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Clinical Director, Uniformed Services University of the Health Sciences F. Edward Hebert School of Medicine
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If not administered during pregnancy, 2 Tdap should be administered immediately postpartum. Women who are unimmunized or only partially immunized against tetanus should complete the primary series. For complete recommendations regarding use of Td and Tdap vaccines in pregnancy, see Pertussis (p 553). In resource-limited countries with a high incidence of neonatal tetanus, Td vaccine routinely is administered during pregnancy without evidence of adverse effects and with striking decreases in the occurrence of neonatal tetanus. Therefore, inactivated infuenza vaccine should be administered to all women who will be pregnant during the infuenza season, regardless of trimester (see Infuenza, p 439). Infuenza immunization of pregnant women also protects infants younger than 6 months of age who cannot be immunized actively and in whom antiviral prophylaxis and treatment options are limited. Infuenza vaccines are not approved for use in infants younger than 6 months of age. Pneumococcal and meningococcal vaccines can be given to a pregnant woman at high risk of serious or complicated illness from infection with Streptococcus pneumoniae or Neisseria meningitidis. Meningococcal conjugate vaccine can be given to a pregnant woman when there is increased risk of disease, such as during epidemics or before travel to an area with hyperendemic infection. Infection with hepatitis A or hepatitis B can result in severe disease in a pregnant woman and, in the case of hepatitis B, chronic infection in the newborn infant. Hepatitis A or hepatitis B immunizations, if indicated, can be given to pregnant women. Although data on safety of these vaccines for a pregnant woman or developing fetus are not available, no risk would be expected. Pregnancy is a contraindication to administration of all live-virus vaccines, except when susceptibility and exposure are highly probable and the disease to be prevented poses a greater threat to the pregnant woman or fetus than does the vaccine. Although only a theoretical risk to the fetus exists with a live-virus vaccine, the background rate of anomalies in uncomplicated pregnancies may result in a defect that could be attributed inappropriately to a vaccine. Because measles, mumps, rubella, and varicella vaccines are contraindicated for pregnant women, efforts should be made to immunize susceptible women against these illnesses before they become pregnant or after pregnancy. Although of theoretical concern, no case of embryopathy caused by the attenuated rubella vaccine strain has been reported. However, a rare theoretical risk of embryopathy from inadvertent rubella vaccine administration cannot be excluded. Of the 827, 54 chose elective termination for unknown reasons, 168 were seronegative, and 605 were unknown or seropositive. Seven hundred twelve of these women were known to have received varicella vaccine inadvertently within 3 months before or during pregnancy and had known pregnancy outcomes available for analysis and considered complete.
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An appropriate epidemiologic unlike pulmonary infection, which occurs more often in immuand exposure history was also absent in the only reported case of nocompromised subjects (241, 242). The Mycobacterium tuberculosis complex rehave nonmicrobiological evidence of infection, such as periprosmains a leading cause of morbidity and mortality worldwide, with thetic purulence, acute infiammation determined by histopatholbone and joint infection occurring in 10% of extrapulmonary ogy, or a sinus tract communicating with the joint, in the absence M. However, patients for whom joint arthroplasty is peravailable microbiological methods, or an inability to detect a recformed in a joint with prior M. Both of these assertions are knee, with one case series suggesting that the hip is more complausible and supported by the literature (29, 223, 248). Two clinical presentations have been dewithholding of antimicrobials prior to surgery and improvements scribed (230). A final possibility is that some cases curtime of the initial arthroplasty (231). The median duration of symptoms is approximately 100 days prior to diagnosis (249). Test characteristics and relative costs of commonly available tests shown in Table 2 may assist clinicians in choosing the most appropriate diagnostic approach for each individual patient. Test performance may vary with joint type and also with timing post-arthroplasty implantation; where data are available that addresses this, they will be presented. The diagnostic criteria tice, the specificity is likely even lower, given that this study exfor each group are shown in Table 3. A large retrospective 45%, although the reported specificity of 87% may be useful in study evaluated 1,962 patients who underwent revision surgery some situations (253). The threshold used was slightly of specificity, a concern for patients with underlying infiammahigher than that in a previous study of early knee arthroplasty tory joint disease such as rheumatoid arthritis. The resulting test characteristics were not reand specificity values of 75 and 70%, respectively. These thresholds are higher than those reported in the threshold value in each of these papers varied from 12 to 40 mm/h, majority of the papers included in the meta-analysis mentioned with the most commonly used threshold being 30 mm/h. This may be related to the higher proportion knee arthroplasty revision surgery (255). In clinical pracis that it rapidly returns to normal shortly after joint arthroplasty, 314 cmr. Furthermore, the use of these techmarker in the early postoperative period as well as for differentiniques is limited by imaging artifacts due to the presence of the ating other, more acute causes of elevated levels of infiammatory metal prosthesis. The above-mentioned metaperformed only with certain metals, such as titanium or tantalum. The intensity of uptake following growth from two or more specimens, suggesting that some painjection of the radiopharmaceutical is measured at three different tients may have been incorrectly classified. Finally, an additional time points, corresponding to blood fiow (immediate), blood study evaluated a number of different serum assays, including pool (at 15 min), and late (at 2 to 4 h) time points (265).
