Case discussion Michael Gardam University Health Network

Do you have any cases you would like to discuss?

Case 1 53 year old male presents with a 6 week history of cough, worsening malaise, weight loss, maybe low grade fever CXR shows a right upper lobe infiltrate

You are worried about TB What information would help you?

Things to think about Where is the patient from? Where have they travelled? Are they immunocompromised? History of contact with an active case? Occupation? Smoker? Homeless?

The medical team’s differential diagnosis is: Lung cancer Community acquired pneumonia Tuberculosis Blastomycosis They order appropriate tests including sputum cytology and sputum for AFB

What else? Airborne isolation? Wait for the sputum smear result and then put in airborne isolation if positive? Ask the team to plant a tuberculin skin test? Collect additional sputum samples?

Results Patient is placed in airborne isolation Sputum cytology pending AFB smear negative The team have started moxifloxacin to treat community acquired pneumonia The team wants to discontinue airborne isolation.

What do you think? Stop isolation? – If not, why not? Await cytology result first? Is Moxifloxacin a good choice in this setting? Ask for molecular testing on the sputum sample?

Update Patient still in airborne isolation Sputum cytology comes back negative Second AFB smear negative Some improvement after 5 days of moxifloxacin Team really wants to discontinue isolation.

What do you think? Discontinue airborne isolation now? – If not why not? – If not, when would you feel comfortable discontinuing? Can you review the case with someone?

Resolution Smear grows MTB after 17 days

Case 2 A patient on your complex continuing care ward develops two episodes of loose stool. Chronically receives laxatives Currently receiving Ancef for an infected heel ulcer

You are worried about C. difficile What information would help you?

Things to think about Any cases of C. difficile recently on that ward? Patient history of C. difficile? Other signs or symptoms beyond loose stool? – Abdominal pain – Fever – Increasing white count? Place in contact precautions now?

Update Stool sample using EIA is negative Patient has another bought of loose stool Patient has no other symptoms Patient has been placed in contact precautions Physician has started flagyl

What now? Send another stool specimen? – How many until you are satisfied it is negative Continue contact precautions?

What if? Stool testing was done using PCR or culture instead of EIA? What if the result was positive but the patient’s diarrhea resolved after the first day? Can you have a positive test result but not be a C. difficile case?

Case 3 You are called by the laboratory regarding a patient who has meropenem-resistant Klebsiella to isolated from a wound. The patient is currently in a 4-bedded room

What now? Do nothing? Move the patient to a single room/institute contact precautions? Bedside contact precautions? Screen roommates for carriage of the organism? Screen clinical isolates of roommates for the organism?

What if? The patient is asymptomatically colonized? The organism is sensitive to other classes of antibiotics? Resistance is due to – a klebsiella pneumonia carbapenemase? – Metallo beta-lactamase? – OXA carbapenemase?

PHAC recommendations Colonized or infected patients should be placed on contact precautions in institutional settings – Including prolonged contacts of known cases and patients with suspected (but not yet confirmed) carbapenemase resistant organisms Colonized patients do not required contact precautions in the prehospital and homecare settings

In this case: Clinical screening of contacts and send clinically– relevant specimens – This does not mean surveillance for asymptomatic colonization Review laboratory records Strongly consider active surveillance of contacts if you find ≥ 2 clinical cases with the same strain Do not screen family, staff, visitors or environment in absence of a major outbreak

Other recommendations Clean your hands… Single room or cohort with the same organism Gloves ± gowns Dedicated equipment Twice daily cleaning with usual disinfectant Normal laundry/waste management

Other recommendations Discontinuing contact precautions – Unknown, likely continue for whole hospitalization – If readmitted within 1 year, consider re-isolation Oh yeah, you should have an antimicrobial stewardship program in place