Controlling and treating infectious diseases in primary care

4.4.2016 1

Controlling and treating infectious diseases in primary care

Topi Turunen, M.D.

Controlling and treating infectious diseases in primary care / Turunen

Disclosure

• National Institute for Health and Welfare (2/2016–)

• City of Lohja, HUCH hospitals Peijas & Lohja (–1/2016)

• No financial conflicts of interest

• Project coordinator / PSR-Finland (Strenghening Youth Friendly Health Services Through Community-Based Interventions in Rural India -hanke)

4.4.2016 Tartuntatautikurssi 2016 2

Content

Infection control in primary care

• Surveillance

• Diseases to report

• Vaccination schedule

Common infections in primary care

• Common respiratory tract, urinary, cutaneous etc. infections

• Some less common infections

• Practical issues

4.4.2016 Controlling and treating infectious diseases in primary care / Turunen 3

4.4.2016 4

Infection control in primary care

Topi Turunen, M.D.


Communicable Disease Act of 1986

• In English: http://www.finlex.fi/en/laki/kaannokset/1986/en19860583.pdf


Surveillance systems

• National Infectious Disease Register

– Founded 1995

– Operation based on the Communicable Diseases Act

• Doctors required to report 1) generally hazardous communicable diseases, 2) some other diseases (~30)

• Laboratories required to report 1) all positive blood- or CSF findings, 2) some other diseases (~70)


National Infectious Disease Register

4.4.2016 Esityksen nimi / Tekijä 7

Doctor

National Infectious

Disease Register

reminder

Laboratory

Population

register

12.9.2014 8

www.tartuntatautirekisteri.fi/tilastot

12.9.2014 9

What to report pt 1 – Generally hazardous diseases

• Hepatitis A

• Smallpox

• Yellow fever

• EHEC E. coli

• H5N1 Influenza

• Cholera

• Syphilis

• Diphteria

• Typhoid fever

• Paratyphoid fever

• Meningococcal disease

• Polio

• Plague

• Anthrax

• Salmonella*

• SARS

• Tuberculosis

• Hemorrhagic fevers

* No need for doctor’s report

What is ”generally hazardous”?

• Defined by the Communicable Diseases Act:

1. it is easily communicable or spreads rapidly;

2. it is dangerous; and

3. its spread can be prevented by measures aimed at persons who have such a disease or are justifiably suspected of having such a disease.

• The attending physician is primarily responsible for referring a patient (and others who may have caught it) to examinations and treatment


What does it matter?

• To prevent the spread of a generally hazardous disease, the following is possible…

– Compulsory physical examination and treatment

– Quarantine for a fixed period

– Ordering a person be absent from their gainful employment

– Obligation to report the manner, date and place of infection, and from whom it may have been caught

– Employer may demand a reliable account of not having a certain generally hazardous disease (TB, Salmonella)

– The police must provide executive assistance if needed.


12.9.2014 12

What to report pt 2 – other notifiable diseases

• Botulism

• CJD*

• Echinococcosis

• Haemophilus influenzae (only sepsis / meningitis)

• Hepatitis B

• Hepatitis C

• Pertussis

• HIV

• Chlamydia*

• Legionella

• Listeria

• Malaria

• Other mycobacteria than TB*

• Tick-born encephalitis*

• Rabies (incl. suspicion)

• Chancroid / LGV

• Mumps

• Gonorrhea

• Measles

• Rubella

* No need for doctor’s report

What is ”notifiable”

• Defined by the Communicable Diseases Act:

1. its monitoring presupposes information from a physician;

2. free of charge treatment for the patient is necessary to break the chain of infection; or

3. it is question of a disease that is preventable by a general vaccination programme.


National Immunization Programme (NIP)


• Vaccines given at child welfare clinics, schools, the military…

• Vaccines are voluntary

• Vaccines belonging to NIP are free of charge

Children and adolescents

• RV = rotavirus

• DTaP = diphteria, tetanus, acellular pertussis

• IPV = inactivated polio vaccine

• Hib = Hemophilus influenzae type B

• PCV = pneumococcal conjugate vaccine

• MMR = measles, mumps, rubella

• HPV = human papilloma virus


Rotavirus (RV) 2 mo

DTaP-IPV-Hib +RV +

PCV 3 mo

DTaP-IPV-Hib + RV

+ PCV 5 mo

DTaP-IPV-Hib + PCV 12 mo

MMR 12–18 mo

Seasonal influenza 6–35 mo (annually)

DTaP-IPV 4 y

MMR 6 y

HPV girls 11–12 y (catch

up 13–15 y)

dtap 14–15 y

Adults

• dT = diphteria, tetanus

• MMR = measles, mumps, rubella


dT-booster every 10th yrs

Polio

if travelling to

endemic country or

other countries with

the known risk of

wild polioviruses and

the last booster has

been given over 5

yrs ago

MMR

one or two doses if

not properly

protected previously

by vaccinations or

actually by the

disease in

childhood.

