Category: Infection

Background The function of the skin is to provide an extreme barrier against bacterial infection. In each day, many bacteria are in contact with the skin and they may cause an infection. The bacteria infection also can range from a small spot to a massive part of the body. In addition, some infections have been reported to be harmless and others life-threatening (Magnussen 1991; Stulberg, Penrod & Blatny 2002, pp. 119–24). The two common bacteria that infect the skin are Staphylococcus and Streptococcus. However, research has indicated the likelihood of skin infections in some particular groups of people (Wannamaker 1970, pp. 23-31). For instance, diabetic patients have poor blood circulation to the feet and hands, and white blood cells are unable to fight infections due to high sugar levels. In addition, people with low immunity are likely to get infected than their counterparts. Introduction Impetigo is a bacterial skin infection, the fourth most common dermatological skin disorder in children seen in general practice. Impetigo is a type of skin infection caused by Staphylococcus aureus or Streptococcus pyogenes or both (Koshi 1982, pp. 11-4; Ruoff, Whiley & Beighton 2003). The major symptoms brought about by impetigo are scabby skin; the sores are yellow-crusted and in some patients, the sores contain blisters filled with yellowish fluid. Impetigo is a common infection mostly affecting children. It can affect any part f the body although it mostly affects the arms, feet and face. The blisters formed are called bullous impetigo and occur in varying sizes from pimple-like to large balls which may last for several days or weeks. Although impetigo may affect normal skin, most commonly affected skin had previously been injured, insect bitten, sun-burned or fungal infected. Other environmental factors suggested to have contributed to impetigo infection include moist conditions and poor hygiene. Recent research has demonstrated that some individuals are nasal carriers. Nasal carriers have Staphylococcus bacteria in their nose which cause no harm (Procop & Wilson 2001, pp. 1589–601). However, they may accumulate and cause repeated infections in some individuals and others. What’s more, impetigo infections are itchy and to some extent painful. The slight itchy skin turns to a considerable scratching which leads to skin breakage and contributes to more spread of the infection. This is because impetigo is extremely contagious to other areas of the body as well as to other people. The clusters of sores typically rapture and a yellow-colored crust develop over them. In addition, a case of bullous impetigo has been reported to be similar except that the sores in some individuals may enlarge to form painful blisters. When the blisters burst, a large base is eventually exposed which becomes covered by yellow-colored varnish or crust. Impetigo is diagnosed by the appearance of rashes. Laboratory diagnosis. The diagnosis of infectious skin disease requires the combination of a number of laboratory and pathological tests. This involves microbiological cultures for isolation and for identifying the causative organisms in addition to antimicrobial susceptibility testing (Johnson et al. 1996). The diagnosis for impetigo is based on clinical history, physical examination findings and if necessary, culture and Gram staining. The swab is taken from the patient and cultured in the laboratory. Although swabs are inexpensive samples for culture, they possess a number of disadvantages such as, they are most likely to be contaminated, they inhibit the growth of pathogens, insufficient volumes for culturing, microorganisms may fail to appear on the Gram staining, among others. Cytopathologic examination such as Gram staining provides preliminary diagnoses more rapidly than a culture particularly when culture yields bacteria that could be pathogenic or contaminant. Gram stain is an insensitive test for detecting bacteria (Winn et al. 2006). However, gram-positive may sometimes lose the ability to retain crystal violent and appear as gram negative whereas gram-negative may appear as magenta and be misinterpreted as gram-positive bacteria. In addition, bacteria grow in the different milieu and therefore fail to exhibit the same morphological characteristics. For instance, staphylococci may not form clusters, and streptococci may not form chains (Howard et al. 1993). Organism identification Most laboratory tests have reported a group of microorganisms in the impetigo samples. Commonly named are streptococcus and methicillin-resistant Staphylococcus aureus (MRSA). Other laboratories results have also identified Gram-positive cocci, S. anginosus and Peptostreptococcus micros by utilizing a serological streptococcal typing kit in their investigation. Optimal collection and transport instructions for the sample One of the major disadvantages of skin sampling is that once sin microorganisms have been removed and put into a liquid storage medium, their viability begins to drop very rapidly. For instance, a recent finding of stored skin microbes at room temperature in phosphate-buffered saline established that 20% of the microbes die after one hour. After 24-hours, less than 5% were viable. Samples therefore must be rapidly plated out and the best way to achieve this is to process them at the location they were taken (Collee & Marr 1996). Such problems sample collection and processing are usually overcome by either the patient attending the hospital or the Mobile Microbiology Laboratory unit. The patient cutaneous microflora is usually sampled using a range of established techniques. These include techniques for sampling microorganisms on the skin surface in the skin squames and from the skin surface. Once the samples have been taken, they are processed immediately using the onboard facilities (Lawrence & Ameen 1998, pp. 232–3).

The swab suspension is spiral plated using the WASP system onto a range of media that are selective for micro-organisms. To culture propionibacteria a Reinforced Clostridial Agar is used whereas Iso-Sensitest Agar is used for coagulase-negative staphylococci. In addition, Malassezia furfur medium has been formulated for the yeast. These plates are incubated for appropriate time Malassezia furfur (14 days), propionibacteria (7 days) and coagulase-negative staphylococci (48 hours). After incubation, a total viable count is carried out using techniques such as the Protocol automated colony counter (Okano Noguchi & Matsumoto 2000, pp. 942-4). Finding’s report An impetigo analysis was studied through clinical data and microorganisms samples collected from a given number of patients with the disease (Mathai & Thomas 2006, pp. 46-8). After sample culturing, the patients are usually grouped in accordance with their different skin cultures. A certain percent will be reported to have S. aureus-positive skin culture or bullous and non-bullous impetigo isolates. Nasal carriers are also categorized as well as Methicillin-resistant S. aureus (Kaplan & Wannamaker 1974, pp. 205-8). This kind of data report is important to doctors to understand the most prevalent infection and to determine key preventions. Treatment If a person is suspected to have repeated infections, a scrub of the nose is taken and checked in the laboratory if the person is a nasal carrier of staphylococci. Care should be taken at the infected areas. People are advised to wash the infected places gently with soaps and water numerous times a day in order to remove the crusts. Generally, topical antibiotics have been used to treat small infected areas (Dobie & Gray 2004, pp. 74-7). On the other hand, if large areas are to be treated, oral antibiotics have responded positively. Nasal carriers are usually treated by spreading topical antibiotics to the nasal passages. Since impetigo is contagious, the school nurse is greatly concerned with this infectious disease. A child may be required to leave school until he or she is treated (Koning & van-der Wouden 2004, pp. 695-6). For the individual patient, impetigo is a minor disease as a cure can be expected within weeks with most treatments. In developed countries, serious complications such as acute glomerulonephritis are rare. Recent research has suggested that treatment of impetigo with topical antibiotics is at least more effective than treatment with oral antibiotics. However, a considerable threat has been imposed on the resistance rates of Staphylococcus aureus against fusidic acid (topical antibiotic) and calls for its prudent use (Woodhead, Fleming & Wise 2004; Espersen 1998, pp. 4-8).

Conclusion Most medical organizations offer mobile test trials to patients which make treatments effective the skin diseases. The new treatments for impetigo concentrate on reducing or removing these bacteriological from the skin surface (Stevens 1992, pp. 2 -13). Clinical trials for novel drugs are applied to human skin since they contain unique features absent in animal skin. Healing of impetigo is expected if an appropriate antibiotic is used between 7 to 10 days. However, cases of antibiotic-resistant strain are becoming common and therefore alternative therapy should be used. Moreover, one way of preventing impetigo is by keeping the skin clean especially around rashes or wound areas. Also, avoid touching other areas of your body to lessen spread as well as sharing personal items like towels.

