Agents of Terrorism

Terrorism

• Dispensing of disease pathogens

(bioterrorism) or other agents (chemical,

nuclear, radioactive, explosive devices) to

express harm

2

Inhalation Anthrax

• Bacillus anthracis: spores multiply in the

lungs

• Causes hemorrhage and destruction of lung

tissue

• S/sx: dyspnea, cough, chest pain

• Tx: ATB

3

Cutaneous anthrax

• 95% of anthrax infections

• Spores enters thru skin

• Toxins destroy surrounding tissues

• s/sx: small papule resembling insect bite,

depressed black ulcer, swollen lymph nodes

4

Smallpox

• Variola major and minor viruses

• Highly contagious, droplet

• S/sx: fever, HA, myalgia, papules to

pustular vesicles

• Tx: No known cure, Cidofovir (exp),

vaccination (Vaccinia immune globulin)

5

6

Botulism

• Clostridium botulinum

• Spore forming anaerobe (soil)

• Lethal bacterial neurotoxin; can die in 24hrs

• S/sx: abd cramps, diarrhea, n/v, cranial nerve

palsies, resp failure

• MOT: air or food (contaminated wound or

improperly canned food)

• Antitoxin, vomiting, PCN, enemas

7

Plague

• Bacteria found in rodents and fleas

• Bubonic, pneumonic, septicemic

• Hemotypsis, cough, high fever, resp failure

• Tx: ATB (aminoglycosides)

8

Hemorrhagic fever

• Ebola virus, Lassa virus

• Fever, conjunctivitis, hemorrhage of tissues

and organs, n/v, hypotension

• Rodents and mosquitoes, virus can be

aerolized

• NO Tx; Isolate, Ribavirin (effective at

times)

9

Chemical Agents of Terrorism

• Sarin: highly toxic nerve gas

- Enters thru eyes and skin paralyzing resp muscles

- Antidote: Atropine sulfate

• Phosgene

- Colorless gas causing resp distress

• Mustard gas: yellow brown color; garlic like odor

- Irritates the eyes and causes skin burns and blisters

10

Ionizing radiation • Nuclear bomb or nuclear reactor explosion

• If with external contamination: decontamination

procedures should be done

• Acute radiation syndrome develops after substantial

exposure

• Depends upon the amount of radiation

• 0-100 rad, 100-200rad, 200-600rad, 600-800rad, 800-

3000rad, >3000rad

11

12

BLAST INJURIES • Bombs and explosions can cause unique patterns of

injury seldom seen outside combat

• Expect half of all initial casualties to seek medical care

over a one-hour period

• Most severely injured arrive after the less injured, who

bypass EMS triage and go directly to the closest hospitals

• Predominant injuries involve multiple penetrating injuries

and blunt trauma

• Explosions in confined spaces (buildings, large vehicles,

mines) and/or structural collapse are associated with

greater morbidity and mortality

13

BLAST INJURIES TYPES

• •Primary: Injury from over-pressurization force

(blast wave) impacting the body surface — TM

rupture, pulmonary damage and air embolization,

hollow viscus injury

14

• Secondary: Injury from projectiles (bomb

fragments, flying debris) — Penetrating

trauma, fragmentation injuries, blunt trauma

15

• • Tertiary: Injuries from displacement of

victim by the blast wind —

Blunt/penetrating trauma, fractures, and

traumatic amputations

16

• Quaternary: All other injuries from the blast

— Crush injuries, burns, asphyxia, toxic

exposures, exacerbations of chronic illness

17

DIAGNOSTIC EVALUATION • Document amusculoskeletal, neurological, and vascular exam for each