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Silibovsky, Randi Marculescu, Camelia Post, Zachary Seyler, Thorsten Martson, Scott Parsley, Brian Shapiro, Irving Noble, Phillip Parvizi, Javad Simpendorfer, Claus Mason, J. Bohannon Poultsides, Lazaros Smith, Eric Matsen, Laura Pulido, Luis Spangehl, Mark McCarthy, Joseph C. Thus, elective arthroplasty should be delayed in patients with active infection until they are adequately treated and infections are confirmed to be eradicated. An appropriate infection workup, as discussed elsewhere in this document, should be undertaken in all patients who have had previous surgery at the site of an upcoming arthroplasty. This will allow for any necessary modification of 10 the operative approach and technique to minimize risk of developing infection. Uncontrolled Hyperglycemia Numerous studies and meta-analyses indicate that preoperative uncontrolled glucose levels (fasting glucose>180 mg/dL or 10 mmol/L) are associated with increased postoperative 12-14 complications and adverse outcomes. Therefore, efforts should be made to maintain adequately-controlled glucose levels during the entire perioperative time period. Less work has been definitive in elucidating the role of 16, 17 hemoglobin A1C (HbA1C) in predicting joint infection. Further research is needed to evaluate whether patients who are to undergo elective orthopedic surgery should have routine screening for diabetes and hyperglycemia, as has been done for patients who are to have cardiothoracic surgery. Studies have reported 24 18, 21, 22 on the various preoperative tests that may be used to screen patients for malnutrition. Measures of malnutrition have varied and include transferrin, total lymphocyte count, total albumin, and prealbumin. Currently, parameters to evaluate nutritional status include serum albumin (normal 3. Due to the correlation between nutritional status and postoperative recovery, patients suspected of having 23 malnutrition should have their nutritional status checked prior to elective arthroplasty. While the optimal method for correction of malnutrition preoperatively is unknown, options to do so 24 include administration of high protein supplements, vitamin and mineral supplementation, 22 increased consumption of calories, early mobilization, and physiotherapy. The reason for this increased risk may be related to an increase in operative time, greater need for allogenic blood 27, 29-31 transfusion, and the presence of other comorbidities, including diabetes. The risk-benefit must be carefully considered, and appropriate informed consent/informed choice is paramount in this group as postoperative complications are higher in 32 this patient group. It is important to add that obese patients undergoing surgical procedures 33 are at increased risk of underdosed prophylactic antibiotics, and the dose of antibiotic should be accordingly adjusted, as discussed elsewhere in this document. Longer 25 periods of smoking cessation prior to surgery have been found to be associated with lower rates 35-38 of postoperative complications. Studies from orthopaedic and nonorthopaedic fields suggest that smoking intervention programs, even when instituted four-six weeks prior to elective surgery, may diminish the risk of infectious and wound-healing 40 complications. Alcohol Consumption Patients who consume alcohol on a frequent basis may have a significantly increased risk for 41 postoperative complications after arthroplasty. Using the Alcohol Use Disorders Identification Test-Consumption questionnaire on 9,176 male United States veterans who underwent major non-cardiac surgery, Bradley et al.
