Angela L. Hewlett

Clinical Management of Ebola Virus Disease in the United States and Europe

BACKGROUND Available data on the characteristics of patients with Ebola virus disease (EVD) and clinical management of EVD in settings outside West Africa, as well as the complications observed in those patients, are limited. METHODS We reviewed available clinical, laboratory, and virologic data from all patients with laboratory-confirmed Ebola virus infection who received care in U.S. and European hospitals from August 2014 through December 2015. RESULTS A total of 27 patients (median age, 36 years [range, 25 to 75]) with EVD received care; 19 patients (70%) were male, 9 of 26 patients (35%) had coexisting conditions, and 22 (81%) were health care personnel. Of the 27 patients, 24 (89%) were medically evacuated from West Africa or were exposed to and infected with Ebola virus in West Africa and had onset of illness and laboratory confirmation of Ebola virus infection in Europe or the United States, and 3 (11%) acquired EVD in the United States or Europe. At the onset of illness, the most common signs and symptoms were fatigue (20 patients [80%]) and fever or feverishness (17 patients [68%]). During the clinical course, the predominant findings included diarrhea, hypoalbuminemia, hyponatremia, hypokalemia, hypocalcemia, and hypomagnesemia; 14 patients (52%) had hypoxemia, and 9 (33%) had oliguria, of whom 5 had anuria. Aminotransferase levels peaked at a median of 9 days after the onset of illness. Nearly all the patients received intravenous fluids and electrolyte supplementation; 9 (33%) received noninvasive or invasive mechanical ventilation; 5 (19%) received continuous renal-replacement therapy; 22 (81%) received empirical antibiotics; and 23 (85%) received investigational therapies (19 [70%] received at least two experimental interventions). Ebola viral RNA levels in blood peaked at a median of 7 days after the onset of illness, and the median time from the onset of symptoms to clearance of viremia was 17.5 days. A total of 5 patients died, including 3 who had respiratory and renal failure, for a mortality of 18.5%. CONCLUSIONS Among the patients with EVD who were cared for in the United States or Europe, close monitoring and aggressive supportive care that included intravenous fluid hydration, correction of electrolyte abnormalities, nutritional support, and critical care management for respiratory and renal failure were needed; 81.5% of these patients who received this care survived.

Prevention of orthopaedic implant infection in patients undergoing dental procedures

&NA; The Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures evidence‐based clinical practice guideline was codeveloped by the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association. This guideline replaces the previous AAOS Information Statement, “Antibiotic Prophylaxis in Bacteremia in Patients With Joint Replacement,” published in 2009. Based on the best current evidence and a systematic review of published studies, three recommendations have been created to guide clinical practice in the prevention of orthopaedic implant infections in patients undergoing dental procedures. The first recommendation is graded as Limited; this recommendation proposes that the practitioner consider changing the long‐standing practice of routinely prescribing prophylactic antibiotic for patients with orthopaedic implants who undergo dental procedures. The second, graded as Inconclusive, addresses the use of oral topical antimicrobials in the prevention of periprosthetic joint infections. The third recommendation, a Consensus statement, addresses the maintenance of good oral hygiene.

Administration of Brincidofovir and Convalescent Plasma in a Patient With Ebola Virus Disease

From 2014 to May 2015, >26 000 Ebola virus disease (EVD) cases were reported from West Africa. We present a patient with EVD who received brincidofovir and convalescent plasma. The relative contributions of supportive care, investigational therapies, and patients immune-response on survival could not be determined. Randomized trials are needed.

Lessons learned: critical care management of patients with Ebola in the United States.

Objective:This report will describe the preparations for and the provision of care of two patients with Ebola virus disease in the biocontainment unit at the University of Nebraska Medical Center. Data Sources:Patient medical records. Study Selection:Not applicable. Data Extraction:Not applicable. Data Synthesis:Not applicable. Conclusions:Safe and effective care of patients with Ebola virus disease requires significant communication and planning. Adherence to a predetermined isolation protocol is essential, including proper donning and doffing of personal protective equipment. Location of the patient care area and the logistics of laboratory testing, diagnostic imaging, and the removal of waste must be considered. Patients with Ebola virus disease are often dehydrated and need adequate vascular access for fluid resuscitation, nutrition, and phlebotomy for laboratory sampling. Advanced planning for acute life-threatening events and code status must be considered. Intensivist scheduling should account for the significant amount of time required for the care of patients with Ebola virus disease. With appropriate precautions and resources, designated hospitals in the United States can safely provide care for patients with Ebola virus disease.

Ebola virus disease: preparedness and infection control lessons learned from two biocontainment units.

Purpose of review This review details infection control issues encountered in the management of patients with Ebola virus disease (EVD), with emphasis on how these issues were confronted in two biocontainment patient care units in the United States. Recent findings There is a notable paucity of medical literature to guide infection control policies and procedures when caring for patients with EVD. Thus, the experience of the Serious Communicable Diseases Unit at Emory University Hospital and the Nebraska Biocontainment Unit at the University of Nebraska Medical Center serves as the basis for this review. Facility issues, staffing, transportation logistics, and appropriate use of personal protective equipment are detailed. Other topics addressed include the evaluation of patients under investigation and ethical issues concerning the safe utilization of advanced life support. Summary This review intends to serve as a reference for facilities that are in the process of creating protocols for managing patients with EVD. Given the lack of literature to support many of the recommendations discussed, it is important to utilize the available referenced guidelines, along with the practical experiences of biocontainment units, to optimize the care provided to patients with EVD while strictly adhering to infection control principles.