extremity

• Extremities should be thoroughly evaluated from a vascular

perspective

• Each open wound should be well documented—noting size, exposed

bone, and type of contamination—and, ideally, photographed

• X-rays of injured extremities should be utilized to identify deep

foreign bodies and to characterize bony injuries

• Also, the absence of external injuries never rules out internal organ

damage due to blunt trauma or blast wave injuries

18

INITIAL MANAGEMENT • Lung Injury

– Signs usually present at time of initial evaluation, but may

be delayed up to 48 hours

– Reported to be more common in patients with skull

fractures, >10% BSA burns, and penetrating injury to the

head or torso

– Varies from scattered petechiae to confluent hemorrhages

– Suspect in anyone with dyspnea, cough, hemoptysis, or

chest pain following blast

– CXR: “butterfly” pattern

– High flow O2 sufficient to prevent hypoxemia via NRB

mask, CPAP, or ET tube

19

• Crush Injury and Crsuh Syndrome

– Due to increased muscle breakdown

– Crush syndrome can cause local tissue injury, organ

dysfunction, and metabolic abnormalities, including

acidosis, hyperkalemia, and hypocalcemia

– Manage initially with IV fluids and maintain hydration

– Compartment syndrome, rhabdomyolysis, and acute

renal failure are associated with structural collapse,

prolonged extrication, severe burns, and some

poisonings

20

• Abdominal Injury

– Gas-filled structures most vulnerable (esp. colon)

– Bowel perforation, hemorrhage (small petechiae to

large hematomas), mesenteric shear injuries, solid

organ lacerations, and testicular rupture

– Suspect in anyone with abdominal pain, nausea,

vomiting, hematemesis, rectal pain, tenesmus,

testicular pain, unexplained hypovolemia

– Keep patient NPO until properly assessed in a

medical facility

21

• Traumatic Brain Injuries

– Check GCS, observe for any lucid interval, CSF

leaks

– Concussions are common and easily overlooked

• Ear Injury

– Tympanic membrane most common primary blast

injury

– Signs of ear injury usually evident on presentation

(hearing loss, tinnitus, otalgia, vertigo, bleeding from

external canal, otorrhea)

– Can cause problems in communication – provide a

pen and paper

22

INITIAL MANAGEMENT • Extremity Injuries

– Tourniquet and pressure especially for amputees

– Traumatic amputation of any limb is a marker for multi-

system injuries

• Eye Injuries

– Significant percentage of survivors will have serious eye

injuries

– Cover both eyes in case of injury, but use a convex

plastic or eye shield, do not remove foreign objects!

23

• Thermal Injuries

– Rule of nines, ABCs, and IVF replacement

– Consider possibility of exposure to inhaled toxins

(CO, CN, MetHgb) in both industrial and terrorist

explosions

• Other Injury

– Consider delayed primary closure for grossly

contaminated wounds, and assess tetanus

immunization status

24

25

FIRE PREPAREDNESS

26

Notification System

• Public Address system (PA)

• Alarm Pull Stations

• Voice – call out fire, “Code

Red” etc.

An alarm system of one kind or the other must be in

place to notify the staff and patients of a fire. This may

include one or more of the following:

27

Means of Egress

• A continuous and unobstructed way of exit

travel from a building or structure.

• Egress must be unobstructed and unlocked

while the structure is occupied.

28

• All exits must be clearly visible – no mirrors,

curtains, or other camouflage.

• All exits must be clearly illuminated

Emergency Exits

• Doors which may be mistaken

as exits must be clearly

labeled as “Not an Exit.”

29

Fire Doors

– Door stops, wedges

and other

unapproved hold-

open devices are

prohibited on fire

doors

– Swinging fire doors

shall close from the

full-open position

and shall latch

automatically

NO!!!

30

Building Evacuation

• Proceed to nearest exit in an orderly fashion,

closing doors behind you.

• Assemble at the designated meeting location

and account for all patients, visitors, and staff.

• Provide safety representatives with

information about people still in the building.

• Never re-enter a building until instructed to by

the police department or fire department

31

RACE Method Of Evacuation

• R Remove All Persons In Danger!

• A Always Pull The Alarm;

• C Contain The Fire By Closing the Windows

and Doors.

• E Extinguish the Fire Only if You Are Trained

and Confident.

32

Emergency Procedures

• Staff members should

have specific roles in

equipment shutoff.

• All doors should be

checked for visitors and

shut on the way out in

order to contain smoke

and fire.

33

Patient Evacuation

All patients should be

escorted to the

designated meeting

location immediately

after the alarm sounds.

A staff member should

remain with patients at

all times.