References

1. Collee, J. & Marr, W. 1996, ‘Specimen collection, culture containers and media’, In : Mackie & McCartney Practical Medical Microbiology, Collee JG, Fraser AG, Marmion BP, Simmons A. editors. Churchill Livingstone: Edinburgh, p. 103
2. Dobie, D. & Gray, J. 2004, ‘Fusidic acid resistance in Staphylococcus aureus’, Archives of Disease in Childhood, vol. 89, no.1, pp. 74-7.
3. Espersen, F. 1998, ‘Resistance to antibiotics used in dermatological practice’, British Journal of Dermatology, vol. 139, no. 53, pp. 4-8.
4. Howard, B. et al. 1993, Streptococci and related organisms, In Clinical and Pathogenic Microbiology, 2nd edn. Mosby Co. St. Louis, MO. James, D., Berger, H., Timothy, G. et al. 2006, ‘Andrews’ Diseases of the Skin’, Clinical Dermatology, Saunders Elsevier
5. Johnson, D. R., Kaplan, E.L., Sramek, J. et al. 1996, Laboratory diagnosis of group A streptococcal infections, World Health Organization, Geneva.
6. Kaplan, E. & Wannamaker, L. W. 1974, ‘Streptolysin O. Suppression of its antigencity by lipids extracted from skin’, The Society for Experimental Biology and Medicine, vol. 147, no. 2, pp. 205-8 Koning, S., & van-der Wouden, J. 2004, ‘Treatment for impetigo’, British Medical Journal, vol. 329, no. 2, pp. 695-6.
7. Koshi, G. 1982, ‘Microbiological confirmation of streptococcal pharyngitis’, ICMR Bull, vol. 12, no. 2, pp. 11-4
8. Lawrence, C. & Ameen, H. 1998, ‘Swabs and other sampling techniques’, Journal of Wound Care, vol. 7, pp. 232–3
9. Magnussen, R. 1991, Skin and soft tissue infections, In RE Resse, RF Betts (edn.) A Practical Approach to Infectious Diseases 3 edn. Little, Brown and Company, Boston, MA. Mathai, E. & Thomas, C. 2006, ‘Interpretation of Bacterial Culture and Antimicrobial Susceptibility Reports’, Indian Journal for the Practicing Doctor, Vol. 3, No. 4, pp. 46-8. Okano, M., Noguchi, S. & Matsumoto, Y. 2000, ‘Topical gentian violet for cutaneous infections and nasal carriers with MRSA’, International Journal of Dermatology, vol. 39, no. 2, pp. 942-4
10. Procop, G. & Wilson, M. 2001, ‘Infectious disease pathology’, Journal Clinical Infectious Diseases, vol. 32, pp. 1589–601.
11. Ruoff, K., Whiley, R. & Beighton, D. 2003, Streptococcus, In PR Murray, et al (edn.), Manual of Clinical Microbiology, 8 edn., American Society for Microbiology, Washington, D.C.
12. Stevens, D. 1992, ‘Invasive group a streptococcus infections’, Journal Clinical Infectious Diseases, vol. 14, no. 1, pp. 2 -13. Stulberg, D., Penrod, M. & Blatny, R. 2002, ‘Common bacterial skin infections’, American family physician, vol. 66, no. 1, pp. 119–24
13. Wannamaker, L. 1970, ‘Differences between streptococcal infections of the throat and skin’, New England Journal of Medicine, vol. 282, no. 1, pp. 23-31.
14. Winn, W., Allen, S. D., Janda, W. et al. 2006, Koneman’s color atlas and textbook of diagnostic microbiology, 6 edn, J.B. Lippincott, Philadelphia.
15. Woodhead, M., Fleming, D. & Wise, R. 2004, ‘Antibiotics, resistance and clinical outcomes’, British Medical Journal, vol. 328, pp. 1270-1.

Abstract

The systematic review is devoted to the consideration of the reasons for urinary tract infection and the measures which are to be taken in order to reduce the cases of contamination. The focus of this paper is the research based on defining a minimized introduction of microorganisms for adult patients with short-term insertion or removal of a catheter in comparison with no risk of infection. The review shows that there is no specific difference whether sterile or nonsterile catheter technique takes place as simple water cleaning may help. Besides, the review shows that personal hygiene around the meatal area is important as failure to do it may cause serious urinary tract infections. Additionally, the review points to several techniques which are to be utilized in order to reduce infection.

Pico Question

What would minimize the introduction of microorganisms for adult patients with short-term insertion or removal of a catheter in comparison with no risk of infection?

Discussion of Systematic Review for the PICO Components

P: adult patients

I: short-term insertion or removal of a catheter

C: no risk of infection during insertion or removal of a catheter

O: minimized introduction of microorganisms for adult patients with short-term urinary catheter

The authors’ objectives for the systematic review

The main objective of the selected review conducted by Sandeep Moola and Rie Konno (2008) was to consider as much research in the sphere of the reasons of the urinary tract infection as possible with the purpose to define the best evidence aimed at preventing contamination associated with the utilization of sterile catheter technique vs. nonsterile one in a short-term period. The review gathered information devoted not only to the sterile catheterization as one of the ways of infection but also to the “introduction of microorganisms into the urinary system during catheterization” was used along with the preventing intraluminal and extraluminal contamination of urinary catheters (Moola & Konno, 2008, p. 698).

The authors’ search process and the criteria to include studies in the review.

Criteria. The review was based on the credible published and unpublished studies found in the following databases, MEDLINE, CINAHL, Current Contents, Expanded Academic Index, Cochrane Library, Embase EBM Reviews, EMBASE, Scopus, TRIP, and Biomed Central. The selection of the studies lies in consideration of the keywords which were noticed in the titles of the studies and abstracts. This was the first stage of the review. At the second stage of the study, the authors referred to the index terms. Finally, at the third stage, the reference lists and biographies were considered for identifying relevant articles. The articles are included only in case all the following aspects are included: the guidelines, the case-study control, the relevant intervention, and the firm outcomes.

Data Collection and Evaluation. As a result, Moola and Konno (2008) selected the following data from the studies, the year of the intervention and publishing of the research results, design, setting and sample, age and gender of the participants, intervention, and its outcomes. Having gathered all the relevant information from the studies in the mentioned databases, which contained the necessary information and met the stated criteria, the authors of the review used the checklist developed by the Joanna Briggs Institute. All the articles were considered in accordance with that checklist.

Synthesis of the Findings. The data gathered and considered was synthesized by means of the Cochrane Collaboration Review Manager Software meta-analysis. Moola and Konno (2008) did not find comparable studies. Therefore, it was impossible for them to create a statistical analysis of the study. As a result, the outcomes of the research were presented in a narrative way. However, a table was created where the main categories of the six selected studies were presented.

Effectiveness of the Interventions

Six selected interventions used for this review were effective for several reasons. First, the sample size allowed Moola and Konno (2008) to generalize the results, which was very important. Second, the interventions were effective and argumentative. Moreover, the outcomes and outcome measures also met the requirements. The authors of the review considered the following intervention issues, “catheterization technique, meatal care, bladder irrigation, drainage systems, indwelling versus intermittent catheterization, and education” (Moola & Konno, 2008, p. 701).

Similarities and Differences of the Effects Found between the Studies

Dwelling upon similarities and differences in the research, it is important to state that the research objectives in different studies were various. Therefore, the comparison was impossible. Focusing on different aspects and possible reasons for urinary tract infection, the authors of the review managed to find one new technique applicable to the removal of the catheter system. In most cases, the studies under consideration supported the hypotheses aimed at reducing the cases of urinary tract infection and creating a supportive environment for faster recovery and absence of extra movement. Thus, the research helped to prove that many of the contemporary used techniques and solutions were unnecessary. The research results which may be applied in practice are considered in the following section.

How the Results Could Be Applied to the PICO Question in Clinical Practice

The review offers the following implications for practice. First, water is enough for cleaning genitalia as a part of the hygiene around the meatal area. Besides, to be effective, the procedure is to be conducted daily. Second, the authors of the review state that the silver-impregnated catheters may be more effective. However, the study has not shown the category of patients who may benefit from this application as well as the cost efficiency is not calculated. Third, sealed drainage systems are not to be used as the sole mechanism for the elimination of the infection case. Fourth, antibacterial solutions should not be added to the drainage bags due to their inefficacy as well as the authors of the research do not see the efficiency of the drainage changes for any reason apart from the clinical need. Finally, the catheter should be removed as early as possible as this prevents urinary tract infection.

Conclusion

Therefore, it should be concluded that the review conducted by Moola and Konno (2008) was effective and credible. The authors excluded numerous research projects and studies that did not correspond to the selected criteria and analyzed only the ones whose results were credible and could be generalized. The research question was answered in the review. The intervention is one of the studies that proved that it did not matter whether sterile or nonsterile catheterization was applied. Personal hygiene of the meatal area was crucial. The process could be provided using tap water with the requirement that the procedure is taken every day. Therefore, the case under consideration where nurses used nonsterile techniques of catheterization was not harmful and did not put the patient in the group of increased risk for urinary tract infection.

Reference List

Moola, S., & Konno, Rie. (2008). A systematic review of the management of short-term indwelling urethral catheters to prevent urinary tract infections. JBI Library of Systematic Reviews, 8(17), 695-729.

Abstract

The 2009 H1N1 influenza pandemic started in Mexico last spring and recently declared a pandemic by the WHO has brought the 1918 pandemic to memories with its cost of millions of lives. Efforts to acquire more knowledge about the virus, develop treatments, produce vaccines, and come up with better prevention and prophylaxis strategies are escalating all over the world. Therefore, there is a need to provide an overlook or a synopsis of the current knowledge about this pandemic. This essay aims to provide a synopsis of H1N1 infection in light of the recent outbreak.

Introduction

There are three types of influenza viruses, classified according to infection severity. First, type A that causes the severest form of infection, type B and type C cause less severe forms of infections with type C being the weakest. Another classification of influenza viruses is according to the chemical structure of surface proteins (antigens) of the virus particle. There are two major proteins; hemagglutinin (known as H antigen) and neuraminidase (known as N antigen), both proteins are essential for virus replication and survival. More than 10 forms of H antigen and 9 identified N antigens are known; thus, the influenza viruses are identified as H1N1, H5N1, and H3N2…etc. Neuraminidase (N protein) as the name points is an enzyme that facilitates the new viruses escape from the cell once replicated. It breaks the sugar-protein linkage at the surface of the infected cell (Potter, 2000, pp. 254, 255). The H1N1 virus is an influenza A virus subtype that commonly infects pigs, which gave it the common name swine flu. The virus crossed the species barriers sporadically to infect humans, yet cases of human-human transmission were occasional until March-April 2009 when an outbreak occurred in Mexico (Myers et al 2007).