Specific risk groups

BCG children under 7 yrs*

PCV + PPV children under 5 yrs of

old**

Seasonal influenza

all at medical risk for

severe influenza

all 65 y or older

all pregnant

part of HP´s and Social

Workers

conscripts (the Finnish

Defense Forces)

relatives or close

persons of those who

are at higher risk to

have a severe

influenza.

• BCG = Bacillus Calmette-Guérin

• PCV = pneumococcal conjugate vaccine

• PPV = pneumococcal polysaccharide vaccine


*BCG-vaccinations only for children at

high risk

**Pneumococcal conjugate and

Pneumococcal Polysaccharide

vaccinations since 2010

Hepatitis A and B Some risk groups

Tick Borne

Encephalitis, TBE***

3 yrs and older living in

Åland (an island near

south-western coast)


4.4.2016 19

Common infections in primary care

Topi Turunen, M.D.


Upper respiratory infections

• Most are caused by viruses

• But check for possible bacterial infection

– Sinusitis

– Tonsillitis

– Otitis media

– Pneumonia

– …

• Even benign infections may lead to worsening of underlying disorders: asthma, COPD…


Viral upper respiratory infections

• Often managed by nurses, no need for doctor’s appointment

• No need for specific diagnostics

• Self-limiting, no antibiotics


Flunssa

Acute maxillary sinusitis

• Develops after viral URI in 0,5–5 % – usually takes at least 10 days

• Facial or dental pain, postnasal discharge

• Before antibiotics, diagnose with ultrasound, x-ray (or needle puncture – quite rare nowadays)

• 1st-line treatment: amoxicillin/penicillin


Poskiontelontulehdus

Tonsillitis

• Inflammation of pharyngeal tonsils: fever, sore throat, odynophagia, tender cervical lymph nodes

• Viral or bacterial – test before treating! If streptococcal, 1st-line treatment is penicillin

• Complication: peritonsillar abscess (severe pain, trismus, drroling etc.) – refer to ENT


Nielutulehdus / angiina

Mononucleosis

• Caused by Epstein-Barr virus, very common

• Often asymptomatic in early childhood, or: fever, sore throat, lymphadenopathy, splenomegaly, hepatitis

• Diagnosis by FBC, rapid test, antibodies (n.b.: can coexist with streptococcal tonsillitis)

• Warn about the possibility of splenic rupture


Mononukleoosi / ”pusutauti”

Acute otitis media

• Common follow-up of viral infections

• Fever, ear pain, difficulty hearing, irritability, loss of appetite, vomiting…

• Diagnosis by pneumatic otoscopy – note the color, position, mobility, and possible perforation


Korvatulehdus

• Most AOMs resolve by themselves; ”1st-line treatment” is paracetamol

• Discuss other treatment options with family

a) Amoxicillin right away (e.g. if <2 years, both ears affected, perforation)

b) Prescribe amoxicillin ”just in case” but suggest they wait for 2–3 days

c) New checkup after a few days

• Paracentesis performed very rarely

• Checkup after 1 month until effusion gone or consult ENT


Influenza

• Epidemic every winter

• Vaccinations given in Oct-Nov for free:

– Over 65-yr-olds

– Pregnant women

– Children aged 6–35 months

– Social & healthcare workers

– Conscripts

– Serious medical condition

– …and their relatives / close ones.


Influenssa

• After 2-3 days: high fever, chills, headache, muscle pains, cough…

• Diagnosis on clinical grounds (mostly) or by rapid test

• Treatment: supportive (oseltamivir / tsanamivir can be considered if symptoms for <48 h)

• Complications: pneumonia, sinusitis


Pneumonia

• Cough, high fever, dyspnea, chest pain

• Elderly may present with atypical symptoms, e.g. only confusion, no cough or fever

• Auscultate lungs, note respiratory rate & take X-ray

• Note: pneumococcal vaccine is in NIP for children and also recommended to the elderly and people with underlying medical conditions


Keuhkokuume

• Consider hospital care, if

– Notable changes in vital signs (RR, HR, temp)

– B-leuk <3 or >15 x 10E9

– Underlying illness

– Large infiltrate in X-ray

– Condition seems bad otherwise.

• 1st-line treatment

– At home: amoxicillin (consider macrolide or doxycycline if Chl. pneumoniae or M. pneumoniae suspected)

– In hospital: cefuroxime or penicillin i.v.


Some other viral diseases of children

• Difficulty breathing in

– Laryngitis / croup

– Laryngotracheitis

– Bacterial tracheitis

– (Epiglottitis)

• Difficulty breathing out

– Obstructive bronchitis

– Bronchiolitis

• Remember also: asthma, foreign object


Laryngitis / croup

• Caused by viruses. Common in 6 – 23 month-olds: hoarse voice, ”barking” cough, coldlike symptoms, stridor, respiratory distress

• Treatment: Cool air, consider p.o. corticosteroids, inhaled adrenaline

• Outpatient care usually sufficient, consider monitoring at hospital if severe difficulty breathing, bacterial pneumonia/tracheitis suspected etc.


