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Infection Control and Managing Tuberculosis at Long Term Care Facility: A Case Report
B6
Poster Abstracts / JAMDA 15 (2014) B3eB28
Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
Human Metapneumovirus Outbreak in a Long Term Care/Skilled Nursing Facility Presenting Author: Siobhan Folan, RN, Genesis HealthCare Author: Siobhan Folan, RN
Introduction: Human Metapneumovirus (hMPV) is an enveloped Paramyxoviridae virus isolated in 2001 by Dutch researchers. Although hMPV is known to cause illness in adults and geriatric populations, few outbreaks in US nursing facilities have been described. Our experience with a hMPV outbreak suggests that this illness may mimic influenza in its presentation and course within a skilled and long term care nursing facility. Case Description: A detailed concurrent outbreak investigation was performed subsequent to identification of hMPV in facility residents. Information was collected from patients, care providers, and medical records. Nasopharyngeal samples were collected from patients experiencing influenza like illness and tested by polymerase chain reaction for a panel of respiratory viruses. A total of 27 (36%) of 76 facility patients experienced respiratory illness between March 9th and May 14th of 2013. On the long term care floor, 22 of 44 were affected representing an attack rate of 50%. On the skilled nursing floor, 5 of 32 patients were affected with an attack rate of 16%. Human Metapneumovirus was detected by polymerase chain reaction in 6 specimens with no other respiratory pathogens found. The most prevalent symptoms were fever (100%) and cough (93%). Duration of illness ranged from 2-47 days, with an average of 15.4 days. No mortality was observed in this outbreak. Discussion: Human Metapneumovirus may present as a widespread outbreak in nursing facilities, mimicking influenza in its manifestations. Supportive care of affected patients, plus scrupulous infection control pratices are indicated. Recognition of this cause of respiratory outbreak may help minimize the inappropriate use of antimicrobial and anti-viral agents, neither of which are efficacious against the hMPV organism. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
Infection Control and Managing Tuberculosis at Long Term Care Facility: A Case Report Presenting Author: Sandeep R. Pagali, MD, MPH, College of Medicine Mayo Clinic Author(s): Sandeep R. Pagali, MD, MPH, Brandon P. Verdoorn, MD, Mark L. Wieland, MD, MPH, Paul Y. Takahashi, MD; and Anupam Chandra, MD
Introduction: The incidence of Tuberculosis (TB) in the United States has decreased; however, clinical and isolation management in Long Term Care (LTC) facilities remains a challenge. LTC residents are at higher risk of primary and reactivation TB because they live in confined spaces and have impaired immunity. All patients admitted to LTC are required to have screening for TB at admission because of these risks. However guidelines for isolation of patients with known Tuberculosis at LTC are less known. We present a patient with active TB who required placement in a LTC facility. Case Description: An 86 year old female who had a history of tuberculosis infection in her 20’s was admitted to a LTC facility following an above the knee amputation. Postoperative course was complicated by acute shortness of breath in the setting of chronic cough for three years and forty pound weight loss. She denied any excessive sputum production, fever, chills, night sweats, hemoptysis or lymph node enlargement. Chest x-ray showed minimal bilateral infiltrates. She had negative initial blood and sputum culture, acid fast stain and polymerase chain reaction for tuberculosis. She was treated for hospital acquired pneumonia and discharged to the LTC facility for two weeks. Sputum culture grew Mycobacterium
Tuberculosis at 6 weeks.We diagnosed her as relapsed smear negative culture positive pulmonary TB. We readmitted her to the hospital for negative-pressure airborne isolation for two weeks. We treated her with four drug therapy including isoniazid, ethambutol, pyrazinamide, and rifampin. Three acid fast smears were negative. We repeated cultures which remained positive for pan-sensitive Mycobacterium Tuberculosis. She was considered to be low risk for infection transmission given resolution of cough and absence of sputum production and completion of two weeks of anti-tubercular therapy in isolation. She was discharged to the LTC facility with direct observation therapy of antitubercular drugs by the public health department and advice to continue isolation with surgical mask. Discussion: This case highlights the importance of maintaining a high clinical suspicion for TB and need for infection control and isolation in the LTC population in appropriate clinical context. Management of active TB includes isolation in a negative pressure room for at least two weeks after initiating medical therapy, and droplet isolation. This negative pressure isolation may require acute hospital admission. Patients are considered noninfectious if they meet all the three criteria: 1) Three consecutive negative AFB sputum smears collected in 8- to 24-hour intervals (at least one being an early morning specimen); 2) Clinical improvement of symptoms; and 3) Compliant with an adequate treatment regimen for 2 weeks or longer. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