The virus

Brief historical background

Influenza A viruses are omnipresent, the H1N1 subtype infects humans, pigs, and birds. Epidemiologists believe it was responsible for the 1918 influenza pandemic (worldwide epidemic) when over 20 million people died because of the disease. Despite that, the first isolation of the H1N1 virus from a human was in 1974 (Smith et al 1976). In 1976, a local epidemic of swine flu virus with severe respiratory illness occurred in Fort Dix (New Jersey) affecting 13 soldiers with one death. In this epidemic, there was no history of exposure to pigs for any of the cases (Gaydos et al 1977). There is evidence suggesting that pigs are not only reservoir hosts to H1N1, but also act as mixing bags for the genetic assortment of the virus because they are susceptible to infection from birds, cats, and other mammals. Isolation of H1N2 viruses in Japan and the variant H3N2 in Italy from pigs proves that genetic remixing between influenza viruses occurs naturally in pigs with the possibility of producing new human pandemic strain (s) (Wentworth et al 1994).

Evolutionary changes and emergence of the 2009 pandemic H1N1 virus

The H1N1 virus responsible for the pandemic of 1918 is believed to have emerged concurrently from birds to swine and humans. Swine-origin influenza virus (S-OIV) believed to blame for the current pandemic probably emerged from swine into humans. The direct genetic event that led to the appearance of the new virus is a reassortment (genetic mix into new combinations) between two H1N1 swine viruses, which originally were the result of four unimpeded avians to mammalian cross-species transmissions. This was preceded by a minimum of four other previous reassortments of gene segments among avian, human, and swine H1N1 viruses. Because of this tangled history, S-OIV shares three genetic segments with H1N1 and three other genetic segments with H3N2 viruses. Despite repeated reassortments, it is not known if cross-immunity against remote shared H1N1 antigenic determinants (epitopes) produces clinical protection. A look back to previous epidemics shows the virus is rarely transmitted from an individual to another. The Fort Dix local epidemic was the only exception as there was no history of exposure to swine and the virus was never transmitted beyond the locale. The appearance of a triple genetically mixed (reassortants) H1N1 in 1998 in the USA heralds the tendency to override the species barrier and cause swine-human infections (Zimmer and Bruke 2009).

The H1N1 virus is an RNA virus having eight segmented genomic (nucleic acids sequence) ribonucleic acids, besides three polymerase genes (control the polymerase enzyme activity responsible for the catalysis of nucleic acids polymerization into a strand). The 8 segmented genomic RNA(s), PB2 and PA (polymerase genes) evolved from avian virus introduced to swine population in 1998, while the remaining PB1 (polymerase gene) evolved from an avian virus entered humans in 1968 (Shen and Shih 2009). Nelson et al (2008, p. 1) examined data of 71 complete genome sequences (1918-2006) to demonstrate the role played by segmental reassortment in H1N1genomic evolution. They inferred intrasubtype reassortment of H1N1 is more significant to epidemiology than previously believed.

Pathogenicity of the H1N1 virus

Multiple factors determine the pathogenicity of the H1N1 virus, however, the hemagglutinin proteins remain the most important determinant. This protein facilitates virus-host cells binding and consequent fusion of the viral and endosomal membranes for viral ribonucleic acid precursors release into the cytoplasm. Different HN subtypes have variable host cells-receptors binding capacity, thus, receptors distribution on the host cells and the virus receptor-binding capacity would explain influenza virus-host specificity. Hemagglutinin split (cleavage) is necessary for viral infectivity because it exposes an amino acid boundary (fusion peptide) that facilitates fusion of the viral envelop to the host cell endosomal membrane. PB2 protein contributes to viral pathogenicity possibly by affecting viral growth; further, both H and PB2 proteins are essential to droplet transmission. PB1 protein induces host cell apoptosis by interacting with two mitochondrial proteins, and through the same mechanism, it enhances the frequency and severity of superimposed bacterial infections (Neumann et al 2009).

Diagnosis

The first diagnostic difficulty met by the clinical staff is to answer the question is the case a seasonal flu case or a swine flu case? This needs a high suspicion index enough not to miss cases and at the same time not to create panic or lab overload. Clinically, Fever (100-102 degrees F) that last lasts for 3-4 days characterize H1N1 cases, in addition, headache, generalized body aches are severe with prominent fatigue and weakness that may last for 2-3 weeks. Upper respiratory tract manifestations are unlike seasonal flu (stuffy nose, sneezing, and sore throat) are not severe. However, cough and chest discomfort are evident and may be severe, complications are more severe in H1N1 infections commonly in the form of bronchitis and pneumonia (Sabharwal et al 2009).

Clinical diagnosis

The Novel Swine-Origin Influenza A (H1N1) Virus Investigation Team (2009) reviewed 399 cases (of 642) with available clinical data; the age range for confirmed cases was 3 months to 81 years. Fever was prominent in 94% of cases, cough in 92%, and sore throat in 66% of cases. Interestingly 25% of patients had diarrhea and-or vomiting. Nadkar et al suggested the virus’ incubation period (18-72 hours) is the time needed for inflammatory mediators to build-up followed by symptoms of acute onset. Besides, they suggested the overall vulnerability of the patient (immune suppressed, age, pregnancy…) plays an important role in determining the severity of the case at the time of presentation. Nadkar et al (2009, p.455) classified H1N1 cases into three categories; first, are suspected cases who are patients with fever (100-102 F, or 38 C) giving a history of contact with a confirmed case within 7 days before symptoms appeared. Second, are probable cases who are patients with febrile acute respiratory illness testing positive to influenza A but not sub-typed; and confirmed cases who tested positive for the H1N1 virus.

Laboratory diagnosis

Currently, there are three common methods for H1N1 (S-OIV) lab diagnosis namely rapid influenza diagnostic tests (RIDTs), real-time polymerase chain reaction (RT-PCR) assay, and virus culture. RIDTs are less expensive and available in many clinical laboratories; however, they have low sensitivity (40 to 69%), which decreases further as the virus level decreases. Despite that, they are useful to confirm, but not to rule out infection. Therefore, in positive cases, the result in interpretation should be, infection with influenza A is likely which could be H1N1, S-OIV, H3N2, or any other. In negative cases, the test result cannot rule out influenza virus infection. Second, is RT-PCR, which is the most sensitive test approved by the FDA, and is currently the best available means to differentiate H1N1 or S-OIV infection from seasonal influenza infection. Third, is virus culture and isolation for hemagglutination or immunofluorescence subtyping (Holmes et al, 2009), which has the disadvantage of being time-consuming since the virus culture takes nearly 7 days. Specimens (swabs) are taken using a synthetic material (nylon, plastic…) but not cotton swabs to minimize adsorption of the organism on the swab surface, and transferred immediately to the lab. If there must be some time before transferring the specimens, they should be kept at 4 C in an upright position for a maximum of 72 hours (Kaore et al 2009).

Radiological diagnosis of H1N1 infection

Lee et al (2009, p. 533) described the chest X-ray features of cases of H1N1 infection, which are bilateral patchy alveolar opacities associated with basal interstitial opacities taking linear, reticular, or nodular shadows. Ct findings are typical for viral pneumonia (peri-bronchial ground-glass opacities and air space consolidation) which may take an ill-defined or lobar consolidation configuration.

H1N1 infection and pulmonary disease

Chowell et al (2009, p. 674) examined 2155 cases of severe pneumonia complicating H1N1-S-OIV infection reported to the Mexican Ministry of Health in one month period (24-03 to 24-04-2009). Of these cases, 821 were hospitalized and there were 100 deaths, 87% of the deaths, and 71% of the cases were among the 5 to 59 years age group. This represented an age shift compared to the distribution of pneumonia among age groups in previous seasonal influenza epidemics (2005-2008), it also displayed a sharp rise in both rates compared to 17% and 32% for deaths and severe cases in seasonal epidemics. They also noticed a decreased rate among the 60 years or over age group possibly because of previous exposure to H1N1 infection, which may have caused cross-immunity. Perez-Padilla et al (2009, p. 680) examined 98 cases reported to one center (the National Institute of Respiratory Diseases in Mexico City) and reported nearly the same results. Interestingly, their results showed that 22 healthcare workers developed mild to moderate illness within seven days of initial contact with patients.

H1N1 infection in special populations

H1N1infection in the pediatric population

In many cases, the course of disease in children can be mild and self-limiting; however in the severe case and the underlying medical condition often exists. Boughton (2009) suggested asthma, sickle cell disease, and congenital heart disease are the commonest, Shah (2009) suggested, in India, diabetes, lung disease, heart disease, and AIDS is the commonest conditions.

Gastrointestinal manifestations are commoner than adults (49%) and accounted for one death in Boughton’s (2009) series. Febrile seizures are common, low oxygen saturation levels below 95% occurred in 35% of children with H1N1 infection, nearly 16% of children needed admission to the ICU, and 5% needed mechanical ventilation (Boughton 2009).

H1N1 infection during pregnancy

Infection with influenza A virus during pregnancy causes serious maternal and fetal effects, which include preterm labor, pneumonia, adult respiratory failure, and even maternal death. Most cases reported by the US Disease Control and Prevention Center (CDC) (15 April to 24 July 2009) were mild, and only 11% of patients required hospitalization. Despite that, the rate of hospitalization is higher among H1N1 infected pregnant females. It is imperative to evaluate these patients with serial vital signs monitoring including pulse oximetry. Guided judgment is essential for radiological evaluation and invasive procedures like arterial blood gases measurement. Because of the potential of rapid disease progression, close follow-up is always necessary especially within 24 hours of prescribing medications (Saleeby et al 2009).

