Preferred Treatments: Ceftazidime and Avibactam (Avycaz)
CONTRIBUTION TO ANTIBIOTIC RESISTANCE
Healthcare Provider Contributions:
May contribute through over-prescription or incorrect usage of antibiotics.
Patient Contributions:
Lack of adherence to dosage guidelines and the complete course of treatment.
Patient & Caregiver Education Tables:
Refer to Tables 15-7 & 15.9 for recommended educational materials.
TYPES OF ISOLATION PRECAUTIONS
Standard Precautions:
Used for all patients, regardless of diagnosis or infection status.
Includes handwashing and the use of appropriate personal protective equipment (PPE).
Transmission-Based Precautions:
Airborne Precautions:
For infections spread by small particles in the air (e.g., Varicella, Measles, TB).
Droplet Precautions:
For infections spread by large droplets (e.g., Influenza, Bacterial Meningitis).
Contact Precautions:
For infections spread through skin-to-skin contact (e.g., C. difficile, MRSA, VRE).
DRUGS USED TO TREAT INFECTIONS
Selection Criteria:
The selection of drugs for treating infections considers the type of infection, pathogen involved, and patient factors.
INFECTIONS IN THE AGING ADULT
Higher Rates of HAIs:
Hospital-acquired infections (HAIs) occur two or three times more often in older patients than in younger patients.
Common UTIs:
Urinary tract infections (UTIs) are more prevalent in older adults, especially within long-term care facilities.
Risk Factors:
The presence of indwelling catheters increases the risk of infections.
Atypical Symptoms:
Older adults can present with cognitive and behavioral changes as indicators of infection rather than classic symptoms like fever, pain, or lab alterations.
Important Note: Do not solely rely on the presence of fever to indicate infection, as many elderly individuals display lower core body temperatures and diminished immune responses.
HUMAN IMMUNODEFICIENCY VIRUS INFECTION
Epidemiology:
More than one million people in the U.S. are living with HIV.
Approximately 37,600 new infections occur annually.
Death rates have been decreasing due to advancements in treatment.
HIV INCIDENCE STATISTICS
As of 2019, newly reported HIV infections reduced by 8% from 2015 to 2019.
Total Number of HIV Diagnoses in 2019:
36,801 diagnoses, with 87% of the estimated 1.2 million people with HIV in the U.S. aware of their status.
Regional Distribution of Diagnoses:
(Percentage breakdown by region available in the original document).
TRANSMISSION OF HIV
Body Fluids:
HIV is transmitted through body fluids: blood, semen, vaginal secretions, and breast milk.
The virus can be transmitted a few days after infection and continues for life.
Modes of Transmission:
Not transmitted through casual contact.
Unprotected Sex: Most common mode of transmission.
Blood Products: Transmission from exposure to infected blood (1%).
Perinatal Transmission: During pregnancy (25% risk), delivery, or breastfeeding.
Risk can be reduced to <2% if the HIV-positive mother is treated with Antiretroviral Therapy (ART).
PATHOPHYSIOLOGY OF HIV
Type of Virus:
HIV is an RNA virus, specifically a retrovirus, which replicates backward (RNA to DNA).
Replication and Targeting:
HIV cannot replicate without a host, targeting CD4 T-cells.
Triggers reverse transcriptase for conversion from RNA to DNA.
CD4 Count and Immune Function:
Normal CD4 count is between 800-1200 cells/μl.
> 500 cells/μl: minimal immune effects.
< 500 cells/μl: immune impairment.
< 200 cells/μl: risk for opportunistic diseases.
ACUTE HIV INFECTION
Viral Load:
Characterized by a high viral load during the initial phase.
CD4 T-cell Response:
CD4 counts initially fall but return to baseline within 2-4 weeks post-infection.
Includes an interval of approximately 10 years between HIV and AIDS.
Typically asymptomatic with limited signs of infection; individuals may be unaware they are infected and can still transmit the virus.
Symptomatic Infection:
Manifestations appear as the CD4 T-cell count drops below 200 cells/μl.
HIV progresses to an active stage with symptoms like persistent fever, night sweats, chronic diarrhea, recurrent headaches, and severe fatigue.
Common Infections During Symptomatic Stage:
CD4+ T cells drop leading to opportunistic infections such as shingles (varicella-zoster virus), oral & genital herpes, Kaposi sarcoma, oral hairy leukoplakia (Epstein-Barr virus), Candida overgrowth, thrush, and vaginal yeast infections.
ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS)
Criteria for Diagnosis:
An individual with HIV is diagnosed with AIDS if they meet any of the following:
CD4+ T-cell count drops below 200 cells/μl.
