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By: U. Rathgar, M.B. B.A.O., M.B.B.Ch., Ph.D.
Medical Instructor, Uniformed Services University of the Health Sciences F. Edward Hebert School of Medicine
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Airborne transmission: particles 5 fim or smaller remain suspended in the air for prolonged periods, and therefore can travel longer distances and infect susceptible hosts several meters away from the source. Standard precautions represent a basic list of hygiene precautions designed to reduce the risk of healthcare-associated transmission of infectious agents. In addition to standard precautions, extra barrier or isolation precautions are necessary during the care of patients suspected or known for colonization, or an infection with highly transmissible or epidemiologically important pathogens. These practices are designed to contain airborne-, droplet-, and direct or indirect contact transmission. These precautions combine the 7 8 major features of universal precautions and body substance isolation, and are based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. Gloves should be worn if there is contact with blood, body fluids, secretions, excretions, mucous membranes, non-intact skin, or when potentially contaminated objects are manipulated. Gloves must be changed between patients and before touching clean sites on the same patient. Hand hygiene should be applied immediately after gloves are removed, before and between patient contacts. A mask and eye protection as well as a gown should be worn to protect mucous 3 membranes, skin, and clothing during procedures that are likely to result in splashing of blood, body fluids, secretions, or excretions. Reusable equipment should be cleaned and sterilized before reuse and soiled linen should be transported in a (double) bag. Needles should not be recapped, and all used sharps instruments must be placed in designated punctureresistant containers. Examples of conditions necessitating isolation precautions and a summary of measures to be taken are shown in Tables 7. Wear a clean, nonsterile gown when entering, and remove it before leaving the room. Limit transport of patients to medically necessary purposes, and maintain isolation precautions during transport. Patients with excessive cough and sputum production should receive a single room first. Therefore, susceptible healthcare personnel are restricted from entering the rooms of patients known or suspected to have measles, varicella, disseminated zoster, or smallpox. As for the other infections requiring airborne precautions, patients with suspected or known infection by Mycobacterium tuberculosis should be nursed in a private room where the air flows in the direction from the hall into the room (negative air pressure), with 6 to 12 (optimal) air changes per hour, and appropriate discharge of air outdoors. Cohorting can be done in rare circumstances for patients infected with strains presenting with an identical antimicrobial susceptibility. However, a moulded surgical mask may be as effective in dealing with healthcare associated outbreaks and better complied with because of cost. However, if transport is unavoidable, the patient should wear a surgical mask that covers both mouth and nose.
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Chapter 7 / Pharyngitis 85 A chart review study found that recurrent group A hemolytic streptococcal infections were more common in the 1990s than in previous decades (34). It is unclear whether patients have a relapse of the initial infection or are becoming re-infected. Numerous theories have been created to explain these findings, which include lack of compliance, repeat exposure, eradication of protective pharyngeal microflora, penicillin resistance, and antibiotic suppression of immunity (30). In patients with continued infection, other reservoirs of infection must be examined. Group A hemolytic streptococci can persist for up to 15 days on unrinsed toothbrushes and orthodontic appliances (35). Thorough rinsing of these items may decrease spread of infection and help to prevent re-infection. If a patient has a positive posttreatment culture, it means that the patient is a chronic carrier and is of little concern to spread infection. Chronic carriers will only be treated if they are associated with treatment failure in a close contact (9). Another treatment recommendation is that all patients with pharyngitis should be offered analgesics, antipyretics, and other supportive care. These tests will increase the accuracy of diagnosis, but will likely be more costly. The target for the vaccine is the streptococcal M protein, but this research will take many years to potentially reach the market (36). Future research may also need to be directed into recurrences of infection and changing drug sensitivities. Antibiotic prescribing for adults with colds, upper respiratory infections, and bronchitis by ambulatory care physicians. Illness in the home: a study of 25,000 illnesses in a group of Cleveland families. Number of hemolytic streptococci expelled by carriers with positive and negative nose cultures. The reemergenceof serious group A streptococcal infections and acute rheumatic fever. Reappearance of scarlet fever toxin A among streptococci in the Rocky Mountain West: Severe group A streptococcal infections associated with a toxic shock-like syndrome.