H1N1 infection in immunocompromised patients

A patient who has received organ or stem cell transplant, on chemotherapy, or systemic steroids, or AIDS patients (immunocompromised) are at higher risk for H1N1 complications. Also, immunosuppression may limit vaccine response (Kunisaki and Janoff 2009). Sharma and Gupta (2009, p. 179) reported the CDC identified evidence of resistance to oseltamivir (antiviral medication) in two severely immunosuppressed patients. These patients continue shedding oseltamivir-resistant virus for longer periods; thus, they are infectious for a longer time, besides, transmit oseltamivir-resistant infection (Sharma and Gupta 2009).

Treatment, vaccination, prophylaxis, and prevention

Antiviral medications

The FDA approved two classes of antiviral drugs for the treatment and prevention of influenza virus infections namely M2 ion channel blockers, and neuraminidase inhibitors. M2 ion channel blockers like amantadine and rimantadine were effective in the treatment of influenza A but not influenza B infections as the virus lacks the M2 protein. However, all tested viruses isolated from H1N1 and S-OIV infections were resistant to these drugs. The second group (neuraminidase inhibitors) includes oseltamivir (Tamiflu) and zanamivir. Both drugs are effective in managing the H1N1 case but differ in bioavailability, the first is administered orally, while the second is by inhalation (CDC, 2009). The Center for Disease Control and Prevention advises using antiviral medications for hospitalized patients and high-risk groups; children below 5 years, adults 65 years or more, immunocompromised patients, or those with underlying chronic medical disease (after Dhamija et al 2009). The WHO advises using oseltamivir almost immediately in serious cases or cases rapidly deteriorating (after Dhamija et al 2009).

Cheng et al (2009) classified antiviral medication treatment strategies according to age, underlying medical diseases, and the case severity into four categories. 1- Patients with H1N1 09 influenza but healthy otherwise; since anti-neuraminidase agents reduce the duration of symptoms, treatment with these drugs is indicated to shorten work absence but is subjected, at all times, to public health and hospital policies. 2- In infants and children; antiviral medications are indicated in high-risk groups (5 years age or less, or with associated comorbidities), although oseltamivir showed efficacy up to 1 year age yet there is limited safety evidence below that age. However, the US FDA has approved oseltamivir use below 1 year age only in emergency authorized cases. 3- Patients at risk of complications; based on Meta-analysis, Cheng et al (2009) suggested oseltamivir reduces the incidence of lower respiratory tract infection, progression to pneumonia, and rate of hospitalization. 4. Patients with severe H1N1 09 infection; although solid evidence of efficacy in these cases is lacking; yet, based on previous experiences with H5N1 (avian flu) cases there is a clinical consensus that the drug can be used in these cases. This is based on the assumption that it may reduce viral replication which contributes significantly to the severity of the disease. Tables 1 and 2 (see appendix) show the recommended doses of anti-neuraminidase drugs for treatment and prophylaxis of H1N1 infection. Table 3 (see appendix) shows the indications for antiviral treatment and prophylaxis for H1N1 influenza (human swine influenza) infection, based on the likelihood of benefit and stage of pandemic (Cheng et al 2009).

Poland et al (2009) pleaded not to use monotherapy antiviral treatment lest resistant strains should develop; instead, they advised using combination therapy based on risks and point of care.

Vaccination

Vaccination increases population immunity, slows down the spread of infection, and decreases the epidemic height; thus, pacifies the rush to deal with epidemic cases. Despite limited uncertainties about the effectiveness of the ultimate vaccine, yet, its necessity and usefulness remain unchanged (Yang et al 2009). Trivalent influenza vaccine (H3N2, seasonal H1N1 virus, but not S-OIV, and influenza B) has been given in Mexico during the early 2009 H1N1 epidemic. The vaccine effectiveness was 73% and none of the vaccinated cases died (Garcia-Garcia et al 2009).

Greenberg et al (2009) evaluated the immunogenicity and effectiveness of the recently developed monovalent inactivated vaccine (for H1N1 2009 virus). Their results showed an antibody titer 1:40 after 21 days of vaccine administration, with no deaths or serious disease complications occurring among the 120 vaccinated individuals. Table 4 (see appendix) shows the types, dosage, and administration routes of monovalent vaccines (adapted from CDC 2009).

Prophylaxis and prevention

Using antiviral medications for chemoprophylaxis is indicated for individuals at high risk (like healthcare workers) or at high risk of acquiring complications (like those with underlying medical disease), or as an adjuvant to vaccination at the high peak point of the epidemic. Hand hygiene is probably the single most significant prophylaxis measure to reduce the risk of transmission from one individual to another. Cough hygiene is a necessity for all individuals with manifestations of respiratory infection (Dahmija et al 2009).

Quarantine and school closure

Quarantine is on two levels; contacts and international at ports. Close contacts of suspected, probable, or confirmed cases should be put to voluntary home quarantine for 7 days with monitoring of fever, notification to health authorities if symptoms develop. International quarantine at ports aims at preventing the import of novel cases or novel viruses; thus, influencing the positive control of domestic disease (Kuo et al 2009).

Sypsa and Hatzakis (2009) designed a mathematical model based on epidemiological data of the Mexico 2009 epidemic to assess school closure among other intervention strategies to affect the epidemic possible spread in Europe. They inferred a 100% school closure (in a community of 2000 population) at the threshold of 1% cumulative incidence of disease can result in an 89.3% reduction of symptomatic cases. If school closure accompanies voluntary home quarantine of contacts this may result in a reduction of incidence rate by 94.8%.

Prophylaxis and prevention among healthcare workers

Healthcare workers are among the high-risk groups; besides being responsible for infection control and proper patient care, therefore; they must adopt effective prophylaxis-prevention techniques. They should use standard droplet infection control protocols at all times; they should also adopt proper hand and cough hygiene protocols. Waste disposal, utensils, and laundry protocols should be revised and proper policies adopted. Thorough environmental cleaning and handling of patient care equipment should be performed and supervised. Precautions of specimens’ handling and transport should be clear and followed strictly. Observation, strict discipline of family or patient visitors during visiting hours, and limiting their number should be monitored by health care staff. Observing patients’ commitment to proper hygiene and infection control protocols during transport between hospital facilities (X-ray, lab …). Patient support and care are always a primary priority of healthcare workers that should never be compromised in any situation (WHO interim guidance, June 2009).

Concluding remark: Prevention of 2009 H1N1 epidemic- an all society task

Because of the considerable social and economic impact of the pandemic, the WHO report (2009) on prevention of H1N1 2009 pandemic suggested the efforts of governments; businesses, and civil society should work cooperatively to develop prevention plans. Since both impact and duration of the pandemic are unknown, authorities at all levels (local, national, regional, and global) should be prepared to respond to the pandemic effectively. Global and national levels should provide leadership to local and regional authorities, which in turn should be ready to take specifically planned actions. The report highlighted the importance of prevention among workers in vital sectors (Energy, water, healthcare…) as they use materials that might be handled by others, as well as their wide spectrum of mixing with the public. The report also stressed preparing scenarios for different possible situations affected by the vulnerability and capacity to respond. In all cases, plans and protocols should be in line with ethical and legal considerations and fundamental human rights.

References

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Appendix

Introduction

At children’s hospital (CHOP) the ER and clinics are always busy. A 5 year old white male child in good general health and physical condition was presented at the Saturday walk in clinic by his mother. He was brought in because he had a fever, was cranky and had complained of a sore throat for about 24 hours. On physical examination by the attending resident, the patient had a fever of 39 c. He had considerable swelling and drainage of the pharynx and in the conjunctivae. His tonsils were enlarged and coated with a white patchy exudates. He had a red throat and swollen anterior cervical lymph nodes. His ears were clear. His chest sounded clear and he had no additional remarkable findings on routine examination. A rapid strep test run ASAP by the lab was positive. Bacteria grown from a throat swab taken at the time of examination indicated gram positive Beta hemolytic bacteria

Presumptive Diagnosis

Based on the presented data of the patient’s primary examination and the basic symptoms reported to the practitioner, the presumptive diagnosis for the considered patient can be Group “A” Streptococcal Infection ranging from Strep Throat to the Bacterial Tonsillitis.

Diagnostic Testing after Examination

The post-examination testing applicable to the discovered symptoms should include three basic stages (Wright, 2001). First, the exudates from the patient’s tonsils are to be analyzed for the presence/absence of streptococci and any other bacteria (NIAID, 2007). Second, the blood test should be carried out in order to see the severity of the infection at the moment and to determine the urgent treatment measures (NIAID, 2007). Third, the urine test should be carried for the purpose of defining the range to which infection has developed and the extent to which its producers, i. e. probably Group “A” Streptococci are led out by urine (Wright, 2001). The diagnostic testing procedures might either confirm of reject the presumptive diagnosis stated above.

Disease Treatment

Group “A” Streptococcal Infections are considered to be among the most widely spread illness human beings suffer from. According to the data by NIAID (2007), over 10 million occurrences of this infection are observed annually around the globe. Drawing from this, methods of treatment for this illness are also well developed and considerably effective. Wright (2001) argues that penicillin is the most common medicine used for this purpose. There are two major ways of administering penicillin during Group “A” Streptococcal Infections treatment. The first involves the use of penicillin V 25-50 mg/kg/day divided into a 4-dose-per-day schedule for 10 days while the second way consists in administering benzathine penicillin (penicillin G) 25,000 u/kg intramuscular as a single injection (NIAID, 2007; Wright, 2001).

