiving active therapy it has not been tolerated due to nausea, vomiting, inability to eat, and mucositis. We may start it upon discharge when they are doing better or in the outpt setting.

 olsenmi 

“Strict” was one to one nursing care and full isolation (e.g. mask, gown, gloves, etc.) We have private rooms for all of our oncology patients. We still do this strict isolation for multidrug resistant cases.

 kkaiser 

Thx, that helps.

 sheltbr 

Last few minutes here- do any of you have more questions, concerns?

 sheltbr 

How have some of you in ambulatory care managed to track and institute isolation pts?

 Laurl at ONS 

It’s about five minutes before the end of our chat- please don’t stop asking questions! However, when you can, please take a moment after the chat to cut and paste this URL into a browser window and take our very brief survey –we’d love to hear what you think of these chats! The URL is http://research.zarca.com/k/RsTUTRsTQPsXYUSUsPsP

 olsenmi 

What type of isolation precautions do you use for VRE?

 sheltbr 

We are constantly challenged with isolation and protecting other patients in ambulatory care given the open-ness and volume. Do any of you have dedicated space for this?

 kkaiser 

No but we are considering this.

 sheltbr 

kkaiser- are use answering Mikaela or me?

 kkaiser 

kaiser is answering sheltbr and ambulatory issues.

 kkaiser 

The RNs clean surfaces in patient rooms when they leave ambulatory between pts

 sheltbr 

We don't have dedicated space either, but feel an obligation to try to protect ambulatory pts the same as inpts. We try to have identified before coming and educate pts and families to let us know with initial encounter, then their interventions are performed in one place rather than moving from one station to another (e.g. phlebotomy).

 kkaiser 

We are taking acinobacter patients directly to a private exam room.

 Laurl at ONS 

Thanks so much everyone - unfortunately we are out of time.

 sheltbr 

Thanks to everyone for a great chat. Hope some of you can join us on the others.

 kkaiser 

Thanks!

 Laurl at ONS 

Many thanks for your great participation! Our next chat is tomorrow at 5:00 PM Eastern - focusing on antibiotic selection and special precautions.

 Laurl at ONS 

Please join us then. Thank you Brenda, Mikaela and Amy!