34

Patient Evacuation

• Each institution must develop a procedure

to account for all patients at the meeting

location.

• One example is for a staff member working

at the front desk to bring the patient check-

in sheet to the meeting location.

35

Emergency Evacuation Plan

• All employees should have read the Emergency

Evacuation Plan (EEP) and fully understand it.

• It is important to update Safety Representatives

and contacts whenever a change is made.

• The meeting locations should be away from any

traffic areas that might be a danger.

36

• All faculty and staff should be trained on emergency

evacuation plans and participate in scheduled drills.

• This training should be updated annually and/or

when staff or the facility changes.

Training

37

Common Causes of Fires in

Health Care Facilities

• Electrical Malfunctions

• Friction

• Open Flames

• Sparks

• Hot Surfaces

• Compressed O2

• Anesthetic Gases

38

Precautions Against Fire

• Extension cords and flexible cords cannot be a

substitute for permanent wiring.

• Regularly inspect electrical cords for damage.

• Use caution when working with open flames or hot

surfaces.

39

Electrical Safety

• Surge Protectors are the only approved means of

multiplying a receptacle.

• Some parts of this extension cord are approved, the problem is that it is not approved as a unit.

• All appliances must have a UL label.

40

How Does a Fire Work? • Three components

• Need all three

components to start a fire

• Fire extinguishers

remove one or more of

the components

• Oxygen is required as a

catalyst – may come

from the air OR from the

fuel itself

• Fire extinguishers are used to ‘extinguish’ one of the

three components that allow the fire to exist.

41

Portable Fire Extinguishers

• Locate and identify extinguishers so that they are readily accessible.

• Only approved extinguishers shall be used.

• Maintain extinguishers in a fully charged and operable condition.

42

Classification of Fires & Extinguishers

Class A Fires

Wood

Paper

Rags

Some rubber

and plastic

materials

43

Class B Fires

Gasoline

Oil

Grease

Paint

Flammable Gases

Some rubber and

plastic materials

Classification of Fires & Extinguishers

44

Classification of Fires & Extinguishers

Class C Fires

Electrical Fires

– Office Equipment

– Motors

– Switchgear

– Heaters

45

Classification of Fires & Extinguishers

Class D Fires

Metals

– Magnesium

– Titanium

– Sodium

– Zirconium

– Potassium

– Lithium

46

Multi-Class Ratings

• There are several

types of multi-class

extinguishers: A-B,

B-C, or A-B-C.

• Be sure the correct

extinguisher is provided

for the hazards.

NOT for Electrical Equipment

fires

• Generally, ABC combinations are used at to extinguish

a wide variety of fires including: Combustibles,

Flammable Liquids, and Electrical Fires.

47

Different Kinds of Extinguishers

–All Purpose Water

–Carbon Dioxide

–Multi-Purpose Dry

Chemical

–Dry Powder

Carbon Dioxide Water

48

How to Use an Extinguisher

P: Pull the pin.

A: Aim extinguisher nozzle at the

base of the flame.

S: Squeeze trigger while holding

the extinguisher upright.

S: Sweep the extinguisher from

side to side, covering the area

with the extinguisher agent.

P A S S

49

• Visually inspected monthly

• Maintained annually

• Hydrostatically tested

periodically (5 or 12 yrs.)

Fire Extinguishers

Inspection, Maintenance and Testing

50

Partnership with Red Cross

• Pre-fire planning

• Campus building surveys

• Training / Education

51

Do You Know???

• Where is the nearest fire alarm pull

station?

• Where is the nearest fire extinguisher?

• Where are the primary and secondary

exits?

• Where are the primary and secondary

designated meeting locations?

• Where is the emergency procedures

manual?

• What is your specific role in patient

evacuation and emergency equipment

shut-off?

