i bc27f85be50b71b1 (191 page)

5ands. JF Marek (ed�). Medical-Surgical Nursmg. Concepts and Clinical Practice (6th

ed). St. LOUIS: Mosby. 1999:237-245: and KN Anderson (ed), Mosby's Medlc:lI, Nurs�

mg, and Allied Health Dictionary (Sth ed). St. LOUIS; Mosby, 1998;2BA5.

Antibiotic-Resistant lnfections

Methicillill-Resistat,t Sraphylococcus aureus [nfectiOl'

Merhicillin-resistant S. allrells (MRSA) is a strain of Staphylococcus

that is resistant [0 methicillin or similar agents, such as oxacillin and

nafcillin. Met/nCll/iI, is a synrheric form of penicillin and was developed because S. allrells developed resisrance to penicillin, which was originally the treatment choice for S. aureus infection. However, since

rhe early 1980s, rhis particular strain of S. aureus has become increas-

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AClITE CARE HANDBOOK FOR PHYSICAL THERAPISTS

ingly resistant to methicillin. The contributing factor that is suggested

to have a primary role in the increased incidence of this nosocomial

infection is the indiscriminate use of antibiotic therapy.'7. '8

Additionally, patients who are at risk for developing MRSA infection in the hospital are patients wh018-20

• Are debilitated, elderly, or both

• Are hospitalized for prolonged time periods

• Have multiple surgical or invasive procedures, an indwelling

cannula, or both

•

Are taking multiple antibiotics, antimicrobial treatments, or both

•

Are undergoing treatment in critical care units

MRSA is generally transmitted by person-to-person contact or person-to-object-to-person cOntact. MRSA can survive for prolonged periods of time on inanimate objects, such as telephones, bed rails,

and tray tables, unless such objects are properly sanitized. Hospital

personnel can be primary carriers of MRSA, as the bacterium can be

colonized in healthy adults.

Management of M RSA is difficult and may consist of combining

local and systemic antibiotics, increasing antibiotic dosages, and

applying whole-body antiseptic solutions. In recent years, vancomycin has become the treatment of choice for MRSA; however, evidence has shown that patients with this strain of S. au,eus are also developing resistance to vancomycin (vancomycin intermediate S. allrells

VISA).17 Therefore, prevention of MRSA infection is the primary

treatment strategy and consists of the following16·18-zo:

•

Placing patients with MRSA infection on isolation or contact

precautions

• Strict hand-washing regulations before and afrer patienr care

• Use of gloves, gowns (if soiling is likely), or both

• Disinfection of all contaminated objects

Vancomycin-Resistant Enterococci Infection

Vancomycin-resistant enterococci (VRE) infection is another nosocomial infection that has become resistant to vancomycin, aminoglyco-

INFECTIOUS !)ISEA E.S 617

sides, and ampicillin. The infection can develop as endogenous

enterococci (normally found in the gastrointestinal or the female

reproductive tracr) become opportunistic in patient populations similar to those mentioned earlier with MRSA.16, 17,21

Transmission of the infection can also occur by (1) direct patientto-patient contact, (2) indirect contact through asymptomatic hospital personnel who can carry the opportunistic strain of the microorganism, or (3) contact with contaminated equipment or environmental surfaces.

Management of VRE infecrion is difficult, as the enterococcus can

withstand harsh environments and survive well on rhe hands of health

care workers and on hospital objects. Treatment options are very limited for patients with VRE, and the best intervention plan is to prevent the spread of the infectious process.17 Strategies for preventing VRE infection include the following2 1:

• The controlled lise of vancomycin

• Timely communication between the microbiology laboratory

and appropriate personnel to initiate contact precautions as soon

as VRE is detected

• Implementation of screening procedures to detect V RE infection

in hospitals where VRE has not yet been detected (i.e., randomly

culturing potentially infected items or patients)

• Preventing the transmission of VRE by placing patients in isolation or grouping patiems with V R E together, wearing gown and gloves (which need to be removed inside the patient's room), and

washing hands immediately after working with an infected patient

• Designating commonly used items, such as stethoscopes and

recral thermometers, ro be used only with V R E patients

• Disinfecting any item that has been in contact with V R E

patients with the hospital's approved cleaning agent

Clinical Tip

Equipment that is used during physical therapy treatments

for patients with MRSA or VRE, such as assistive devices,

Cliff weights, or goniometers, should be left in the patient'S

room and not be taken out until the infection is resolved.

If there is an equipment shortage, thorough cleaning of the

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AClITE CARE HANDBOOK FOR PHYSICAL THERAPISTS

equipment is necessary before using the equipment with

other patients.

Respiratory Tract Infections

Infections of the respiratory tract can be categorized as upper or

lower respiratory tract infections. Upper respiratory tract infections

that are discussed in this section consist of allergic and viral rhinitis,

sinusitis, influenza, and pertussis. Lower respiratory tract infections

that are discussed in this section consist of TB, histoplasmosis, and

legionellosis. Pneumonia is the mOSt common lower respiratory tract

infection and is discussed in Pathophysiology in Chapter 2.

Upper Respiratory Tract Infectio1lS

Rhinitis

Rhinitis is the inflammation of the nasa) mucous membranes and can

result from an allergic reaction or viral infection. Allergic rhinitis is

commonly a seasonal reaction from allergens, such as pollen, or a

perennial reaction from environmental triggers, such as pet dander or

smoke. Viral rhinitis, sometimes referred to as the common cold, is

caused by a wide variery of viruses that can be transmitted by airborne particles or by contacr.

Clinical manifestations of allergic and viral rhinitis include nasal

congestion, sneezing, watery, itchy eyes and nose, altered sense of

smell, and thin, watery nasal discharge. In addition to these, clinical

manifestations of viral rhinitis include fever, malaise, headache, and

thicker nasal discharge.

Management of allergic rhinitis includes antihistamines, decongestants, and nasal corticosteroid sprays. Management of viral rhinitis includes rest, fluids, antipyretics, and analgesics.22.B

Sinusitis

Sinusitis is the inAammation or hypertrophy of the mucosal lining of any

or all of the facial sinuses (frontal, ethmoid, sphenoid, and maxillary).

This inflammation can result from bacterial, viral, or fungal infection.

Clinical manifestations of sinusitis include pain over the affected

sinus, purulent nasal drainage, nasal obstruction, congestion, fever,

and malaise.