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Infection Control Questions:Inpatient and Outpatient

The high 5

DisclosuresI have nothing to disclose

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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

of 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 l ine treatment usually 1% permethrin lotion (Nix) or a pyrethrin

+ piperonyl butoxide (e.g. Rid)• Does not ki l l ni ts, reapply after 9 days• Look for l ive, moving l ice after treatment• Not necessary to remove nits but can be done

• Other therapies include• Malathion (Ovide) - part ly 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 bacill i (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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ZSFG

ZSFG

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ZSFG

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 outside 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