52

Earthquake

• Most destructive and frightening of all

forces of nature

• Caused by breaking and shifting of rock

beneath the earth’s surface

• Richter scale: measures the magnitude and

intensity or energy released by the quake

53

Instrument which measures and detects seismic waves/vibrations

Weight and pen remain still during an earthquake; drum moves with the Earth Earthquake measuring stations have at least 3 seismographs Locations of epicenters are determined using data from 3 measuring stations

Photo courtesy of : http://www.thetech.org/exhibits/online/quakes/seismo/

Written record of earthquake waves Used to determine epicenter and

when earthquakes occurred Shows magnitude (strength) of waves

with height of lines

Epicenter: surface origin of seismic waves (surface waves) directly above focus

Focus: underground point of origin for earthquake body waves

Why do you need

3

stations reporting the

same earthquake data?

Triangulation results in one epicenter location.

•Strength/Energy released by an earthquake •Measured by Richter Scale

•Scale from 0-10 •Each increasing number is 10x more ground shaking

•A measure of how much damage is done and the degree to which an earthquake is felt by people •Measured by Modified Mercalli Scale

•Scale from I-XII •Each location that felt the event will have a different intensity level

Liquefaction Vibrations cause pressure in ground water between grains of sand and silt. This turns sand into a viscous liquid ”quicksand”.

Tsunamis

giant waves that travel at speeds of 700-800 km/hr and reach height of

20+meters

Earthquake hazard is a measurement of how likely an area is to have damaging quakes in the future.

It’s determined

by past and present seismic activity

Seismologists look for patterns in earthquake data to try and predict future earthquakes.

The strength and frequency are important factors in the prediction of earthquakes.

Major earthquake is more likely to occur along part of an active fault that have had few or no

earthquakes happen in recent times. This is known as the…

Changes in the behavior of animals

These methods are not completely accurate and will only suggest

that an earthquake may occur

Changes in water level (lakes, streams, wells, etc.)

• DROP down onto your hands and knees before the earthquake would knock you down. This position protects you from falling but still allows you to move if necessary.

• COVER your head and neck (and your entire body if possible) under the shelter of a sturdy table or desk. If there is no shelter nearby, get down near an interior wall or next to low-lying furniture that won't fall on you, and cover your head and neck with your arms and hands. Try to stay clear of windows or glass that could shatter or objects that could fall on you.

• HOLD ON to your shelter (or to your head and neck) until the shaking stops. Be prepared to move with your shelter if the shaking shifts it around.

66

• If you are outside, stay outside, and stay

away from buildings utility wires,

sinkholes, and fuel and gas lines.

• The area near the exterior walls of a

building is the most dangerous place to be

• Stay away from this danger zone--stay

inside if you are inside and outside if you

are outside.The greatest danger from falling

debris is just outside doorways and close to

outer walls

67

Establish Priorities

• Take time before an earthquake strikes to

write an emergency priority list, including:

– important items to be hand-carried by you

– other items, in order of importance to you and

your family

– items to be removed by car or truck if one is

available

– things to do if time permits, such as locking

doors and windows, turning off the utilities, etc.

68

Write Down Important

Information

• Make a list of important information and put it in a

secure location. Include on your list:

• important telephone numbers, such as police, fire,

paramedics, and medical centers

• the names, addresses, and telephone numbers of

your insurance agents, including policy types and

numbers

• important medical information, such as allergies,

regular medications, etc.your bank's telephone

number, account types, and numbers

69

Gather and Store Important

Documents in a Fire-Proof Safe

• Birth certificates

• Ownership certificates (automobiles, boats,

etc.)

• Social Security cards

• Insurance policies

• Wills

• Household inventory

70

FLOODS, FLASH FLOODS

• Flash floods and floods are the #1

cause of deaths associated with

thunderstorms...more than 140

fatalities each year.

• Most flash flood fatalities occur at

night and most victims are people

who become trapped in automobiles.

• Six inches of fast-moving water can

knock you off your feet; a depth of

two feet will cause most vehicles to

float.

Hurricanes and Typhoons

• Hurricane: tropical storms with winds of

constant speed of >74 miles/hr

• Atlantic: hurricane; Pacific: typhoons

• Tropical depression, tropical storm: depends

upon wind force- measured by Beaufort

scale

72

Health Impact

• Drowning

• Electrocution

• Lacerations and punctures

• GI, respiratory, vector borne diseases and

skin disease

• Failure to evacuate, failure to follow

guidelines on food and water safety: main

causes of problems 73

Causes of Floods

• Uncontrolled urbanization

• Deforestation

• Effects of El Nino

74

Flash Flood Safety Rules

• Avoid walking, swimming, or driving in flood waters.