Development of one of the following opportunistic infections:
Fungal
Protozoal
Bacterial
Viral
Development of one of the following opportunistic cancers:
Invasive cervical cancer
Kaposi sarcoma (KS)
Burkitt's lymphoma
Immunoblastic lymphoma
Primary lymphoma of the brain
DIAGNOSTIC STUDIES
HIV Detection Timelines:
It takes several weeks for HIV to be detected (window period).
Testing during this time can result in a FALSE NEGATIVE.
Types of Testing:
HIV Antigen Testing (Blood):
Rapid HIV-Antibody Testing:
Accurate and convenient, with results available in 20 minutes.
In-home HIV test kits available (saliva test).
Screens for antibodies, not for antigen.
If the rapid test is negative, assess risk and determine the need for repeat tests.
MONITORING TESTS
Components:
CD4 T-cell Count:
Marker for immune function with a normal range of 800-1200 cells/μL.
Viral Load:
Assesses disease progression; lower viral load indicates less active disease.
Complete Blood Count (CBC):
Common observations include changes in WBC, lymphocytes, neutrophils due to the disease, and RBC, platelets due to ART.
INTERPROFESSIONAL CARE GOALS
Focus Areas:
Monitor HIV disease progression and immune function.
Initiate and monitor Antiretroviral Therapy (ART).
Prevent development of opportunistic diseases.
Detect and treat opportunistic diseases promptly.
Manage symptoms effectively.
Prevent or decrease complications from treatment.
Prevent further transmission of HIV.
DRUG THERAPY GOALS
Reduce the viral load.
Maintain or raise CD4+ counts.
Prevent symptoms of HIV and opportunistic infections.
Delay disease progression.
Prevent HIV transmission.
Effectiveness of ART:
ART therapy can reduce viral load by 90-99% if taken consistently at the same time each day.
DRUG THERAPY STRATEGIES
Approach:
Attack HIV at different points in the replication process using various drug classes.
ART Combination:
Generally involves prescribing 3+ drugs from different groups at full strength, often in a single pill taken once daily.
This strategy helps reduce the risk of drug resistance.
Preventive Measures against Opportunistic Infections:
Immunizations (e.g., for hepatitis B, influenza, pneumococcal infections).
PRE-EXPOSURE PROPHYLAXIS (PrEP)
Definition of PrEP:
PrEP is a daily medication that can significantly reduce the chance of getting HIV.
Highly effective when adhered to daily; less effective if not taken consistently.
Important to note that while PrEP reduces HIV risk, only condoms protect against other STDs (e.g., syphilis, gonorrhea).
HIV PREVENTION
Strategies for Modification of Risk Behaviors:
Address risks related to sexual intercourse, drug use, perinatal transmission, and occupational exposure to HIV.
CDC Risk Reduction Tool:
Accessible at https://hivrisk.cdc.gov/
EDUCATION ON HIV MANAGEMENT
Improving Adherence to ART:
Education on timing, costs, side effects, and drug interactions (e.g., antacids, PPI, St John’s Wort).
Consequences of Poor Adherence:
Poor adherence can lead to treatment failure and increased viral load.
DELAYING PROGRESSION OF HIV
Importance of Early Treatment:
Initiating HIV treatment early is crucial to achieving an undetectable viral load.
Maintaining an undetectable viral load is essential to prevent transmission to HIV-negative partners during sexual activity.
Regular visits to healthcare providers and adherence to medication are vital for effectiveness.
Resources for finding a healthcare provider include locator.hiv.gov.
EDUCATION AND SUPPORT
Concept of Undetectable Viral Load:
Achieving an undetectable viral load signifies effective treatment.
Patients should report any concerning symptoms to their provider (see Table 14.9).
Utilizing Technology for Care:
Access to care provider networks and resources is essential for steady care and management.
Lifestyle Recommendations:
Promoting healthy eating and exercise contributes to overall health and supports the immune system in combating infections.
SOCIAL CONSTRUCTS
Social Stigma Associated with HIV:
Individuals with HIV may face stigma due to behaviors perceived as immoral or uncontrollable, leading to discrimination.
Discrimination often results in significant social impacts such as job loss, homelessness, and loss of insurance, disproportionately affecting women.
Legal Protection:
The Americans with Disabilities Act offers protections against discrimination for individuals with HIV.
MONITORING PROGRESS TOWARD HIV EPIDEMIC GOALS
CDC Indicators:
Incidence: Reduce new infections by 75% by 2025.
Diagnoses: Reduce new HIV diagnoses by 75% by 2025.
Knowledge of Status: Increase awareness of HIV status to 95% by 2025.
PrEP Coverage: Increase PrEP coverage to 50% by 2025.
Linkage to Care: Link 95% of newly diagnosed individuals to care by 2025.
Viral Suppression: Increase viral suppression rates among diagnosed individuals to 95% by 2025.