The high 5 Disclosures I have nothing to disclose 1 2/6/2020 5. - - PDF document

2/6/2020 1

Infection Control Questions: Inpatient and Outpatient

The high 5 Disclosures I have nothing to disclose

2/6/2020 2

• 5. When can my hospitalized patient

with C. difficile come off contact precautions? What are the recommended precautions after discharge home?

• C. difficile
• Continue contact precautions for the “duration of illness”

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• C. difficile guidelines: infection

control recommendations

• C. difficile guidelines: infection

control recommendations

• Use contact precautions
• Implement contact precautions when C. difficile is

suspected, unless test result available same day

• Continue contact precautions for at least 48 hours

after diarrhea has resolved (weak recommendation, low quality of evidence)

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• C. difficile: discontinuation of isolation
• Heterogeneity (??? chaos)
• UCSF: resolution of diarrhea for > 48 hrs. and

patient moved to a clean room

• ZSFG: at least 5 days of treatment and resolution
• f diarrhea for > 48 hrs.
• SF VAMC: resolution of diarrhea for > 24 hrs.
• Many institutions: duration of hospitalization

Guidance for C. difficile at home

• All household members wash hands frequently

with soap and water

• Use a dedicated bathroom while symptomatic,

if feasible

• Consider cleaning bathroom with dilute bleach
• 1:10 solution (1 cup bleach, 9 cups water)

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• 4. My hospitalized patient was treated

for scabies in the ED yesterday. She is still scratching and says the itching is

• severe. Should we treat her again? When

can she come out of isolation? What should I tell her husband about getting treated?

Scabies

For infection control purposes, the most significant issue is to detect crusted scabies Scabies Crusted scabies

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Scabies

• Usual treatment is permethrin cream 5% - often given

as two applications one week apart

• Wash off after 8 – 14 hours
• In the hospital, contact precautions can be discontinued 24

hours after treatment is started

• Itching can persist up to 4 weeks
• Oral ivermectin can be used in cases of failure or

intolerance

• Two doses (200 mcg/kg/dose) one week apart

Scabies – at home

• Treatment recommended for household members,

especially if skin-to-skin contact

• Treat at same time as patient
• Mites survive only 2-3 days in environment
• Launder bedding and clothing from last 3 days or store

in a closed plastic bag for several days

• Normal cleaning and vacuuming is appropriate
• Clean thoroughly with crusted scabies
• No pesticide sprays or fogs

https://www.cdc.gov/parasites/scabies/prevent.html

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• 3. My clinic patient has bugs in his

hair and on his body. He does not want to shave his head. The clinic staff are wearing head-to-toe personal protective equipment (PPE). What should we tell the patient to do?

Head lice

• Lice crawl – they don’t jump or fly
• Spread by close person-to-person contact
• Head lice survive maximum 1-2 days off a

person

• Head lice are a nuisance but cause no illnesses
• Head shaving is effective but not necessary

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Head lice

• First line treatment usually 1% permethrin lotion (Nix) or a pyrethrin

+ piperonyl butoxide (e.g. Rid)

• Does not kill nits, reapply after 9 days
• Look for live, moving lice after treatment
• Not necessary to remove nits but can be done
• Other therapies include
• Malathion (Ovide) - partly ovicidal
• Spinosad (Natroba) – ovicidal
• Ivermectin, topical and oral
• In the hospital, contact precautions can be discontinued 24 hours

after effective therapy

Head lice – at home

• Check household members; consider treating

bedmates even if lice not seen

• Launder clothing and bedding that had contact

with head in 2 days prior to treatment (or seal in plastic bag)

• Soaks combs and brushes in hot water
• Judicious vacuuming can be done

https://www.cdc.gov/parasites/lice/head/health_professionals/index.html

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Body lice

• Access to shower and clean clothing only required therapy –

typically seen only in persons who are homeless or refugees

• Pediculicide often used (permethrin)
• CDC recommends standard precautions in the hospital
• Can transmit epidemic typhus (Rickettsia prowasekii), trench

fever (Bartonella quintana), epidemic relapsing fever (Borelia recurrentis); can cause iron-deficiency anemia

• 2. My hospitalized patient probably

has community-acquired pneumonia. But, TB is on the differential. What specimens do I need to collect to “rule out” TB? When can airborne respiratory precautions be discontinued?

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Traditional TB recommendations

• Discontinue airborne precautions when the

likelihood of infectious TB is negligible, and either

• Another diagnosis explains the clinical syndrome

Or

• 3 sputum smears are negative for AFB – collected

at least 8 hrs. apart and 1 in early morning

https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation‐guidelines‐H.pdf

Discontinuing TB airborne precautions in the hospital

• Acid fast bacilli (AFB) smear positive: minimum 14 days of

therapy and 3 follow up negative smears

• Not generally required to go home but needed if going to jail,

SNF, etc.

• AFB smear negative, suspicion high and started on therapy:

minimum 5 days of therapy

• AFB smear negative, not on therapy: discontinue isolation after

2-3 negative smears collected at least 8h apart

• GeneXpert very helpful in ruling out smear positive TB

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Suspected TB – in the community

• Contact local TB Control / Public Health

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• 1. My hospitalized patient has clinically

diagnosed shingles. It looks pretty bad. She has lesions in the left C4 and C5 dermatomes and maybe in C6. There are also a few spots on the right side of the body – not sure if those are from

• shingles. What should we do regarding

isolation?

Localized vs. disseminated zoster

• Localized zoster: commonly affects one or two

adjacent dermatomes

• Disseminated zoster: ? more than 20 lesions
• utside the affected dermatome and the

immediately adjacent dermatomes

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Zoster: isolation precautions

• Localized zoster in immunocompetent patient?

Standard

• Localized zoster in immunocompromised

patient?

Airborne and contact until dissemination ruled out

• Disseminated zoster or primary varicella?

Airborne and contact until lesions crusted

Localized zoster – at home

• Contacts with a history of chicken pox are at

minimal risk

• Cover lesions, avoid others having direct

contact with affected skin

• If lesions can be covered, okay to attend work

and school