• Stay away from high water, storm drains, ditches, ravines,. If it is moving swiftly, even water six inches deep can knock you off your feet.

• Climb to higher ground

• Do not let children play near storm drains.

Planning for Disaster

Disaster Preparedness Isn’t Just a Case of

Preparing for the Worst, it’s Being Prepared

To Do Your Best When it Matters Most!

Preparation

• Turn Off Utilities to Your Home.

• Turn Off Gas, Water and Electricity

• Turn Off the Water to Your Home.

Advanced Preparation Can Save Precious Time!

Prepare Kit in a Large, Watertight Container that can be moved easily (large plastic garbage can with wheels).

72 Hour Emergency Kit (cont.)

• 3 Day Supply of Non-Perishable Food Items (canned meats, fruits & vegetables)

• 3 Day Supply of Water (1 gallon per person, per day)

• Manual can opener, cooking supplies & utensils

• Portable, Battery Operated Radio or TV (extra batteries)

• Flashlight & Batteries

• First Aid Kit & Large Trash Bags

• Matches & Waterproof container

• Whistle

• Warm clothing & Rain Gear

• Sanitation & Hygiene Items (Soap and Feminine Supplies)

• Special Need Items for Children, Seniors or People w/Disabilities

• Photocopies of Credit Cards and Identification (proof of address, DL, or Electric Bill)

• Cash & Coins

• Blanket or Sleeping Bags

• Supplies for Pets

All supplies should be checked every 6 months

and out dated items replaced

Go Bag Items

• Flashlight

• Portable Radio or TV

• Extra Batteries

• Whistle

• Dust mask

• Pocket Knife

• Emergency Cash & Coins in Small Denominations

• Sturdy Shoes, Change of Clothing and Warm Hat

• Water & Food

• First Aid Kit

• Permanent Marker, Paper and Tape

• List of Emergency Phone Numbers

• List of Allergies to Any Drug (especially antibiotics)

• Copy of Health Insurance & Identification Cards

• Extra Prescription Eye Glasses, Hearing Aid & Other Vital Items

• Toothbrush & Toothpaste

• Extra Keys to House & Vehicles

• Special Need Items for Children, Seniors and People w/Disabilities

• Photocopies of Credit Cards and Identification (proof of address, DL, or Electric Bill)

Health Impacts of Flooding

• Infectious disease

• Compromised personal hygiene

• Contamination of water sources

• Disruption of sewage service and solid

waste collection

• Increased vector borne diseases

(leptospirosis, hepa A, E.coli, giardiasis)

80

81

82

83

84

Epidemics

• An outbreak or occurrence of one specific disease

from a single source in a group or population in

excess of the usual or expected

• Exists when new cases exceed the prevalence of

disease

• Prevalence: number of people within a population

who have a certain disease at a given point in time

• Acute outbreak

85

Requirements for Epidemic

• Susceptible population

• Presence of disease agent

• Large scale transmission (contaminated

water or vector population)

• Can lead to serious disability or death

• Inability of authorities to cope adequately

86

87

• SARS: Severe Acute Respiratory Syndrome

• Viral (coronavirus)

• O2, anti-pyretics, ventilatory support

• Influenza A (H1N1) virus is a subtype of influenza A virus

and was the most common cause of human influenza (flu)

• Some strains of H1N1 are endemic in humans and cause a

small fraction of all influenza-like illness and a small

fraction of all seasonal influenza

• Other strains of H1N1 are endemic in pigs (swine influenza)

and in birds (avian influenza)

88

• MERS-COV

• viral respiratory illness

• a beta coronavirus.