Reasons for the Presumptive Diagnosis

The reasons for the presumptive diagnosis according to which the patient had one of the forms of the Group “A” Streptococcal Infections is based mainly on the symptoms reported and the preliminary examination data. First, the patient reports having fever at the level of 39 C and the feeling of the soar throat, which are common symptoms for Streptococcal Infections on the whole, and Group “A” Streptococcal Infections in particular (NIAID, 2007; Wright, 2001). Second, the examination data reveal that the patient has swollen tonsils covered with the layer of white patchy exudates. This symptom is observed in the number of diseases but in combination with soar throat, fever, and the relatively stable and non-problematic health condition of the patient and absence of any other complaints, the diagnosis of the Group “A” Streptococcal Infection becomes the most probable one.

Serious Consequences in Case of Insufficient/Untimely Treatment

The post-examination diagnostic testing procedures in this case should be carried out urgently. The point, according to NIAID (2007) and Wright (2001), is that Group “A” Streptococcal Infections might have serious consequences if not treated properly and timely. The most dangerous of the consequences range from rheumatic fever and post-streptococcal glomerulonephritis (PSGN or inflammation of kidneys) to cancer and death (NIAID, 2007). Further on, if the treatment is not carried out within 18 days after sore throat symptoms are observed, streptococci might cause a heart disease or the Sydenham chorea also known as St. Vittus dance (NIAID, 2007; Wright, 2001). Thus, urgent examination and fast reaction to the first streptococci infections sings is crucial for preventing the serious consequences and saving the patient’s health and life.

Works Cited

Wright, Wendy. What Is the Recommended Treatment for Bacterial Tonsillitis? Medscape Today, 2001. Web.

NIAID. Group A Streptococcal Infections. National Institute of Allergy and Infectious Diseases, 2007. Web.

In an article entitled “Further evidence for infection of pigs with human-like H1N1 influenza viruses in China” by Hai Yu et al which appeared in the 3^rd of January 2009 issue of Virus Research journal, a detailed molecular virology study has been reported which gives important scientific explanation that can help explain the current re-emergence of human like H1N1 influenza virus, and why pigs are important reservoirs of the influenza infection.

Swine influenza is an acute respiratory disease caused by influenza virus which can lead to clinical manifestation including fever and acute respiratory distress in pigs, birds and even humans (Brown, 2000). The disease is common in China which has been regarded as the historic epicenter of the pandemic influenza viruses (Shortridge and Stuart-Harris, 1982).

According to Ito et al (1998) and Peiris et al (2001), “the tracheal epilithium in pigs expresses receptors for both humans and avian influenza viruses, and this provides a biological basis for the susceptibility of pigs to both avian and human influenza viruses”. Pigs therefore act as important reservoirs of the influenza infection as they offer opportunity for human avian and human viral genetic “mixing” through co-infections, replications, and re-assortment which can also lead to inter-species transmissions (Brown, 2000; Landolt et al., 2003).

In the study by Hai Yu et al (2009), various molecular virology methods were used for understanding the molecular epidemiology of the influenza virus and unraveling the dynamics of the of the influenza zoonosis. The influenza viruses were isolated from pigs by inoculation and culture in embryonated chicken eggs (Yu et al, 2007). Viral RNA was then extracted from infected allantoic fluids and then reverse transcription polymerase chain reaction (RT-PCR) done before cloning the transcripts into appropriate cloning vector (PMD18-T Vector), and then sequencing of the viral genes before phylogenetic analysis using bioinformatics tools (Hai Yu et al, 2009).

In the study under review, serum samples were also collected from pigs and serological analysis was done using haemagglutination inhibition (HAI) tests (WHO, 2002), and neutralizing antibody immunoassays for determination of cytopathic effects of the viruses (Hai Yu et al, 2009). The study reported for the first time, “the co-existence of recent (about 2000) human-like and early (1980s) human-like swine H1N1 influenza viruses in pigs in China” (Hai Yu et al, 2009). This was shown by the sequence homology assays, and the phylogenetic relationship and lineage analysis which detected the existence of human, classical swine, and avian strains of the influenza virus in the pigs. Molecular analysis for the determination of antigenic sites detected the interspecies transmission of H1N1 influenza virus from human to pigs and also showed interspecies conserved glycosylation sites in the swine viruses. Glycosylation sites analysis was important in understanding how new influenza virus strains are generated in the pigs (Schulze, 1997; Hai Yu et al, 2009). The study also showed that the “human-like H1N1 swine influenza virus might sporadically infect pigs in China” as revealed by the serological surveillance results (Hai Yu et al, 2009).

Molecular virology research as reported in the article by Hai Yu et al (2009) is important in the field of biology as it can help in understanding the fine mechanisms of molecular evolution which can help in understanding the speciation process through generation of genetic diversity, and adaptation to environmental conditions. In the field of biomedicine, the research can help us understand how disease causing pathogens (such as viruses, bacteria and parasites) adapt to the host organisms in which they cause diseases. The research can also help in detection of antigenic sites which can help in vaccine development studies.

The kind of molecular research, as reported by Hai Yu et al (2009) can have several applications. First, as has been seen in the study under review, it can help in understanding the molecular epidemiology of infectious disease pathogens and also help in their surveillance and designing control strategies in the affected populations. Secondly, the techniques are highly transferable and can be used for developing diagnostic tools (both molecular and immunological) for detection of disease pathogens. Thirdly, the molecular PCR amplification, sequencing and cloning including the associated isolation and culture techniques, can be used for similar studies or research of other infectious diseases and even for non disease related studies of animals and plants.

References

Brown, I. H., 2000. The epidemiology and evolution of influenza viruses in pigs. Vet. Microbio. 74, 29-46.

Hai Yu, Yan, J. Z., Guo-Xi, L., Gui-Hong, Z., Hui-Li, L., Li-Ping, Y., Ming, L., Guang- Zhi, T. (2009). Further evidence for infection of pigs with human-like H1N1 influenza viruses in China. Virus research, 140, 85-90.

Ito, T., Couceiro, J. N., Kelm, S., Baum, L. G., Krauss, S., Castrucci, M. R., Donatelli, I., Kida, H., Paulson, J. C., Webster, R. G., Kawaoka, Y. (1998). Molecular basis for the generation in pigs of influenza A viruses with pandemic potential. J. Virol. 72. 7367-7373.

Landolt G. A., Karasin, A. I., Philips, L., Oslen, C. W. (2003). Comparison of pathogenesis of two genetically different H3N2 influenza A viruses in pigs. J. Clin. Microbiol. 141, 1936-1941.

Peiris, J. S. M., Guan, Y., Markwell, D., Ghose, P., Webster, R. G., Shortridge, K. F. (2001). Co-circulation of avian H9N2 and contemporary “human” H3N2 influenza A viruses in pigs in southeastern China: potential for genetic re-assortment? J. Virol. 75, 9679-9686.

Schulze, I. T. (1997). Effects of glycosylation on the properties and functions of influenza virus hemagglutinin. J. Infec. Dis. 1(Suppl.), S24-S28.

Shortridge, K. F. & Stuart-Harris, C. H. (1982). An influenza epicenter? Lancet 11, 812-813.

World Health Organisation, (2002). WHO Manual on Animal Influenza Diagnosis and Surveillance. World Health Organisation, Department of Communicable Diseases Surveillance and Control, Geneva, pp. 28-50.

Yu, H., Zhang, G. H., Hua, R. H., Zhang, Q., Liu, T. Q., Liao, M., Tong, G. Z. (2007). Isolation and genetic analysis of human original H1N1 and H3N2 influenza viruses from pigs in China. Biochem. Biophys. Res. Commun. 365, 91-96.

Summary

The research question being addressed in this study is “what is the main challenge faced by medical surgeons in the course of delivering care services to patients?” The search strategy for the required articles began by identifying the relevant medical databases such as Ebscohost, Elsevier, and Science Direct. Keywords such as surgical, site, infection, problems, challenges, and surgery were typed and searched through the available databases.

The designs used in the studies above were varied. For instance, in a study by Butterworth, Gilheany, and Tinley (2010), a standard patient questionnaire design was employed to obtain quantitative data for a period of six months. Lee et al. (2012) used a retrospective study design that ran for 28 days. This took place immediately after pediatric HSCT recipients had received an implant while Rajkumari et al (2014) used a retrospective observational study design. On the other hand, Tang, Fend, Chen, Zhang, Ji and Luo (2014) employed a randomized controlled trial study design. All the above research studies fall within the same level of evidence because they are quantitative research studies.

In regards to finding, a 3.1 % of infection rate was recorded (Butterworth et al., 2010). The authors also note that hospital readmissions accounted for about 0.25 percent of the infection rate. Tang et al (2014) found out that a closed blood conservation device can significantly reduce the transfer of infections. The other two studies also give similar findings. Hence, the studies fully answer the research question stated above.

All the samples used in the four studies were randomly selected. However, a sample size of 9 participants was rather low for a countrywide study cohort (Butterworth et al., 2010) because of the large population being represented. The screening method used to obtain final participants was a more effective sampling method in a study by Rajkumari et al (2014). This made it possible for the researchers on the most productive elements in the study.