It Is Never Too Late: Using a Computer Program to Treat Hand Contractures Associated With Parkinsons Disease Presenting Author: Xiangrong Shao, MD, VA Maryland Health Care System, Loch Raven Community Living and Rehabilitation Center, University of Maryland, School of Medicine Author(s): Abisola Mesioye, MD, Xiangrong Shao, MD, Romi Carriere; and Chantel Youssef, MD
Introduction: Hand and foot deformities in Parkinson’s disease have been described since 1877. However their management is not always addressed by clinicians who often pay more attention to managing other aspects of the disease. These deformities may result in contractures which can further compromise the functional ability and independence of an already disabled patient. The treatment for these hand contractures is limited. Case Description: Mr. W is a 77 yr old retired airforce colonel. He was admitted to a VA CLC in 09/2011 for long term care on account of gait dysfunction, frequent falls, and paranoid ideation. His past medical history is significant for Parkinson’s disease for 10 yr, PTSD for 35 yr, and a TBI from a MVA in 2009. He was an avid runner until the accident. Admission medications included: Amantadine; Carbidopa/Levodopa 25/250; Comtan; Mirtazapine; Finasteride; Tamsulosin; Quetiapine ime; Rivastigmine; Plavix; Colace; Lorazepam; Acetaminophen. Pertinent physical findings included an unsteady gait, right hand tremor, mild right upper extremity rigidity and right foot drop, significant cognitive impairment with MMSE of 23/30 on admission. He was slowly weaned off Lorazepam to prevent falls and his large dose of Quetiapine (300mg daily) was reduced to 25 mg daily using cognitive behavioral therapy. He was not able to participate in skilled therapy due to his cognitive impairment, short attention span and lack of carry over. Despite comprehensive fall prevention effort, he had several falls, some resulting in injury and continued to decline physically and cognitively. He developed hand deformities which gradually became severe bilateral hand contractures. His hand contractures were not only compromising his ability to perform ADLs, e.g. self-feeding, but also severely affecting the nurse’s ability to provide nursing care, e.g. difficulty with trimming his fingernails due to his painful hand contracture. We applied custom made soft hand splint to prevent the hand contracture from worsening. In 08/2013, Mr. W was introduced to the “Never Too Late” computer based program with the hope that it would provide cognitive and physical exercise and improve his quality of life as well as reduce the severity of his severe hand contractures. After multiple trials with different programs, it was clear that the “Microsoft Flight Simulator” was the most
Poster Abstracts / JAMDA 15 (2014) B3eB28
Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
Human Metapneumovirus Outbreak in a Long Term Care/Skilled Nursing Facility Presenting Author: Siobhan Folan, RN, Genesis HealthCare Author: Siobhan Folan, RN
Introduction: Human Metapneumovirus (hMPV) is an enveloped Paramyxoviridae virus isolated in 2001 by Dutch researchers. Although hMPV is known to cause illness in adults and geriatric populations, few outbreaks in US nursing facilities have been described. Our experience with a hMPV outbreak suggests that this illness may mimic influenza in its presentation and course within a skilled and long term care nursing facility. Case Description: A detailed concurrent outbreak investigation was performed subsequent to identification of hMPV in facility residents. Information was collected from patients, care providers, and medical records. Nasopharyngeal samples were collected from patients experiencing influenza like illness and tested by polymerase chain reaction for a panel of respiratory viruses. A total of 27 (36%) of 76 facility patients experienced respiratory illness between March 9th and May 14th of 2013. On the long term care floor, 22 of 44 were affected representing an attack rate of 50%. On the skilled nursing floor, 5 of 32 patients were affected with an attack rate of 16%. Human Metapneumovirus was detected by polymerase chain reaction in 6 specimens with no other respiratory pathogens found. The most prevalent symptoms were fever (100%) and cough (93%). Duration of illness ranged from 2-47 days, with an average of 15.4 days. No mortality was observed in this outbreak. Discussion: Human Metapneumovirus may present as a widespread outbreak in nursing facilities, mimicking influenza in its manifestations. Supportive care of affected patients, plus scrupulous infection control pratices are indicated. Recognition of this cause of respiratory outbreak may help minimize the inappropriate use of antimicrobial and anti-viral agents, neither of which are efficacious against the hMPV organism. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
Infection Control and Managing Tuberculosis at Long Term Care Facility: A Case Report Presenting Author: Sandeep R. Pagali, MD, MPH, College of Medicine Mayo Clinic Author(s): Sandeep R. Pagali, MD, MPH, Brandon P. Verdoorn, MD, Mark L. Wieland, MD, MPH, Paul Y. Takahashi, MD; and Anupam Chandra, MD