Safety considerations in the laboratory testing of specimens suspected or known to contain Ebola virus.

Reference to the Ebola virus causes concern among all individuals, whether from the public or within the medical community. Realization that patients with Ebola virus disease (EVD) have now been recognized in the United States in response to the major outbreak occurring in West Africa has heightened this fear. Recently, the World Health Organization declared the Ebola epidemic to be a Public Health Emergency of International Concern to provide containment of this major international health threat. In response to this threat to public health, the United States has stepped up efforts to provide care for infected patients, which include bringing individuals with EVD into the United States for treatment. These activities, along with the increased possibility of having more individuals recognized with EVD in the United States, have caused hospitals to evaluate how to contain and care for patients suspecting of having EVD. As a part of this response, laboratorians have been asked to be prepared to test specimens from persons under investigation (PUIs) for EVD or patients known to have EVD. Recently, the Centers for Disease Control and Prevention (CDC) provided an interim guideline followed by a supplemental document for how US laboratories could safely manage specimens from …

Animals in Healthcare Facilities: Recommendations to Minimize Potential Risks

Animals may be present in healthcare facilities for multiple reasons. Although specific laws regarding the use of service animals in public facilities were established in the United States in 1990, the widespread presence of animals in hospitals, including service animals to assist in patient therapy and research, has resulted in the increased presence of animals in acute care hospitals and ambulatory medical settings. The role of animals in the transmission of zoonotic pathogens and cross-transmission of human pathogens in these settings remains poorly studied. Until more definitive information is available, priority should be placed on patient and healthcare provider safety, and the use of standard infection prevention and control measures to prevent animal-to-human transmission in healthcare settings. This paper aims to provide general guidance to the medical community regarding the management of animals in healthcare (AHC). The manuscript has four major goals:

Nebraska biocontainment unit patient discharge and environmental decontamination after Ebola care

Department of Environmental, Agricultural and Occupational Health, University of Nebraska Medical Center, Omaha, NE Nebraska Biocontainment Unit, Nebraska Medicine, Omaha, NE Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE d Trauma and Preparedness Services, Nebraska Medicine, Omaha, NE Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE College of Nursing, University of Nebraska Medical Center, Omaha, NE Division of Infection Control and Epidemiology, Nebraska Medicine, Omaha, NE Office of the Vice Chancellor for Research, University of Nebraska Medical Center, Omaha, NE

Gaseous chlorine dioxide as an alternative for bedbug control.

OBJECTIVE This study evaluated the efficacy of gaseous chlorine dioxide (ClO(2)) for extermination of bedbugs (Cimex lectularius and Cimex hemipterus). BACKGROUND Bedbugs have received attention because of recent outbreaks. Bedbug eradication is difficult and often requires a time-consuming multifaceted approach. SETTING Laboratory and hospital room. METHODS Bedbugs were exposed to concentrations of ClO(2) of 362, 724, and 1,086 parts per million (ppm) in an exposure chamber. Bedbug mortality was then evaluated. The ability of ClO(2) to penetrate various spaces in a hospital room was evaluated using Bacillus atropheus as a surrogate organism. RESULTS Concentrations of 1,086 and 724 ppm of ClO(2) yielded 100% bedbug mortality assessed immediately after exposure. Live young were not observed for any eggs exposed to ClO(2) gas. ClO(2) at a concentration of 362 ppm for 1,029 parts per million hours (ppm-hours) achieved 100% mortality 6 hours after exposure. A ClO(2) concentration of 362 ppm for 519 ppm-hours had 100% mortality 18 hours after exposure. Up to a 6-log reduction in B. atropheus spores was achieved using similar concentrations of ClO(2) in a hospital room, indicating that the concentrations needed to kill bedbugs can be achieved throughout a hospital room. CONCLUSIONS ClO(2) is effective at killing bedbugs in the laboratory, and similar concentrations of ClO(2) gas can be achieved in a hospital room. ClO(2) can be removed from the room without residuals.

New Developments in the Prevention of Intravascular Catheter Associated Infections

Central line-associated bloodstream infections (CLA-BSI) are one of the leading causes of healthcare-associated infections, resulting in significant morbidity and substantial excess cost. There is a growing recognition that most CLA-BSIs are preventable. Elimination of preventable CLA-BSI is the focus of a recently released CDC Guideline. Universal preventative measures include collaborative performance improvement using checklists and bundles, education of persons who insert and maintain catheters, maximal sterile barrier precautions, and chlorhexidine skin preparation. Technologic innovations including coated catheters, antimicrobial impregnated dressings, and antimicrobial lock solutions should be considered if the rate of CLA-BSI is not acceptable after application of universal precautions.