• It was first reported in 2012 in Saudi Arabia

• not the same coronavirus that caused severe

acute respiratory syndrome (SARS)

• people who got infected developed severe

acute respiratory illness with symptoms of

fever, cough, and shortness of breath

89

Countries Cases (Deaths)

France 2 (1)

Italy 3 (0)

Jordan 2 (2)

Qatar 2 (1)

Saudi Arabia 71 (39)

Tunisia 2 (0)

United Kingdom (UK) 3 (2)

United Arab Emirates

(UAE) 6 (1)

Total 91 (46) 90

Notice

Level

Traveler

Action

Risk to

Traveler Outbreak/Event Example

Level 1:

Watch

Reminder to

follow usual

precautions

for this

destination

Usual baseline

risk or slightly

above baseline

risk for

destination

and limited

impact to the

traveler

Dengue in Panama-Outbreak

Watch:

Because dengue is endemic to

Panama, this notice most likely would

signify that there is a slightly higher

rate of dengue cases than predicted.

Travelers are to follow “usual” insect

precautions.

Olympics in London-Event Watch:

There may be possible health

conditions in London that could

impact travelers during the Olympics,

such as measles. Travelers are to

follow usual health precautions

making sure they are up to date on

their measles vaccine, follow traffic

safety laws and use sunscreen

91

Level 2:

Alert

Follow

enhanced

precaution

s for this

destination

Increased

risk in

defined

settings

or

associate

d with

specific

risk

factors

Yellow Fever in Brazil-Outbreak

Alert:

Because an outbreak of yellow fever

was found in areas of Brazil outside of

the reported yellow fever risk areas,

this would be a change in “usual”

precautions. Travelers should follow

“enhanced precautions” for that risk

area by receiving the yellow fever

vaccine.

Flooding in El Salvador-Event

Alert:

There are possible conditions that

could affect the health of the traveler

and parts of the destination’s

infrastructure could be compromised.

Travelers are to follow special

precautions for flooding

92

Level 3:

Warning

Avoid all

non-

essential

travel to

this

destination

High risk

to

travelers

SARS in Asia-Outbreak

Warning:

Because SARS spread quickly and

had a high case fatality rate, a

warning notice signifies there was a

high chance a traveler could be

infected. Travelers should not

travel if possible.

Earthquake in Haiti-Event

Warning:

The destination’s infrastructure

(sanitation, transportation, etc.)

cannot support travelers at this

time.

93

MULTI-DRUG RESISTANT

ORGANISMS

• Prevention of antimicrobial resistance

depends on appropriate clinical practices

that should be incorporated into all routine

patient care

• As per CDC guidelines

94

MEASURES IN THE

HOSPITAL INCLUDES

• optimal management of vascular and

urinary catheters

• prevention of lower respiratory tract

infection in intubated patients

• accurate diagnosis of infectious etiologies

• judicious antimicrobial selection and

utilization

95

Infection Control Precautions.

• Standard Precautions

– Hand hygiene is an important component of

Standard Precautions.

• Contact Precautions

– prevent transmission of infectious agents which

are transmitted by direct or indirect contact

with the patient or the patient's environment

96

Contact Precautions

• A single-patient room is preferred for

patients who require Contact Precautions.

• When a single-patient room is not available,

consultation with infection control is

necessary to assess the various risks

associated with other patient placement

options (e.g., cohorting, keeping the patient

with an existing roommate)

97

• HCP caring for patients on Contact

Precautions should wear a gown and gloves

for all interactions that may involve contact

with the patient or potentially contaminated

areas in the patient's environment.

• Donning gown and gloves upon room entry

and discarding before exiting the patient

room is done to contain pathogens,

especially those that have been implicated

in transmission through environmental

contamination

98

• discontinue Contact Precautions when three

or more surveillance cultures for the target

MDRO are repeatedly negative over the

course of a week or two in a patient who

has not received antimicrobial therapy for

several weeks, especially in the absence of a

draining wound, profuse respiratory

secretions, or evidence implicating the

specific patient in ongoing transmission of

the MDRO within the facility.

99

• Some bacteria present in an individual as a

colony or flora in the body, without producing

disease, which has a potential to spread

• Decolonization

– entails treatment of persons/Health Care Personnels

(HCP) colonized with a specific MDRO, usually

MRSA, to eradicate carriage of that organism

– possible with several regimens that include topical

mupirocin alone or in combination with orally

administered antibiotics plus the use of an

antimicrobial soap for bathing

100

• HCP implicated in transmission of MRSA

are candidates for decolonization and

should be treated and culture negative

before returning to direct patient care.

