How has AIDS changed in the past 26 years?
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drjohnhong 
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MRSA stands for Methicillin-Resistant Staphylococcus Aureus. S. aureus (which I will just call staph) is a bacteria commonly found on a lot of people’s skin and inside the nose (25-30% healthy people). Some Staph types weren’t responding to the antibiotic penicillin, so methicillin was developed to kill these resistant forms of staph in 1959. But MRSA is a sneaky bacterium and started to be resistant against methicillin by the early 1960’s – thereby earning the name MRSA (pronounced Mer-sa). About 1-2% people carry MRSA on their skin or in the nose. In 2005, MRSA was responsible for 94,000 life-threatening infections and 19,000 deaths in USA.
There are 2 types of MRSA: hospital associated (HA) and community-associated (CA) depending on the genetic makeup of the MRSA. But HA vs CA MRSA are now intertwining, so you can see each of them in the “wrong” setting – so some MRSA in the hospital are actually CA-MRSA and some community folks will have Ha-MRSA. 85% of infections are HA and 15% are CA
MRSA isn’t usually a problem and a lot of people probably have it but aren’t aware of it – because who gets routinely tested for MRSA? Almost nobody except those in a hospital or nursing home. So MRSA generally doesn’t cause trouble unless it enters the body through broken skin.
Those at risk for MRSA are those in the hospital and healthcare facilities, especially for those with prolonged hospital stays. Those who receive multiple antibiotics are also at risk for carrying MRSA. Other risk factors: overweight, cosmetic body shaving, skin trauma, lineman or linebacker position in football, prisoner, military, tattoo receipients, illicit drug use, having multiple health problems, and previous antibiotic use. And MRSA can be spread by direct contract with skin, clothes, linens, athletic equipment, hot tub or sauna benches. That is why in a hospital you have to “gown up” if a person is isolated for MRSA – so you don’t carry it and spread it around. MRSA likes to like in warm moist places, like the nostrils, navel, underarms, and groin.
Clinical: Colonization means the person carries MRSA on the skin or in the nose – but there is no infection. Infection means the MRSA is inside the skin or inside the body and causing harm. For hospitalized patients who acquire MRSA, 10-30% will have a problem with infection during or after their hospital stay. So found example after surgery a wound can not heal well due to MRSA infection. Skin infections from bed sores or needles can occur. UTIs especially those with a Foley catheter. If the skin becomes infected (such as a scrape occurs so the MRSA can enter), an abscess can form – which is a pocket of pus. The abscess usually is red, warm, tender, swollen – also called a boil. If the MRSA gets into the blood stream, it can infect internal organs like the lungs, bone, bladder, and brain. A fever is common when MRSA enters the blood stream. CA-MRSA has been known to cause necrotizing pneumonia, necrotizing fasciitis, and endocarditis (heart valve infection) are examples of MRSA infection.
Treatment: In general, CA-MRSA is easier to treat with antibiotics than HA-MRSA. So CA-MRSA often will be susceptible to Bactrim and Clindamycin while HA-MRSA won’t. For those with MRSA in the blood, IV antibiotics are often used. For the skin, the doctor can do an I&D (incision and drainage) of the abscess because oral antibiotics will not enter a pocket of pus well. So it has to be drained and then cleaned well until it heals. We do not treat colonization, but washes well in time can get rid of it.
Prevention: as always – wash your hands, tend any wounds well, stay out of contact with someone you know has MRSA, don’t share personal items (like athletic equipment, bathroom items), don’t demand for antibiotics for viral infections like the cold, and if you do take antibiotics make sure you finish your course so you don’t develop resistance. Alcohol-based hand sanitizers can work if hands are not visibly soiled.
Unfortunately a 17 year old Virginian boy died 10/15/07 of MRSA, though I do not have the details so I don’t know how he got MRSA inside of his body to lead to multi-organ infection. It is a very sad story.
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Chronic Kidney Disease (CKD) affects about 20 million American adults (1 in 9). CKD as defined by the National Kidney Foundation-Kidney Disease Outcomes Quality Initiative workgroup: “The presence of markers of kidney damage for 3 months, as defined by structural or functional abnormalities of the kidney with or without decreased glomerular filtration rate (GFR), that can lead to decreased GFR, manifest by either pathological abnormalities or other markers of kidney damage, including abnormalities in the composition of blood or urine, or abnormalities in imaging tests OR The presence of GFR <60 mL/min/1.73 m2 for 3 months, with or without other signs of kidney damage as described above. “
So basically means the kidneys are filtering the blood too slowly, and/or the kidneys are not filtering well and allowing proteins to spill through. GFR can be calculated by collecting a 24 hour urine sample, but now a days it is easier to estimate it by checking the blood and using some equations based on age, sex, weight, height. Normal GFR is 90-125/ml/min per 1.73m2
Stage 1 CKD: normal GFR but albumin in urine (a protein)
Stage 2 CKD: GFR 60-89 with albumin in urine
Stage 3 CKD: GFR 30-59
Stage 4 CKD: GFR 15-29
Stage 5 CKD (ESRD): <15
The Medicare-funded End-Stage Renal Disease (ESRD) program continues to increase. In 1973 there were 10,000 beneficiaries and in 2004 there were 472,099. Perhaps preventing CKD and managing CKD before it progresses to ESRD will save lives. Also the ESRD program cost about $32.5 billion in 2004, and it is anticipated another $28 billion more by 2010.
