Infectious Disease in Elderly: Tuberculosis & Sinusitis Module

1. Infectious Disease in the Elderly in Community and Long Term Care Facilitiesmodule 3Respiratory diseases:Tuberculosis and SinusitisUnit two UNMC Section of Infectious Diseases Brandi L. Lesiak, PA-C, MPAS Kim Meyer, PA-C, MPAS Claudia Chaperon APRN, Phd Ed Vandenberg MD CMD up dated 11-23-06

2. PROCESS A series of modules and questions Step #1: Powerpoint module with voice overlay Step #2: Case-based question and answer Step # 3: Proceed to additional modules or take a break

3. Objectives Upon completion, the learner will be able to: • Describe the appropriate screening, diagnosis, evaluation and treatment for Tuberculosis • List the common organisms, the diagnostic approach and treatment of sinusitis in the elderly.

4. Tuberculosis

5. 2 step PPD skin test required for all new admits to LTCF for LTCF employees Routine PPD skin test for health care workers required Latent TB Infection (LTBI) 2 step PPD procedure O.5 ml intermediate strength PPD Check at 48-72 hrs If negative repeat within 1-3 weeks Record reaction in mm. TuberculosisScreening

6. Positive if: 5 mm or greater in: HIV positive recent contacts xray changes c/w TB immuncompromised or organ transplant patients 10 mm or greater in: residents/employees of nursing homes or hospitals recentarrivals (< 5 years) from high-prevalence countries 15 mm in: general population Used with permission from Images.MD 12-20-05

7. TuberculosisDiagnosis • Symptoms: • Cough, hemoptysis, weight loss, fever, night sweats, weakness, chronic fatigue, • At risk; exposure to a person with known tuberculosis • New serological test for latent Mycobacterium tuberculosis may hold promise in dx of select patient populations.

8. TuberculosisEvaluation & Treatment • If positive skin test and symptoms • Get CXR • Place in isolation until results of CXR available • If CXR positive with infiltrates, obtain sputum for AFB x 3 and cultures • If AFB and cultures positive, start 4 drug therapy (typically 6 to 9 months, but may vary depending on resistance)

9. TuberculosisEvaluation & Prophylaxis • If CXR negative and no active symptoms patient may be candidate for prophylaxis with INH if: • New converter or is in LTCF • Other prophylaxis decided on case by case basis • If requires prophylaxis INH + pyridoxine for 6-9 months, and follow LFTs -INH 5 mg/kg/d ( max 300 mg) -B6 ( pyridoxine) 50 mg a day

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14. Sinusitis

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16. Diagnosis History Exam Sinus x-ray (Cauldwell and Water’s view) CT ENT referral – rhinoscopy Sinusitis Used with permission from Images.MD 12-20-05

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19. Sinusitis • Causative organisms: • Streptococcus pneumonia, Hemophilus influenza, Moraxella catarrhalis • May be preceded by viral upper respiratory infection • Chronic sinusitis may be secondary to obstruction of sinus ostia, (polyps or multiple other causes).

20. Medical Management of Sinusitis (3)

21. The End of Module Three on Respiratory infectious diseases in the Elderly

22. Post-test • An 80-year-old man with dementia is found to have 15 mm of induration following routine Mantoux skin testing with purified protein derivative (PPD). He has been a resident of a nursing facility for the past 5 years, and he has been screened for tuberculosis annually. His previous PPD skin tests were negative. The patient denies cough. He feels well, his weight is unchanged, and his physical examination is normal. A complete blood cell count, serum electrolyte panel, liver function tests, and chest radiograph are normal. • What is the most appropriate pharmacologic management of this patient at this time? Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.

23. What is the most appropriate pharmacologic management of this patient at this time? • No treatment is necessary. • Begin isoniazid plus pyridoxine. • Begin isoniazid, pyridoxine, rifampin, and ethambutol. • Begin isoniazid, pyridoxine, rifampin, ethambutol, and pyrazinamide

24. Answer: B. Begin isoniazid plus pyridoxine. The purified protein derivative (PPD) skin test is used as a screening test to detect persons who may have had exposure to Mycobacterium tuberculosis and could develop clinically apparent infection with that organism. Unfortunately, a positive PPD skin test reaction is not specific for M. tuberculosis. Exposure to other mycobacteria normally present in the environment can also result in a positive PPD skin test. Thus, the significance of the size of the zone of skin induration that occurs following the administration of PPD must be interpreted with the knowledge of the patient’s risk of developing infection himself or transmitting it to others.

25. The positivity of the skin test can then be used to determine whether a patient requires prophylaxis for clinically latent, inapparent disease or treatment for active infectious tuberculosis. Very small zones of induration (≥ 5 mm) are considered to be positive test findings when the risk of developing active infection is particularly high (eg, in HIV-positive persons, close contacts of newly diagnosed infectious tuberculosis, or in the setting of chest radiographic evidence of old, healed tuberculosis). Somewhat larger zones of induration (≥ 10 mm) are considered positive findings when patients have disorders that place them at somewhat lesser risk of developing active tuberculosis infection than HIV (such disorders include diabetes mellitus, immunosuppressive therapy, hematologic malignancy, and end-stage renal disease). For patients older than 35 years without the above risk factors, a skin test ≥ 15 mm is considered to be positive.

26. The elderly nursing-home resident in this case has an increase in the area of skin induration in response to PPD from 0, recorded on numerous occasions over several years, to positive (15 mm). A change in skin test from negative to positive within a 1-year period presumes that the patient—a new converter—has been newly exposed to tuberculosis and is at increased risk of developing clinically apparent infection within 1 to 2 years.

27. New skin converters should receive antituberculous prophylaxis because the risk of infection to the patient and spread of infection to others outweighs the risk of drug toxicity. In elderly patients with clinically latent infection likely due to a susceptible organism, a single drug such as isoniazid plus pyridoxine is sufficient to prevent active clinical disease because the burden of mycobacteria and their rates of replication are low. • This patient should receive prophylaxis with one antituberculous agent because he shows no evidence by history, physical, or laboratory examination of actively replicating tuberculous infection that requires treatment with a minimum of two or more antituberculous agents. end

28. Resources Tuberculosis (1)MMWR 1990; 39 (No. RR-10) (2) CDC website http://www.cdc.gov/mmwr/preview/mmwrhtml/00001711.htm Accessed 12-17-05 Sinusitis (3) The Sanford Guide to Antimicrobial Therapy 2006, pages 36-37