Limitations of the studies included lack of variety in terms of research settings (Tang et al., 2014), inadequate or missing comparative studies, and poor exploration of all variables affecting the research studies (Butterworth et al., 2010). Subsequent studies can overcome these limitations by expanding the study zone, investigating both dependent and independent variables as well as using a fairly large sample size.

Based on the findings, the evidence found on this topic is indeed strong enough to suggest a change in medical-surgical practice to protect both surgeons and patients from being infected. Unless both parties are protected against infections during operations, then the medical process can be least beneficial.

References

Butterworth, P., Gilheany, M.F. & Tinley, P. (2010). Postoperative infection rates in foot and ankle surgery: A clinical audit of Australian podiatric surgeons, January to December 2007. Australian Health Review, 34(2), 180-185.

Lee, J. H., Jang, J., Lee, S. H., Kim, Y., Yoo, K. H., Sung, K., &… Koo, H. H. (2012). Respiratory viral infections during the first 28 days after transplantation in pediatric hematopoietic stem cell transplant recipients. Clinical Transplantation, 26(5), 736-740.

Rajkumari, N., Gupta, A. K., Mathur, P., Trikha, V., Sharma, V., Farooque, K., & Misra, M. C. (2014). Outcomes of surgical site infections in orthopedic trauma surgeries in a tertiary care centre in India. Journal Of Postgraduate Medicine, 60(3), 254- 259.

Tang, M., Fend, M., Chen, L., Zhang, J., Ji, P. & Luo, S. (2014). Closed Blood Conservation Device for Reducing Catheter-Related Infections in Children After Cardiac Surgery. Critical Care Nurse, 34(5), 53-61.

Abstract

The article in question deals with the difference between autophagy found in herpes simplex virus (HSV) infection and varicella-zoster virus (VZV) infection. It is found that autophagy is proviral when it comes to VZV infection while HSV has genes that block autophagic flux. The experiments held have several implications as they reveal peculiarities of autophagy in similar types of infections. The researchers also stress that the methodology used is effective for autophagy measurement.

Introduction

Autophagy is one of the most important processes associated with a cell’s lifecycle. It is related to cell death, cell development, its survival, metabolism, immunity, as well as infection and aging (Chaabane et al., 2013). Therefore, this process is thoroughly studied in relation to various diseases and processes. For instance, researchers try to understand the way the process can be affected by the disposal of certain nanoscale materials (Stern, Adiseshaiah & Crist, 2012). Su, Yang, Xu, Chen and Yu (2015) explore the role autophagy plays in the development of metastasis.

The article in question written by Buckingham et al. (2015) explores the difference between autophagic flux associated with herpes simplex virus (HSV) infection and varicella-zoster virus (VZV) infection. Buckingham et al. (2015) note that numerous experiments show that autophagy occurs in cultured cells affected by VZV infection. The researchers conclude that autophagy is proviral during VZV while, in cells with HSV infection, it is significantly different.

Methods

Buckingham et al. (2015) explored autophagic flux in xenografts of human skin during the SCID VZV pathogenesis mouse model. The model presupposes the insertion of xenografts of human fetal skin under the skin of a mouse that is affected by SCID. After that, the researchers inoculated human cells with VZV infection. The xenografts are harvested on the 7^th, 14^th, and 21^st days after the inoculation. It was found that autophagy was significant in the infected cells. The researchers also examined autophagic flux in the infected cultured cells. Autophagy was significantly less apparent in the latter case.

Results

It is found that autophagy in VZV infected cells is very unstable and virions are often released, while in HSV virions are enclosed within infected cells only. Buckingham et al. (2015) conclude that inoculation of cells with virions will result in a lower level of autophagy. It is reported that the ratio of particle to PFU was 40,000:1 (Buckingham et al. 2015). The researchers report that VZV-related autophagy is associated with cell stress and that a more significant inoculum induces more significant autophagy.

Discussion

The researchers note that their experiment supports their hypothesis that autophagosome development is primary to autophagy inhibiting. Buckingham et al. (2015) state that the method used is highly effective and can be utilized for other experiments aimed at measuring autophagy. Buckingham et al. (2015) also stress that the experiments conducted show that VZV induces autophagy while a similar HSV infection has a different effect and often blocks autophagosome maturation. In other words, the researchers identified two genes in HSV inhibiting autophagy. These genes are US11 and ICP34.5. The researchers stress the significance of the experiment that justifies early phase autophagy in such diseases as Epstein-Barr virus infection.

Apart from that, the findings can be applied in research associated with other diseases and infections. Thus, it is possible to tie autophagic flux with metastasis development and the role US11 and ICP34.5 genes can play in this process.

Reference List

Buckingham, E.M., Carpenter, J.E., Jackson, W., Zerboni, L., Arvin, A.M., & Grose, C. (2015). Autophagic flux without a block differentiates varicella-zoster virus infection from herpes simplex virus infection. PNAS, 112(1), 256-261.

Chaabane, W., User, S.D., El-Gazzah, M., Jaksik, R., Sajjadi, E., Rzeszowska-Wolny, J., Łos, M.J. (2013). Autophagy, apoptosis, mitoptosis and necrosis: Interdependence between those pathways and effects on cancer. Arch Immunol Ther Exp, 61, 43-58.

Stern, S.T., Adiseshaiah, P.P., & Crist, R.M. (2012). Autophagy and lysosomal dysfunction as emerging mechanism of nanomaterial toxicity. Particle and Fibre Toxicology, 9, 1-20.

Su, Z., Yang, Z., Xu, Y., Chen, Y., & Yu, Q. (2015). Apoptosis, autophagy, necroptosis, and cancer metastasis. Molecular Cancer, 14 (48), 1-14.

According to the school of medicine at the University of California (2012), there is a need to develop algorithmic pathways for best practices toward the treatment of ear, nose and throat infections. Clinical outcomes are used to measure best practices in ENT treatment. In addition, the satisfaction of practitioners and patients should also be put into consideration as best practices. In cases where available resources are inadequate, it is imperative to encourage economic use of these resources by setting priorities. Moreover, the same resources should be used optimally.

When ENT patients are admitted to healthcare centers, a prompt diagnosis should be carried out in order to save the time needed for treatment. For example, a primary care physician may not work speedily on a procedure such as nasopharyngoscopy. In such a case, a specialist in this field should be assigned the task in order to facilitate quick healthcare delivery for ENT patients. On the other hand, when a middle-level or primary care practitioner is assigned a simpler diagnosis or treatment procedure, it amounts to best practice in ENT (Berdeaux et al., 1998).

According to CRNBC (2012), it is vital for medical practitioners who are specialized in the treatment of ear, nose and throat infections to be very cautious when handling patients, especially during their first hospital admissions. This precaution has been found to be integral in the sense that hospital re-admissions are costly to healthcare establishments. Therefore, the ear, nose and throat patients should be assessed thoroughly before any form of treatment is administered.

To begin with, the system review and history of current illness should form the basis of best practice in the ear, nose and throat treatment. It is necessary to explore and elicit the features of all the signs and symptoms such as chronology, the present situation of the admitted patient, impacts of regular activities, suitability and efficiency of past treatments. Moreover, location of the patient, nature of the onset of the infection (whether it is gradual or abrupt), aggravating and precipitating factors, past treatments, the severity of the condition as well as any other relieving factor should be considered (CRNBC, 2012).

In addition to the above overall measures of best practices, a medical practitioner should go further and understand the specific symptoms that are integral in the diagnosis. Some of the specific factors include Q-tip use, vertigo, presence of itching, painful feelings either inside or outside the ear, the efficiency of the hearing aid, discharge from the ear or nose as well as any other latest alterations in the hearing mode of the patient. The aforementioned specific symptoms are necessary so that an ENT expert can narrow down the actual causes and development of the infection. In cases where best practices of these magnitudes are not followed, wrong diagnosis and consequent ineffective treatments are inevitable.

The College of Registered Nurses of British Columbia (CRNBC) is one of the institutes that adhere to best practices in ear, nose and throat treatment. CRNBC has the obligation of making sure that all the registered nurses are certified and also operate within the set guidelines similar to many other medical organizations in this industry.

In terms of the nose and sinuses, principles of best practices stipulate that specific symptoms should entail the presence of watery eyes, incessant sneezing, incidents of rhinorrhea, nasal pains, associated trauma, localized headache, anosmia and epistaxis.

While the target part is the throat, it is worth to mention that the adjacent regions such as the mouth and neck may also show physical symptoms during diagnosis. Therefore, the unique signs and symptoms that should be examined around the throat and mouth include dysphagia, recent changes in the quality of voice, uvula, midline, deep sore pains around the throat, weak gums that bleed especially during brushing, dental instability and oral lesions (CRNBC, 2012). The patient may also complain of some pains in the neck due to glands that have been enlarged and consequently swollen. These symptoms are also known to worsen the general wellbeing of a patient in the sense that he or she may experience vomiting or nausea from time to time. In addition, the patient may encounter malaise with a body temperature above normal as a result of fever. In cases where best medical practices are not exercised, it is possible for a clinician to confound these symptoms with those of other ailments.

