The high 5 C. difficile C. difficile guidelines: infection control - PDF document

2/19/19 5. When can my hospitalized patient with C. difficile come off contact precautions? What are the Infection Control Questions: recommended precautions after Inpatient and Outpatient discharge home? The high 5 C. difficile C. difficile guidelines: infection control recommendations • Continue contact precautions for the “duration of illness” 1

2/19/19 C. difficile guidelines: infection C. difficile : discontinuation of isolation control recommendations • Heterogeneity (??? chaos) • UCSF: resolution of diarrhea for > 48 hrs. and • Use contact precautions patient moved to a clean room • Implement contact precautions when C. difficile is • ZSFG: at least 5 days of treatment and resolution suspected, unless test result available same day of diarrhea for > 48 hrs. • Continue contact precautions for at least 48 hours • SF VAMC: resolution of diarrhea for > 24 hrs. after diarrhea has resolved ( weak recommendation, • Many institutions: duration of hospitalization low quality of evidence ) Guidance for C. difficile at home 4. My hospitalized patient was treated • All household members wash hands frequently for scabies in the ED yesterday. She is with soap and water still scratching and says the itching is • Use a dedicated bathroom while symptomatic, severe. Should we treat her again? When if feasible can she come out of isolation? What • Consider cleaning bathroom with dilute bleach should I tell her husband about getting • 1:10 solution (1 cup bleach, 9 cups water) treated? 2

2/19/19 Scabies Scabies Scabies • Usual treatment is permethrin cream 5% - often given Crusted scabies 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 For infection control purposes, the most significant issue is to • Two doses (200 mcg/kg/dose) one week apart detect crusted scabies Scabies – at home 3. My clinic patient has bugs in his hair and on his body. He does not • Treatment recommended for household members, especially if skin-to-skin contact want to shave his head. The clinic • Treat at same time as patient • Mites survive only 2-3 days in environment staff are wearing head-to-toe • Launder bedding and clothing from last 3 days or store personal protective equipment (PPE). in a closed plastic bag for several days • Normal cleaning and vacuuming is appropriate What should we tell the patient to • Clean thoroughly with crusted scabies • No pesticide sprays or fogs do? https://www.cdc.gov/parasites/scabies/prevent.html 3

2/19/19 Head lice Head lice • First line treatment usually 1% permethrin lotion (Nix) or a pyrethrin • Lice crawl – they don’t jump or fly + piperonyl butoxide (e.g. Rid) • Does not kill nits, reapply after 9 days • Spread by close person-to-person contact • Look for live, moving lice after treatment • Not necessary to remove nits but can be done • Head lice survive maximum 1-2 days off a • Other therapies include person • Malathion (Ovide) - partly ovicidal • Spinosad (Natroba) – ovicidal • Head lice are a nuisance but cause no illnesses • Ivermectin, topical and oral • In the hospital, contact precautions can be discontinued 24 hours • Head shaving is effective but not necessary after effective therapy Head lice – at home Body lice • Check household members; consider treating bedmates even if lice not seen • Access to shower and clean clothing only required therapy – typically seen only in persons who are homeless or refugees • Launder clothing and bedding that had contact • Pediculicide often used (permethrin) with head in 2 days prior to treatment (or seal in • CDC recommends standard precautions in the hospital plastic bag) • Can transmit epidemic typhus ( Rickettsia prowasekii ), trench • Soaks combs and brushes in hot water fever ( Bartonella quintana ), epidemic relapsing fever • Judicious vacuuming can be done ( Borelia recurrentis ); can cause iron-deficiency anemia https://www.cdc.gov/parasites/lice/head/health_professionals/index.html 4

2/19/19 Traditional TB recommendations 2. My hospitalized patient probably • Discontinue airborne precautions when the has community-acquired pneumonia. likelihood of infectious TB is negligible, and But, TB is on the differential. What either specimens do I need to collect to • Another diagnosis explains the clinical syndrome Or “rule out” TB? When can airborne • 3 sputum smears are negative for AFB – collected respiratory precautions be at least 8 hrs. apart and 1 in early morning discontinued? https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf ZSFG 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 • 5

2/19/19 ZSFG ZSFG Suspected TB – in the community 1. My hospitalized patient has clinically diagnosed shingles. It looks pretty bad. • Contact local TB Control / Public Health 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? 6

2/19/19 Zoster: isolation precautions Localized vs. disseminated zoster • Localized zoster in immunocompetent patient? • Localized zoster: commonly affects one or two adjacent dermatomes Standard • Localized zoster in immunocompromised • Disseminated zoster: ? more than 20 lesions patient? outside the affected dermatome and the Airborne and contact until dissemination ruled out immediately adjacent dermatomes • 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 7