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When precautions are discontinued or the patient is moved, terminal cleaning of the room or bedspace and bathroom, changing of privacy curtains, and cleaning or changing of string or cloth call bells or light cords is required. Educate patients, their visitors, families and decision makers about the precautions being used, the duration of precautions, as well as the prevention of transmission of disease to others with a particular focus on hand hygiene. Instruct visitors who are participating in patient care about the indications for and appropriate use of personal protective equipment (barriers). This may not be necessary for parents carrying out their usual care of young children. Instruct visitors to speak with a nurse before entering the patient room, to evaluate the risk to the health of the visitor, the risk of the visitor transmitting infection, and the ability of the visitor to comply with precautions. If the visitor must visit more than one patient, instruct the visitor to use the same barriers as the health care workers and perform hand hygiene before going to the next patient room. Determine the duration of precautions on a case-by-case basis for patients with prolonged symptoms or who are immunosuppressed. Discontinue precautions only after the room or bedspace and bathroom have been terminally cleaned. Handling of Deceased Bodies Routine Practices, properly and consistently applied, should be used in addition to Contact Precautions for handling deceased bodies, preparing bodies for autopsy or transfer to mortuary services. In addition, some facilities and organizations may choose to include precautions for persons at risk of colonization, pending screening results, particularly in outbreak situations. Decisions will need to be made locally, considering the specific microorganism, the patient population, and local experience with duration of colonization. Recognize that patients placed on Contact Precautions may have fewer contacts with health care providers, and this may reduce their quality of care. Modifications for Contact Precautions for Long Term Care, Ambulatory Care, Home Care, Prehospital. Patient Placement, Accommodation and Activities Perform a point of care risk assessment to determine patient placement, removal from a shared room or participation in group activities on a case-by case basis, balancing infection risks to other patients in the room, the presence of risk factors that increase the likelihood of transmission, and the potential adverse psychological impact on the infected patient. Use of Personal Protective Equipment Wear gloves if direct personal care contact with the patient is required or if direct contact with frequently touched environmental surfaces is anticipated. Cleaning of Patient Environment In outbreaks, consider more frequent cleaning and cleaning with disinfectants. This includes bathing and toileting facilities, recreational equipment and horizontal surfaces in the patient room, and in particular, areas and items that are frequently touched. They should reflect the local experience with particular antimicrobialresistant organisms and be flexible enough to accommodate the characteristics of different antimicrobialresistant organisms. It is important to collaborate with other local health care organizations to design a comprehensive and consistent program.
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Feel free to ask other questions to help you gather sufficient information to make your qualification/disqualification decision. Any illness or injury in the last 5 years A driver must report any condition for which he/she is currently under treatment. The driver is also asked to report any illness/injury he/she has sustained within the last 5 years, whether or not currently under treatment. Seizures, epilepsy Ask questions to ascertain whether the driver has a diagnosis of epilepsy (two or more unprovoked seizures), or whether the driver has had one seizure. Gather information regarding type of seizure, duration, frequency of seizure activity, and date of last seizure. Eye disorders or impaired vision (except corrective lenses) Ask about changes in vision, diagnosis of eye disorder, and diagnoses commonly associated with secondary eye changes that interfere with driving. Complaints of glare or near-crashes are driver responses that may be the first warning signs of an eye disorder that interferes with safe driving. Ear disorders, loss of hearing or balance Ask about changes in hearing, ringing in the ears, difficulties with balance, or dizziness. Loss of balance while performing nondriving tasks can lead to serious injury of the driver. Obtain heart surgery information, including such pertinent operative reports as copies of the original cardiac catheterization report, Page 29 of 260 stress tests, worksheets, and original tracings, as needed, to adequately assess medical fitness for duty. High blood pressure Ask about the history, diagnosis, and treatment of hypertension. In addition, talk with the driver about his/her response to prescribed medications. The likelihood increases, however, when there is target organ damage, particularly cerebral vascular disease. As a medical examiner, though, you are concerned with the blood pressure response to treatment, and whether the driver is free of any effects or side effects that could impair job performance. Muscular disease Ask the driver about history, diagnosis, and treatment of musculoskeletal conditions, such as rheumatic, arthritic, orthopedic, and neuromuscular diseases. Does the diagnosis indicate that the driver is at risk for sudden, incapacitating episodes of muscle weakness, ataxia, paresthesia, hypotonia, or painfi However, most commercial drivers are not short of breath while driving their vehicles.
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Infection may occur after the ingestion of contaminated food or water as well as from person to person. Individuals primarily responsible for transmission include those who fail to clean hands and under fingernails thoroughly after defecation. They may spread infection to others directly by physical contact or indirectly by contaminating food. Water and milk transmission may occur as the result of direct fecal contamination; fiies can transfer organisms from latrines to uncovered food items. The elderly, the debilitated and the malnourished of all ages are particularly susceptible to severe disease and death. Common-source foodborne or waterborne outbreaks require prompt investigation and intervention whatever the infecting species. Institutional outbreaks may require special measures, including separate housing for cases and new admissions, a vigorous program of supervised handwashing, and repeated cultures of patients and attendants. The most difficult outbreaks to control are those that involve groups of young children (not yet toilet-trained) or the mentally deficient, and those where there is an inadequate supply of water. Closure of affected day care centers may lead to placement of infected children in other centers with subsequent transmission in the latter, and is not by itself an effective control measure. Preventive measures: Same as those listed under typhoid fever, 9A1-9A10, except that no commercial vaccine is available. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Case report obligatory in many countries, Class 2 (see Reporting). Recognition and report of outbreaks in child care centers and institutions are especially important. Patients must be told of the importance and effectiveness of handwashing with soap and water after defecation as a means of curtailing transmission of Shigella. Thorough handwashing after defecation and before handling food or caring for children or patients is essential if such contacts are unavoidable. Cultures of contacts should generally be confined to food handlers, attendants and children in hospitals, and other situations where the spread of infection is particularly likely.
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