The second consideration to make when diagnosing a suspected ENT patient is an adequate examination of the medical history. Some of the general points of considerations under medical history include whether the patient has ever undertaken past surgeries, the general medical condition of a patient, use of traditional therapies and herbal extracts in the past, whether the patient is under any current form of medication (such as over the counter prescriptions or birth control pills) and finally, whether the patient has any allergies. In any form of best medical practice, the medical history of a patient is paramount during diagnosis and eventual treatment because the onset of most medical complications can often be traced from past medical records (Stephen et al., 2010).

Some of the specific medical history records that are related to the ear, nose and throat infections include loss of hearing, difficulty in breathing as occasioned by asthma, surgery related to the ear, nose or throat, some form of trauma around the ear, nose, throat or the head in general, sinusitis, regular infections around the throat or ear and past screening results which demonstrate that a patient has been suffering from loss of hearing. In addition, there is also some likelihood for a patient to contract cancerous cells around the ear, nose and throat (André, 1995).

Although the above-mentioned best practices in the diagnosis of ENT complications are fundamental towards proper treatment, it is essential to bear in mind that urgent referral of a patient is necessary in cases where the current healthcare establishment lacks adequate equipment or expertise. If the ear, nose and throat infections that have been presented demand immediate referral, then it is highly advisable for such a step to be taken without much delay (Buss, 2011). A case can be referred to a nurse practitioner or physician if the signs and symptoms depicted in the initial diagnosis include vertigo that cannot be easily explained, hoarseness of the voice of the patient in the absence of any illness or fever if the patient has undergone any recent surgery of the ear, nose or throat if the region from the chest to the chin shows positive Brudzinsky symptoms and also if tenderness is felt around the mastoid amidst fever and pain (Estes & Zator, 2010). A patient can also be booked for referral if he or she is experiencing random feverish pains with an unknown source. Referrals may also have opted if there is no positive response after treating ENT complications such as peritonsillar abscess and strep throat for three days. Finally, in the event that epistaxis cannot be controlled or managed, it is highly recommended for a patient to be referred as soon as possible (André, 1995).

References

André, M.J. (1995). Infections of the Ear, Nose and Throat. Essentials of Infectious Diseases. Oxford: Blackwell Scientific Publications.

Berdeaux, G. et al. (1998). Parental quality of life and recurrent ENT infections in their children: Development of a questionnaire. Quality of Life Research, 7(6), 501- 512.

Buss, J. (2011). Health Assessment Made Incredibly Visual! (2nd Ed.). Ambler, PA: Lippincott, Williams and Wilkins.

CRNBC (2012). Adult decision support tool: Ear, Nose and Throat assessment. Web.

Estes, M. & Zator, E. (2010). Health Assessment & Physical Assessment, (4th Ed.) Clifton Park, NY: Delmare, Cengage Learning.

Stephen, T. et al (2010). Canadian Bates’ Guide to Health Assessment for Nurses. Philadelphia, PA: Lippincott, Williams and Wilkins.

University of California (2012). Ambulatory Healthcare Pathways for Ear, Nose, and Throat Disorders. Web.

Introduction

The issue of nosocomial infection management is rather serious across the healthcare projects and programs implemented in the USA. In this respect, the rates of mortality and morbidity from such a kind of infection are very high (Wisplinghoff et al., 2004). The whole body of Medicare in the US should pay more attention to this aspect of direct danger for patients. To say more, the concept of nursing is under revision today. As the closest to patients, nurses should get through a sort of procedures to verify, for instance, general hygiene, sterilization of all appliances, etc. Unfortunately, nosocomial infections still take place within the healthcare system of the United States. It means that people are not guaranteed to be healed after intensive treatment and care in a hospital. It reflects on the medical insurance-related conflicts. In turn, it affects the national economical stability across the country.

Moreover, the problem should be resolved from the inside out. It means that the survey touches upon the specific gram‐negative bacilli, nosocomial bloodstream, and intravascular catheter-related infections. Based on these three areas of infection the discussion follows up the outcomes of the nosocomial infection in its four main types, namely:

• Pneumonia;
• Surgical site infection (SSI);
• Urinary tract infection (UTI);
• Bloodstream infection (BSI) (Gaynes et al., 2005).

Hence, this term paper considers clinical resources, effective methods to cure the outcomes of nosocomial infection, and health promotion resources. The danger of infection can be formidably reduced when applying prophylactic measures and effective approaches in treating patients timely.

Body paragraphs

A hospital-acquired infection is the result of gram-negative organisms. Nurses are at risk to cause trouble to a patient using a neglectful attitude to duties. It means that clinical nursing issue of checking up appliances to work with and conditions for patients’ care. In this respect, the growth of bacilli in the organism will debilitate on top of that weakened immunity of a patient. The result is that gram-negative aerobes and pathogens attack the life-supporting systems of the human organism (Gaynes et al., 2005). Hence, nurses should be aware of the ways for nosocomial infection to affect patients.

Gram-negative pathogens are more associated with the emergence of nosocomial pneumonia, SSI, and UTI. In this respect, medics need to pay more attention to the peculiarities of the locality where a definite hospital is situated. Thus, nosocomial pneumonia is caused by aerobes (Acinetobacter species), UTI is caused by Pseudomonas aeruginosa, SSI is caused mainly by Enterobacter, and Acinetobacter (Gaynes et al., 2005). Taking this into account, medical staff should be aware of the sources for these microorganisms and their delimitation. Moreover, nursing might be supported by innovative methods for processing departments and premises adjacent to the hospital.

Nosocomial bloodstream infections (BSIs) are stated as one of the main reasons for mortality in the United States. This outrageous fact gives reasons to suppose that the healthcare system does not meet the standards of the profession, meaning nursing. Thus, the medical verification among nurses should be provided in terms of certification and improvement of qualification as well. The study reported by Wisplinghoff et al. (2004) outlines that BSI’s proportion increases in ratio to other common nosocomial infections and diseases owing to antibiotic-resistant microorganisms. This idea gains approval in different studies on infection management. Thereupon, Gaynes et al. (2005) researched the rates of nosocomial infections in hospitals across the US and state their dramatic growth. The awareness of patients, however, does not include an idea of aggravating health by going through the cure. This paradox should not be in evidence throughout Medicare. Thus, BSIs are another reason for still growing nosocomial risk in hospitals.

Gram-negative, gram-positive organisms, and fungi are considered to be the three main infectious microstructures to affect the circulatory system. This assumption is no longer a theoretical approach. Wisplinghoff et al. (2004) remark that BSIs are caused by gram-positive organisms (65% of cases), gram-negative organisms (25% of cases), and fungi (9,5% of cases) (309). It means that nurses must be educated and trained to meet the main requirements of public health regulations. Nevertheless, the staff needs to be careful in assisting patients when administering medicines. Touching upon the appliances, medical staff should be aware of how to sterilize them. On the other hand, nonrecoverable appliances after being utilized should be thrown away into special tanks for used medical things. It is rational to follow this piece of advice, especially in the intensive care unit. The question is that in this very unit patients are at risk to have an infection from coagulase-negative staphylococci (CoNS), Enterobacter species, Serratia species, and some other species (Wisplinghoff et al., 2004).

Another source for morbidity and mortality in the United States is intravascular catheter-related infections. Studies reported by Mermel et al. (2001) outline that peripheral and non-tunneled central venous catheters (CVCs) can be easily infected by CoNS along with “S aureus, different species of aerobic gram-negative bacilli, and C albicans” (223). In this respect, nurses need to have more information on contemporary procedures for injecting peripheral and non-tunneled catheters after abiding by rules of hygienic processing of hub and lumen within CVC. This rule is paramount having to do with catheter-related implications. To prevent nosocomial infections, an up-and-coming nurse should follow the steps of utilizing appliances before, during, and after the procedure to be taken. Epidemiology and pathogenesis appear in cases when the nursing unit within medical staff does not get through appropriate verifications on local and national levels.

Current practice states that since the National Nosocomial Infections Surveillance (NNIS) system (Gaynes et al., 2005) along with the Infectious Diseases Society of America (IDSA) (Merel et al., 2001) keep on working, Nosocomial infections can be delimitated. The Healthcare system should function as a whole organism. Thus, experts might help resolve the problem with nosocomial infections and their prevention. It finds more prospects when concerning the fact that within the period between 1970 and 2003 the rates of nosocomial infection decreased significantly due to the work of aforementioned instances (Gaynes et al., 2005). To say more, unless there is a strict order in controlling such a human-directed or life-directed, so to speak, field of activities, the quality of cure in hospital will fall dramatically.

Antimicrobial‐pathogen combinations should be included more intensively to work out the problem. It means that nurses should be capable of implementing antibiotics to decrease the growth of the infection in the initial stage. Antimicrobial resistance and its rate, particularly, are especially seen in the example of Acinetobacter species and P. aeruginosa (Gaynes et al., 2005). It drives the healthcare system and nurses, in particular, to cooperate with physiologists and pharmacists. The most effective antibiotics should be tested shortly to help medics resist the national rate of nosocomial infections.