Risk factors for CKD include: High Blood Pressure, Diabetes, Family History, Older Age, Autoimmune Diseases like Lupus, Kidney stones, Kidney toxic drugs. US ethnic minorities have more CKD than US Caucasions, including African Americans, American Indians, Hispanics, Asian or Pacific Islanders
Screening/Testing: Blood creatinine to estimate the GFR. Urine for albumin/creatinine ratio to estimate if there is microalbumin – a even earlier detection of CKD.
CKD and Morbidity: many people with CKD have cardiovascular disease as well. Those with CKD have increased hospitalization by 3x. Mostly quality of life is decreased in CKD.
www.kidney.org and www.kidneyva.org are resources
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Rocky Mountain Spotted Fever (RMSF) is a tick-borne disease by a bacterium called Rickettsia rickettsii. Even though RMSF sounds like it is only in the Rocky Mountains (where it was first described), it occurs throughout all the Americas. It is most prevalent in the Southeastern and South Central states. North Carolina has a larger percentage of cases, though there aren’t that many cases overall. In 2004, 1,454 cases of RMSF were reported to the CDC.
I’m writing about this because a viewer/reader in Charlottesville, VA asked me to talk about it because her husband was severely affected by RMSF this year (2007). Rural and suburban regions have the most cases of RMSF though some cases from parks in NYC have been reported!
Spring and early summer is when RMSF appears the most, as most tick-borne illnesses are. Outdoors people are obviously most at risk – so, white men. Most cases are in people aged 40-64. Dog can carry the infected ticks and pass them on to their owners.
The common brown dog tick (Rhipicephalus sanguineus – wow say that 3 times fast, or at all) may be a vector (carrier) for RMSF. Possibly infection can occur without a tick bite, in which contamination might be due to contact or inhalation with tick poop or tick tissue.
Clinical: Incubation period is 2-14 days, but most occur a week after infection. Flu like symptoms occur first – in particular a fever, as in the name for RMSF. So there are headache, body aches, nausea. Belly pains occur usually in children. The RASH! That is why RMSF has its name. But it takes 3-5 days for the rash to develop after the flu symptoms occur. So that makes it difficult to diagnose RMSF initially. The rash starts on the ankles and wrists, spreading out from there including to the soles and the palms. It is red and very evident because they aren’t tiny – they are like large constituency of small dots to form polka dots. It isn’t an itchy rash nor like hives. However, 10% of cases don’t get the rash. Or in darker skinned folks, it might be missed. “Spotless RMSF” can be fatal because without seeing the rash, treatment is more likely to be started too late – and with RMSF, starting treatment soon is vital. After 5d of RMSF symptoms, the mortality rate increases with delayed treatment. One study showed those treated in the first 5 days vs. after the 5th day, the mortality rate was 6.5% vs 22.9% respectively. Though it is estimated the overall mortality rate is less at 3.3%. RMSF can cause bleeding, swelling, coughing, confusion, neurological problems including seizures. Gangrene can develop in the fingers, toes, ears, and in men the scrotum. Eventually all the internal organs can fail.
Diagnosis: blood tests can be falsely negative in the early stages of RMSF. So treatment is often initiated upon clinic history and physical exam. The blood test usually doesn’t pop up positive until 7-10 days after symptoms started. This IFA test is 95% sensitive 14-21d after the onset of illness. There is not a test for the tick itself should a patient bring it in.
Treatment: the antibiotic of choice is tetracycline. But in kids with growing bones (or a fetus in a pregnant woman), it can cause tooth and bone problems. Chloramphenicol is an alternative antibiotic. 1 week of antibiotics is usually curative.
Prevention: avoid tick bites. DEET so far is the only proven bug repellent against tick bites. Make sure you check your dog everyday for ticks. Check for ticks on the body everyday. It is estimated it takes about 24 hours for a tick to transmit disease to a person. Prophylactic antibiotics are not recommended. There is no vaccine.
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Tuberculosis (TB): what does PPD+ test mean?
TB (tuberculosis) is a very old bacterial disease that has killed millions and millions of people in the world throughout time. However in the US, TB cases dropped between 1953 to 1985 (from 84,304 to 22,201 per year). With HIV & AIDS, the cases has increased since 1985.
PPD is something everyone hears about but don’t quit understand. It is a skin test to see if a person has been infected with TB. TB usually doesn’t cause active disease (such as the classic pneumonia) right away. In HIV negative people maybe 2-5% will have active TB in the first 3 months (this is called Primary Infection). Some studies indicated primary TB infection might be more like 10% in HIV negative people. For others, TB lays dormant and harmless but there is a 10-20% lifetime risk of it becoming very active – usually when the immune system is down (this is called LTBI-latent tuberculosis infection
So the bottom line on PPD positive skin test: yes, the person has been infected with TB. But it doesn’t mean that person is contagious if the TB isn’t active. If it is dormant, it is a question of if it will become active to cause pneumonia, or even be active in other organs like the kidneys or nervous system.
Andrew Speaker, the personal-injury lawyer, is on the news June 2007 for traveling internationally with a MDR-TB (multi-drug resistant TB). MDR-TB means it is resistant to both antimicrobial drugs, isoniazid and rifampin – the hallmark drugs to cure TB. Often MDR-TB will be resistant to other antimicrobials as well, called XDR-TB: extensively drug-resistant TB. Because people often don’t take their TB medications as instructed (meaning missing doses or ending treatment early), TB strains are becoming resistant to the medicines.
Treatment of PPD+ skin test. Traditionally if someone was over the age of 35 and PPD+, no treatment was given (meaning isoniazid and/or rifampin) because the risk of liver failure on the isoniazid was greater than the risk of developing active TB. However, things have changed and if someone is PPD tested, they need to be prepared to take medicine for 9 months.
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