Introduction: The incidence of Tuberculosis (TB) in the United States has decreased; however, clinical and isolation management in Long Term Care (LTC) facilities remains a challenge. LTC residents are at higher risk of primary and reactivation TB because they live in confined spaces and have impaired immunity. All patients admitted to LTC are required to have screening for TB at admission because of these risks. However guidelines for isolation of patients with known Tuberculosis at LTC are less known. We present a patient with active TB who required placement in a LTC facility. Case Description: An 86 year old female who had a history of tuberculosis infection in her 20’s was admitted to a LTC facility following an above the knee amputation. Postoperative course was complicated by acute shortness of breath in the setting of chronic cough for three years and forty pound weight loss. She denied any excessive sputum production, fever, chills, night sweats, hemoptysis or lymph node enlargement. Chest x-ray showed minimal bilateral infiltrates. She had negative initial blood and sputum culture, acid fast stain and polymerase chain reaction for tuberculosis. She was treated for hospital acquired pneumonia and discharged to the LTC facility for two weeks. Sputum culture grew Mycobacterium
Tuberculosis at 6 weeks.We diagnosed her as relapsed smear negative culture positive pulmonary TB. We readmitted her to the hospital for negative-pressure airborne isolation for two weeks. We treated her with four drug therapy including isoniazid, ethambutol, pyrazinamide, and rifampin. Three acid fast smears were negative. We repeated cultures which remained positive for pan-sensitive Mycobacterium Tuberculosis. She was considered to be low risk for infection transmission given resolution of cough and absence of sputum production and completion of two weeks of anti-tubercular therapy in isolation. She was discharged to the LTC facility with direct observation therapy of antitubercular drugs by the public health department and advice to continue isolation with surgical mask. Discussion: This case highlights the importance of maintaining a high clinical suspicion for TB and need for infection control and isolation in the LTC population in appropriate clinical context. Management of active TB includes isolation in a negative pressure room for at least two weeks after initiating medical therapy, and droplet isolation. This negative pressure isolation may require acute hospital admission. Patients are considered noninfectious if they meet all the three criteria: 1) Three consecutive negative AFB sputum smears collected in 8- to 24-hour intervals (at least one being an early morning specimen); 2) Clinical improvement of symptoms; and 3) Compliant with an adequate treatment regimen for 2 weeks or longer. Author Disclosures: All authors have stated there are no financial disclosures to be made that are pertinent to this abstract.
It Is Never Too Late: Using a Computer Program to Treat Hand Contractures Associated With Parkinsons Disease Presenting Author: Xiangrong Shao, MD, VA Maryland Health Care System, Loch Raven Community Living and Rehabilitation Center, University of Maryland, School of Medicine Author(s): Abisola Mesioye, MD, Xiangrong Shao, MD, Romi Carriere; and Chantel Youssef, MD
Introduction: Hand and foot deformities in Parkinson’s disease have been described since 1877. However their management is not always addressed by clinicians who often pay more attention to managing other aspects of the disease. These deformities may result in contractures which can further compromise the functional ability and independence of an already disabled patient. The treatment for these hand contractures is limited. Case Description: Mr. W is a 77 yr old retired airforce colonel. He was admitted to a VA CLC in 09/2011 for long term care on account of gait dysfunction, frequent falls, and paranoid ideation. His past medical history is significant for Parkinson’s disease for 10 yr, PTSD for 35 yr, and a TBI from a MVA in 2009. He was an avid runner until the accident. Admission medications included: Amantadine; Carbidopa/Levodopa 25/250; Comtan; Mirtazapine; Finasteride; Tamsulosin; Quetiapine ime; Rivastigmine; Plavix; Colace; Lorazepam; Acetaminophen. Pertinent physical findings included an unsteady gait, right hand tremor, mild right upper extremity rigidity and right foot drop, significant cognitive impairment with MMSE of 23/30 on admission. He was slowly weaned off Lorazepam to prevent falls and his large dose of Quetiapine (300mg daily) was reduced to 25 mg daily using cognitive behavioral therapy. He was not able to participate in skilled therapy due to his cognitive impairment, short attention span and lack of carry over. Despite comprehensive fall prevention effort, he had several falls, some resulting in injury and continued to decline physically and cognitively. He developed hand deformities which gradually became severe bilateral hand contractures. His hand contractures were not only compromising his ability to perform ADLs, e.g. self-feeding, but also severely affecting the nurse’s ability to provide nursing care, e.g. difficulty with trimming his fingernails due to his painful hand contracture. We applied custom made soft hand splint to prevent the hand contracture from worsening. In 08/2013, Mr. W was introduced to the “Never Too Late” computer based program with the hope that it would provide cognitive and physical exercise and improve his quality of life as well as reduce the severity of his severe hand contractures. After multiple trials with different programs, it was clear that the “Microsoft Flight Simulator” was the most