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Public Health Advisor Washington Department of Health Office of Immunization and Child Profile Gratitude is also expressed to the school nurses, local health jurisdictions, Washington State Department of Health staff members, licensed health care providers, and others who assisted in the review and updates of this material. Because the authority for control of diseases of public health significance lies with local health jurisdictions, schools should consult with their local health jurisdiction for guidance regarding specific measures to be used in handling individual cases or outbreaks of disease. Examples include chickenpox, cytomegalovirus, Fifth disease, measles, mumps, and rubella. Otherwise, this guide is not intended to be inclusive of adult/employee illness or disease. The law intends also that appropriate recommendation be made to the parent when medical treatment is necessary, and that parents be guided to an appropriate source of community sponsored medical care and/or their primary licensed health care provider. A school should report an outbreak that is associated with the school whether or not it involves a notifiable condition and should report any suspected cases of notifiable conditions that are not yet diagnosed. Cooperate as requested by the local health jurisdiction in investigations of diseases of public health significance. Additionally, schools are required to implement policies and procedures to maintain confidentiality of medical information possessed by the school. School staff should also report suspected or confirmed outbreaks associated with the school. Local health officers may require reporting of additional diseases and conditions within their respective jurisdictions. The local health officer shall take whatever action he/she deems necessary to control or eliminate the spread of the disease. It is recommended that each school district prepare and adopt, in advance, a policy addressing infectious diseases in students so that, when necessary, appropriate action is taken and the parent/guardian is notified without delay. The licensed health care provider will assess the risk and make appropriate recommendations for treatment of his/her patient.
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Aggressive drainage and irrigation of accessible sites of purulent infection should be performed as soon as possible. All foreign bodies, including those recently inserted during surgery, should be removed if possible. Skin and soft tissue infections, such as impetigo or cellulitis attributable to S aureus, can be treated with oral penicillinase-resistant betalactam drugs, such as cloxacillin, dicloxacillin, or a frstor second-generation cephalosporin. In this situation, or for the penicillin-allergic patient, trimethoprim-sulfamethoxazole, doxycycline in children 8 years of age and older, or clindamycin can be used if the isolate is susceptible. Trimethoprim-sulfamethoxazole should not be used as a single agent in the initial treatment of cellulitis, because it is not active against group A streptococci. Infections are more diffcult to treat when associated with a thrombus, thrombophlebitis, or intra-atrial thrombus. A longer course (eg, 7 to 10 days) is suggested if the patient is immunocompromised or the organism is S aureus; experts differ on recommended duration, but many suggest 14 days. If the patient needs a new central line, waiting 48 to 72 hours after bacteremia apparently has resolved before insertion is optimal. If a tunneled catheter is needed for ongoing care, in situ treatment of the infection can be attempted. If the patient responds to antimicrobial therapy with immediate resolution of the S aureus bacteremia, treatment should be continued for 10 to 14 days parenterally. If blood cultures remain positive for staphylococci for more than 3 to 5 days or if the clinical illness fails to improve, the central line should be removed, parenteral therapy should be continued, and the patient should be evaluated for metastatic foci of infection. Vegetations or a thrombus in the heart or great vessels always should be considered when a central line becomes infected. Transesophageal echocardiography, if feasible, is the most sensitive technique for identifying vegetations. However, contact precautions should be used for patients with abscesses or draining wounds that cannot be covered, regardless of staphylococcal strain, and should be maintained until draining ceases or can be contained by a dressing. Prophylactic administration of an antimicrobial agent intraoperatively lowers the incidence of infection after cardiac surgery and implantation of synthetic vascular grafts and prosthetic devices and often has been used at the time of cerebrospinal fuid shunt placement. Measures to prevent and control S aureus infections can be considered separately for people and for health care facilities. Community-associated S aureus infections in immunocompetent hosts usually cannot be prevented, because the organism is ubiquitous and there is no vaccine. However, strategies focusing on hand hygiene and wound care have been effective at limiting transmission of S aureus and preventing spread of infections in community settings. Specifc strategies include appropriate wound care, minimizing skin trauma and keeping abrasions and cuts covered, optimizing hand hygiene and personal hygiene practices (eg, shower after activities involving skin-to-skin contact), avoiding sharing of personal items (eg, towels, razors, clothing), cleaning shared equipment between uses, and regular cleaning of frequently touched environmental surfaces. Another promising technique is the use of bleach in the bath water 2 to 3 times a week (fi cup per fi tub or 13 gallons of water) for approximately 3 months; studies are ongoing to determine whether this intervention reduces the incidence of recurrent infections. Measures to prevent health care-associated S aureus infections in individual patients include strict adherence to recommended infection-control precautions and appropriate intraoperative antimicrobial prophylaxis, and in some circumstances, use of antimicrobial regimens to attempt to eradicate nasal carriage in certain patients can be considered. Children with S aureus colonization or infection should not be excluded routinely from child care or school settings.
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