MDR Case Study Legal Action To Ensure Treatment of Tuberculosis - - PowerPoint PPT Presentation

MDR Case Study

Legal Action To Ensure Treatment of Tuberculosis

Yuma

Yuma

Yuma Territorial Prison State Historic Park

Yuma

Yuma

Yuma

Case History

• 69 year old Native

American male.

• Worked as a custodian
• Hx of DM Type 2
• HTN
• Abnormal Heart

Cath(showing multi vessel disease, in need

• f CABG)

Case History

• Patient underwent preoperative testing.
• 2 days prior to surgery all testing was

completed and showed the following:

• CXR showed Bilateral upper and lower lobe

atelectasis.

• Upon abnormal results patient was sent for CT
• f Chest.

Case History

• CT of Chest revealed thick cavitary lesion in

the left upper lobe measuring 5 cm, and a second thick cavitary lesion in the left lower lobe measuring 2 cm, 5 cm cavitary lesion in right hilar region with two other cavities in the right upper lobe measuring 1 cm.

Case History

• Cardiac surgery was delayed in the process to

verify lung cavitations etiology.

• Patient was admitted to local hospital by

Cardiac surgeon for further testing.

• Pulmonary consult was done.
• With no hx of recent TB exposure or cough, a

differential dx of Cancer was raised.

Case History

• Once evaluated by Pulmonologist, patient

reported symptoms of:

• Night sweats
• Fevers
• Weight loss of 40 lbs in the last 6 months

Case History

• Patient was moved to negative pressure room.
• PPD was placed.
• Bronchoscopy with transbronchial biopsy was

scheduled.

Case History

• Results:
• PPD 26 mm of induration
• Pathology report findings: No malignancy cells

identified.

• AFB smear : (1+)
• PCR: MTB complex with Rifampin resistance

Phenotype detected

Management

• Patient was started on TB medications:

Isoniazid, PZA, and Ethambutol.

• Health Department was notified.
• Health Department collaborated with ADHS.
• Specimen was sent for molecular testing and

secondary drug susceptibilities.

• Heartland consult was done.

Management

• Contact investigation was

started and 13 contacts identified.

• All household contacts

negative (6)

• 2 contacts outside home

had positive PPD’s and preventive tx was started.

• Multiple people at pt’s

work tested by employer with no new positive readings.

Management

• Patient was discharged home after two 2wks
• f treatment.
• Rifampin was added to regimen.
• Recommendations from Heartland received

for new regimen that included IV infusions.

Management

• Challenges:
• No Home Health Agency available to

administer IV infusions

• Difficulty obtaining second line drugs
• No other facilities available
• Collaborated with IHS for possible placement

in IHS facility

Management

• While working through challenges, all TB

medications were discontinued.

• Only option left was local hospital.
• 1 ½ month after TB dx patient was admitted to

local hospital and started on Amikacin IV, Linezolid, Moxifloxacin, Ethionamide, and Ethambutol.

Management

• Patient remained compliant throughout TB

treatment.

• 3 months into TB treatment patient suffered

heart attack while hospitalized.

• Arrangements for CABG to be done while

hospitalized were attempted but unsuccessful.

• 3 consecutive Neg cx, DC, & readmission

Case History

• 26 year old Native

American female Hx of DM, insulin dependent, IV drug use and multiple hospitalizations for DKA

• Presents to Emergency

Department with acute chest pain, cough, and generalized weakness for the past 3 days.

• Lab work was done, CXR,

a complete physical examination.

Case History

• Results showed: DKA, Sepsis, Bilateral

Pneumonia, Hypokalemia and Dehydration

• Patient was admitted to ICU.
• Further testing was done.

Case History

• Patient had CT of Chest : showed prominent

bilateral infiltrates and ill-defined nodular densities with a large thick walled irregular caveating area in the left upper lobe with possible bronchiectasis and a much smaller area of cavitation in the right lower lobe.

• After CT findings patient was scheduled for

Bronchoscopy.

Case History

• Patient underwent bronchoscopy and findings

were as followed:

• Pathology report: No atypical or malignant

cells were identified.

• AFB smear : RARE
• PCR: MTB complex with Rifampin Resistance

Phenotype detected.

Management

• Patient was moved to negative pressure room

and patient was identified as a recent contact to family member with MDR Tuberculosis.

• Health Department was notified.
• Infectious Disease Doctor consulted with

YPHSD and patient was immediately started

• n the 5 drug regimen previous MDR case was

taking: Amikacin IV, Linezolid, Ethambutol, PZA, and Moxifloxacin.

Management

• YCPHSD notified ADHS of secondary MDR case

and a consult to Heartland was initiated and BAL sample from hospital was sent to CDC for Molecular Testing and Secondary Drug Susceptibilities.

• Drug resistance was confirmed and second

contact investigation was done.

Management

• 53 Contacts were identified which included

household members, health care workers and extended family.

• 36 Contacts were evaluated:
• 11 family members positive, 18 were lost to

service and 27 were negative which were mostly healthcare workers.

Management

• ADHS then contacted

the CDC team to assist with contact investigation.

• CDC was able to

investigate possible

• rigin of transmission.

Management

• The team of physicians from the CDC worked

with the community, local hospital and local health department and found previous MDR case had similar genotype from a group of MDR cases found in Mexico in the 70’s and confirmation was made that the patient acquired disease from the primary MDR case.

Management

• MDR case was hospitalized from 4/2/16-7/12/16.

Once patient had 3 consecutive negative sputum cultures she was discharged and outpatient treatment was arranged.

• Patient started outpatient treatment of daily oral

medications and IV infusions three times per week.

• Patient missed her first outpatient dose on

8/1/16

• Order to Cooperate was issued by 8/5/16

Management

• A total of 26 doses were missed in a 2 month

period.

• Patient’s weight dropped from 117lbs to 95lbs

during the period she missed her treatment.

• Patient’s Diabetes was uncontrolled again and

started running blood sugars in the high 400’s to 500’s, with K+ levels of 2.1

• Patient tested positive for Methamphetamine use

and plan for an Emergency Custody Order began.

• Collaboration with ADHS, CDC, local hospital,

County Attorney and Sheriff’s Office continued.

Management

• By 9/30/16 patient was re-

evaluated and placed back into care and Emergency Custody Order was in place.

• Patient was taken to Yuma

County Detention Center and plan is for patient to complete TB treatment.

Outcomes

• Patient has not missed

any more doses and was able to complete IV infusions successfully.

• Patient has gained 52lbs
• Diabetes is well

managed.

• No MDR transmission

to the public.

Outcomes

• All positive contacts

were started on preventive treatment and have successfully completed.

• Contacts tolerated

treatment with no problems.

Outcomes

• Ongoing collaboration

between ADHS, CDC, local hospital, County Attorney, Sheriff Office, and Yuma County TB program enabled us to prevent the transmission of disease, improve the patient’s health, and kept our community healthy and safe.

Questions?