Nurses should take care of patients when in hospital and after intensive treatment until a definite time. This suggestion result from the study reported by Wisplinghoff et al. (2004). The researchers admit that in terms of BSIs the mean intervals (from admission to infection) vary according to the type of bacteria species. Thereupon, Escherichia coli has 13 days interval, S. aureus 16 days, for Candida species and Klebsiella species this period is 22 days, enterococci are 23 days, finally, Acinetobacter species take 26 days (Wisplinghoff et al., 2004, p. 1093). Furthermore, nurses should be accurate in administering blood-related appliances, so that a patient’s epithelium and circular system keep functioning well. Merel et al. (2001) insist that the cure for nosocomial infections lies in using “antibiotic lock technique in addition to standard parenteral therapy for patients with hemodialysis catheter-related infection” (235). Hence, BSIs can be reduced in their flow considerably by forcing them with new combinations of antibiotic-related medicines.

Conclusion

Getting through the studies and problems observed, it is necessary to state that the nursing department in hospitals is quite significant in preventing patients from nosocomial infections. These staff members, as I feel it, should be conscientious about their work. Otherwise, they need to follow the ways to improve their qualification in bacteria knowledge and in methods to eliminate the source of infections (negative-gram, positive-gram microorganisms, fungi, etc.). By exercising entire measures on prophylactics, the nursing unit guarantees the quality of medicine and the usefulness of medical insurance at large.

Reference

Gaynes, R., Edwards, J. R. & the National Nosocomial Infections Surveillance System. (2005). Overview of Nosocomial Infections Caused by Gram‐Negative Bacilli. Clinical Infectious Diseases. 41:848–854.

Mermel, L. A., Farr, B. M., Sherertz, R. J., Raad, I. I., O’Grady, N., Harris, J. S. & Craven, D. E. (2001). Guidelines for the Management of Intravascular Catheter‐Related Infections. Infection Control and Hospital Epidemiology. 22:222–242.

Wisplinghoff, H., Bischoff, T., Tallent, S. M., Seifert, H., Wenzel, R. P. & Edmond, M. B. (2004). Nosocomial Bloodstream Infections in US Hospitals: Analysis of 24,179 Cases from a Prospective Nationwide Surveillance Study. Clinical Infectious Diseases. 39:309–317.

Introduction

This paper presents an explicit critique of the article, Engaging health care workers to prevent catheter-associated urinary tract infection and avert patient harm, by Fakir and others. Reflectively, the review will authenticate relevance of the research article which has comprehensively captured the conceptualization ideas discussed within its periphery of ideal and actualization. Besides, the critique paper reflects on the methodology strategy and adopted methods which appear to have employed quantitative analysis. In addition, the critique investigates research designs and conceptualized results which are quantifiable and assess the same in terms of relevance in the present strategies for preventing the catheter urinary tract infection.

Article critique

The article, Engaging health care workers to prevent catheter-associated urinary tract infection and avert patient harm, is a summary of research on the prevalence of the catheter-associated urinary tract infections (CAUTIs) in hospitals. The research article reviews the impact of the CAUTIs and nursing driven indwelling catheter protocol in terms of reducing the CAUTIs. Through quantitative evaluation, the research involved reviewing the CAUTI prevention strategies that hospitals adopt and why they are more effective in some hospitals than others. The highest effectiveness score was noticed in hospitals which had a proactive implementation process as indicated in the article. Therefore, hospitals with high levels of success in CAUTI prevention tend to have clear road maps, comprehensive team work, and strategy nursing role allocation. It is apparent that “HCW engagement at the hospital level is an essential component for successful implementation of the CAUTI prevention work” (Fakih et al. 2014, p. 225).

As established by Fakir, Krein, Edson, Watson, Battles, and Sanjay (2014), the best strategy for preventing catheter-associated urinary tract infection lies in proactive engagement of the heath care workers. The authors noted that several efforts have been directed by different health agencies to reduce devise use. For instance, the authors noted that the efforts of CDC and HICPAC have resulted in creation of several guidelines for preventing CAUTI through involvement of the healthcare personnel. The main indications suggested by the agencies are;

“(1) acute urinary retention or bladder outlet obstruction, (2) accurate measurements of urinary output in critically ill patients, (3) preoperative use for selected surgical procedures, (4) to assist in healing of open sacral or perinea wounds in incontinent patients, (5) prolonged immobilization requirement, and (6) improved comfort for end-of-life care” (Fakir et al. 2014, p. 224).

Through qualitative research, Fakir, Krein, Edson, Watson, Battles, and Sanjay (2014) noted that involvement of an ideal CAUTI prevention group might reduce infections by more than 40% in a very short time. However, the authors are categorical that the strategy to involve different health care workers must be sustainable. Therefore, “sustainability is achieved if the improvements are maintained or augmented after implementation; for CAUTI prevention, the improvements are reflected in an increase in appropriate catheter use and a reduction in CAUTI events” (Fakir et al. 2014, p. 226). When successfully implemented, the authors concluded that engaging the health care workers will be critical in sustaining all the prevention programs, “thereby providing the ability to implement changes that will enhance patient safety” (Fakir et al. 2014, p. 228).

As part of the socio-adaptive change in prevention of CAUTI, the authors are categorical in insisting that all the preventive strategies must integrate the health care workers. This is achievable through a continuous engagement process comprising of defining the scope of care to the stakeholders, engaging the support of essential groups, ensuring that the collaborative nature is streamlined, and pinpointing the leadership of the prevention process (Fakih et al. 2014). The authors established that open engagement of the relevant agencies in the CAUTI prevention is not only achievable but also sustainable.

From a research spanning for more than two years, the authors noted that proper prevention of infection is both possible and within the reach of health care workers who have the necessary skills and goodwill from the hospitals. Therefore, through a proactive protocol implementation, it is possible to manage the CAUTI rate, duration, number, and costs involved in the prevention. Besides the quality improvement protocol, factors identified in the articles as equally important in CAUTI prevention include nurses’ education, continuous assessment of the feedback, and revue of the scope of shareholder involvement. These factors ensure that the protocol attracts full commitment from the health care workers who are the agent of their implementation (Fakih et al. 2014).

In the article, Engaging health care workers to prevent catheter-associated urinary tract infection and avert patient harm, the authors identified the technical elements of proactively addressing behavioral and socio-adaptive factors that must be incorporated in CAUTI prevention to make it successful. For instance, through qualitative research, the authors noted that observing the quality improvement protocol is significant in reduce the CAUTI, irrespective of the heath care environment. In fact, “feedback between the nurses and the project team fostered communication, collaboration, and improved protocol compliance” (Fakih et al. 2014, p. 225). Through reduced use of catheter, the authors concur that it is possible to reduce the CAUTI infection rates by aggressively implementing the “nurse-directed catheter removal protocol” (Fakih et al. 2014, p.225).

Since the purpose of this proposed study is to evaluate the effectiveness of the nurse driven indwelling catheter protocol in decreasing hospital acquired UTIs, the above findings offer empirical evidence from which the scope of the study will be based. Specially, the findings capture factors which directly and indirectly affect nursing-based protocol for CAUTI prevention. The main factors identified include quality improvement, health care workers involvement, reduction of catheter use, and maximum commitment through training. Therefore, the article is effective in exploring these concepts in addressing prevention of hospital acquired UTIs.

The research article, in my opinion, fails to comprehensively reflect on the aspects discussed in the text. As a matter of fact, the article is silent on segmentation of the research targets who are the nurses, geographical location of the research target, and the dynamics and unique aspects of the segment or sector of study. In addition, the research does not capture focus of the study as pointed towards understanding a quantifiable aspect of CAUTI care environment. Also, the findings and recommendations presented in this research article are restrictive and may not paint actual picture of structural aspects of CAUTI care across the globe.

As a matter of fact, most of the references used in this article are outdated and may not present an accurate literature review on current issues of the topic. Therefore, in my opinion, since the article was done in 2014, the authors ought to have used updated recent literature in order to put into account various social and health dynamics that directly impact prevention and treatment of CAUTI. Besides, the authors are not specific on timeframe for the alleged causes and measurement indices for an otherwise result. As observed in the research methodology, the authors employed the use of quantitative research methodology which measures assumptions given and reflectively develops quantifiable results. However, this method does not comprehensively capture the key theme which is reflection on influence of perceived and real environmental factors on CAUTI treatment and prevention. In order to obtain actual and study psychological reaction for response given, a researcher should adopt a non biased tool for obtaining data. Therefore, the research article would have been more specific if both qualitative and quantitative data collection and analysis approaches were simultaneously employed in the research. In my opinion, this recommendation will minimize biasness in conceptualization of data generated.

Critique of conclusion and implications

The article concludes that “the most important ingredient of success is engaging HCWs at the unit and hospital level, thereby providing the ability to implement changes that will enhance patient safety” (Fakir et al. 2014, p. 228). The conclusion by the authors that significant CAUTI reduction is possible through reducing the use of urinary catheter is backed by the evidence presented. Through intervention study, the authors established that “urinary catheter use, and ultimately CAUTI rates, can be effectively reduced by the diligent application of relatively few evidence-based interventions” (Fakir et al. 2014, p. 225). The most essential part of a properly written research paper should reflect on conceptualization and maintain originality. The conclusion doesn’t provide a clear link between one variable to another and is majorly based on assumptions. Besides, the analysis presented may not present a complete reflection of actual situation in different healthcare environments.

Reference

Fakih, M., Krein, S., Edson, B., Watson, S., Battles, J., & Saint, S. (2014). Engaging health care workers to prevent catheter-associated urinary tract infection and avert patient harm. American Journal of Infection Control, 42(1), 223-229.