Laryngiitti

Obstructive bronchitis / bronchiolitis

• Caused by viruses (e.g. RSV)

• Dyspnea (breathing out difficult), may have expiratory wheeze

• Treat with salbutamol

• Under-1-yr-olds often need hospital care


Bronkioliitti

Conjunctivitis

• Redness, itching, discharge – could be any inflammatory condition of the conjunctiva – but if purulent discharge, most likely bacterial or viral origin

• If any of the following, consider iritis, ceratitis, episcleritis or glaucoma instead – consult eye specialist

– Severe pain

– Light sensitivity

– Worsened vision

– Cornea or pupilla looks odd

• Cloramphenicol of fucidic acid drops/ointment


Sidekalvotulehdus

Erysipelas / cellulitis

• Bacterial infection of the skin

• Fever, redness, CRP & leuk ↑

• Often needs hospital care, 1st-line drug i.v. penicillin or e.g. cefuroxime (if staphylococcus suspected)


Ruusu / selluliitti

Urinary tract infections: Cystitis

• Dysuria, urinary frequency, lower abdominal discomfort, bloody urine

• Lab tests usually not required if pt is a woman aged 18-65 and symptoms typical: just treat.

– Urine dipsticks and culture widely available in health centers.

• Unsymptomatic bacteriuria is not treated - except with pregnant women


Virtsatieinfektio

• Treatment: nitrofurantoin, pivmecillinam or trimethoprim-sulfamethoxazole, 3 days usually enough

• UTI in males often involves prostate: do prostate exam, check PSA, treat with trimethoprim or ciprofloxacin for 7-14 days


Urinary tract infections: Pyelonephritis

• Fever, flank/back pain +/- lower UTI symptoms, CRP ↑

• P.o. fluorocinolones effective, e.g. ciprofloxacin for 7 days

• If hospital care required, e.g. i.v. cefuroxime or p.o. ciprofloxacin


Pyelonefriitti

Chickenpox

• Very common, benign infection in childhood, morbidity increased in adults and the immunocompromised, risk for fetal malformations in pregnancy

• Vesicular rash, possibly fever, malaise

• Treatment:

– Healthy children <13 years: usually none required

– Others: acyclovir (p.o. or i.v.)

• If immunocompromized person / pregnant woman exposed to VZV, consult internist/gynaecologist

•


Vesirokko

Ticks

• Ixodes ricinus (and to some degree, I. persulcatus) widespread in Finland

• Bite humans and animals e.g. during walks in tall grass

• Can carry

1. Lyme disease

2. Tick-borne encephalitis


Punkki

Lyme disease

• Caused by Borrelia sp. bacterium

• Early sign: erythema migrans rash

– No testing needed – treat with amoxicillin/doxycycline

• Late signs: lymphocytoma, arthritis, meningitis, facial paralysis, other neurological symptoms

• Removing the tick within 24 h is likely to prevent Lyme disease (but not TBE)


Borrelioosi

Tick-born encephalitis

• Often asymptomatic, or

– After 1 week: fever, malaise

– After 1–2 more weeks: encephalitis, fever, headache, light sensitivity, neurological symptoms

• Can be confirmed serologically

• A vaccine exists


Puutiaisaivokuume

Epidemic nephropathy

• Caused by Puumala virus (a hantavirus) in mostly Eastern and Central Finland, contracted from moles

• After 2–4 weeks, fever, headache, muscle pains, decreased or increased urination, proteinuria, hematuria, visual disturbance, vomiting, …

• FBC, CRP, creatinine, antibodies

• Treatment symptomatic

– Fluids, paracetamol

– Some may require dialysis


Myyräkuume

Underlying conditions

• Many infections can cause complications in people with

– Diabetes

– Asthma, COPD

– Alcoholism

– Corticosteroid or other immunosuppressive medication

– …

• …all of these are quite common in Finland!


Perussairaudet

A word on antibiotics

• In Finland, 80 % prescribed for respiratory infections

• Do have side effects

– Diarrhoea, C. difficile infections, UTIs

– Autoimmune conditions?

– Antibiotic resistance

– Cost

• Indicated in certain cases: even then, a narrow-spectrum drug (e.g. penicillin or amoxicillin) is often enough


Antibiootit

Most practices are equipped by…

• Bedside tests

– CRP

– Streptococcus A (rapid test / culture)

– Mononucleosis (rapid test)

– Influenza (rapid test)

– Urine dipsticks

• Otoscope, nose speculae

• Indirect laryngoscopy mirrors

• Tympanometer

• Sinus ultrasound


When in doubt…

• The Lääkärin tietokannat database

• The Käypä hoito guidelines

• Every municipality has “a physician in charge of communicable diseases” – ask them!


Health & Medicine

Controlling and treating infectious diseases in primary care