• In contrast, HCP who are colonized with

MRSA, but are asymptomatic, and have not

been linked epidemiologically to

transmission, do not require decolonization.

101

Resistant Microorganisms • MRSA:

– Methicillin resistant Staphylococcus Aureus

– Vancomycin is the treatment of choice

– Necessary to do a nasal swab to detect presence

in persons at risk

– Treated accordingly with Vancomycin in

infected individuals

– Decolonize persons withtopical mupirocin

alone or in combination with orally

administered antibiotics plus the use of an

antimicrobial soap for bathing

102

VRE: Vancomycin Resistant

Enterococcus

• In some instances, enterococci have become

resistant to vancomycin

• These bacteria are normally present in the

human intestines and in the female genital

tract and are often found in the environment

103

RISK FACTORS

• People who have been previously treated with the antibiotic

vancomycin or other antibiotics for long periods of time.

• People who are hospitalized, particularly when they receive

antibiotic treatment for long periods of time.

• People with weakened immune systems such as patients in intensive

care units, or in cancer or transplant wards.

• People who have undergone surgical procedures such as abdominal

or chest surgery.

• People with medical devices that stay in for some time such as

urinary catheters or central intravenous (IV) catheters.

• People who are colonized with VRE

104

MANAGEMENT

• People with colonized VRE (bacteria are present,

but have no symptoms of an infection) do not

need treatment.

• Most VRE infections can be treated with

antibiotics other than vancomycin.

– IMPORTANT TO HAVE SENSITIVITY TEST 1ST!

• For people who get VRE infections in their

bladder and have urinary catheters, removal of

the catheter when it is no longer needed can also

help get rid of the infection. 105

Brukholderia cepacia

• Can be present in the environment even in

betadine solutions, mouthwashes, and soil

• Causes severe pneumonia in susceptible

patients

• Treated with a wide range of antibiotics as

long as it is sensitive to it

106

Clostridium difficle

• a form of a Hospital acquired infection

• clinical manifestations of infection with

toxin-producing strains of C. difficile

• range from symptomless carriage, to mild

• or moderate diarrhea, to fulminant and

sometimes fatal pseu­domembranous

colitis.

107

RISK FACTORS

• commonly seen in older adults, who take

antibiotics and also get medical care.

108

TREATMENT

• Vancomycin as 1st line drug

109

• Klebsiella: type of gram-negative bacteria that can cause

infections in healthcare settings, including pneumonia,

bloodstream infections, wound or surgical site infections,

and meningitis.

• Klebsiella bacteria have developed antibiotic resistance,

most recently to the class of antibiotics known as

carbapenems.

• When bacteria such as Klebsiella pneumoniae produce an

enzyme known as a carbapenemase, they are referred to as

KPC producing organisms or carbapenem-resistant

Klebsiella pneumoniae (CRKP)

110

BETA-LACTAMASE

PRODUCING BACTERIA

• Metallo-beta-lactamase-1 (NDM-1)

– Commonly gram negative

– makes bacteria resistant to a broad range of

beta-lactam antibiotics

– These include the antibiotics of the carbapenem

family, which are a mainstay for the treatment

of antibiotic-resistant bacterial infections

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Metallo-beta-lactamase-1

(NDM-1)

• resistant to multiple different classes of

antibiotics, including beta-lactam

antibiotics, fluoroquinolones, and

aminoglycosides

• most were still susceptible to the polymyxin

antibiotic COLISTIN.

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Extended-spectrum beta-

lactamase (ESBL)

• confer resistance to penicillins

• Also are resistant to extended-spectrum

cephalosporins including cefotaxime, ceftriaxone,

and ceftazidime and aztreonam

• Once an ESBL-producing strain is detected, the

laboratory should report it as "resistant" to all

penicillins, cephalosporins, and aztreonam, even if

it is tested (in vitro) as susceptible

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Extended-spectrum beta-

lactamase (ESBL)

• Currently, carbapenems are, in general,

regarded as the preferred agent for

treatment of infections due to ESBL-

producing organisms

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