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ATI Nursing, Assessment Technologies Institute, LLC (2016). RN Pharmacology for Nursing (7th ed.)

Allen, U. D., Robinson, J. L., & Canadian Paediatric Society, Infectious Diseases and Immunization Committee. (2014). Prevention and management of neonatal herpes simplex virus infections. Paediatrics & Child Health, 19(4), 201–206.

How antibiotics work. (2014, November 17). Retrieved from https://www.youtube.com/watch?v=X1GT2bKgci8S. (2016, May 11).

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Honey: Bacteria's Worst Enemy. Retrieved from https://www.youtube.com/watch?v=7FlzHiURdTsD., Edward Group DC, & NP. (2013, December 16).

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What is Kombucha? The 10 Facts You Need to Know. Retrieved from https://www.globalhealingcenter.com/natural-health/what-is-kombucha-10-facts-need-to-know/

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If you're into health food, you may have heard of kombucha. Kombucha is a lightly fermented tea which has achieved considerable popularity among the healthy eating crowd. Advocates claim it enhances cognition, stimulates immune function, supports weight loss, can be applied as a therapy for almost any ailment, and even promotes longevity. But, before you dive into your first cup, it's a good idea to know why it's good and what to look out for.

10 Must-Know Facts About Kombucha

1. What is Kombucha?

Kombucha consists of tea, sugar, clean water and a SCOBY. "SCOBY" stands for symbiotic culture of bacteria and yeasts. The sugar feeds the yeast and bacteria which form the SCOBY layer - the very identifiable, thick, mushroomy layer that rests on the top of the kombucha. This SCOBY adds the flavor, acidity and promotes the fermentation which creates the health benefits of kombucha. It also contains a small amount of alcohol (only .5%-3% depending on fermentation), gluconic, acetic, lactic acids and some substances that discourage bacteria. Many people describe the taste of kombucha as sweet and acidic, almost like soda with a slight vinegar taste.

As for its origins, kombucha is traditionally associated with Asia, Russia and Germany but became a popular drink globally by the late 1990's. Exploratory animal research offers substantial evidence to support the health claims that kombucha drinkers have known for decades.

2. How is Kombucha Made?

Remember as you read this, kombucha is a fermented drink. To make kombucha, tea is steeped in purified water and sugar is added. To this mixture, a culture of fungus and bacteria is added. Typical fermentation time runs about 14 days. The culture used is a very specific SCOBY, and anyone looking to brew their own (often recommended), should find a detailed recipe to ensure best results and maximum safety. Safety? Yes, you want to be sure you're only using friendly organisms that are free of contaminants.

3. Why It's Best to Make Your Own

Fresh food is the best food and that's especially true for kombucha. Making it at home ensures the freshest ingredients with the greatest amount of active nutrients. Studies have shown that commercially produced kombucha loses much of its antioxidants when stored in warehouses and on store shelves. An active fermentation process in storage can also cause films to form, this substantially degrades the quality. Although various processes have been tried in order to improve storage quality, none have proven successful.

4. A Caution About Making your Own

Keep the fungus and bacteria culture "clean" when making your own. While the SCOBY contributes to the health value, any common mold will contaminate the product. Contaminating mold would appear black, green or blue. If this appears on the culture, dispose of it, clean and sterilize all containers and tools used to make the kombucha and start over.

5. The Probiotic Benefits

The bacteria-fungus culture creates a tea loaded with beneficial probiotic organisms. The benefits of probiotics are well documented and linked to digestive health and immune function, just to note a few. One study found that kombucha may provide substantial activity for controlling e. Coli and Staph bacteria, a common benefit of many probiotics.

Different brewing factors such as tea selection, brewing time, sugar, and fermentation time alter the specific nutrients and probiotics present in any given batch. If you make your own, you can work with these different elements to create the batch which makes you feel the best!

6. How Kombucha Protects the Liver

Research suggests that kombucha tea consumption does appear to have protective effects for the liver. One animal study reported that kombucha decreased levels of toxins known to cause liver damage. A similar study reported of anti-stress benefits from the tea. These benefits are unique to Kombucha and do not result from unfermented teas.

7. Kombucha May Even Promote Lung Health

Chinese researchers discovered a unique, potential application for kombucha tea. Used as an inhalant, kombucha was found to remove silica from lungs in an animal model. This may be extremely promising for the men and women with construction, masonry and mining jobs who are exposed to dangerous silica dust. The American Lung Association estimates over 2 million men and women are exposed to such lung contaminants and have the potential for developing complications. Although still exploratory, it's exciting to hear that kombucha may be a potential life saver and support normal lung function.

8. Kombucha and Blood Sugar

Metabolic problems and liver and kidney dysfunction are frequent side effects of diabetes. Good news, the antioxidants created by kombucha fermentation may help support liver, kidney and pancreatic function. Shown to suppress glucose levels and increase HDL cholesterol levels in animal trials, researchers have indicated kombucha may be a good health support option for those with diabetes.

9. Kombucha and Stomach Ulcers

Research in 2010 indicated the antioxidant effect of kombucha may heal stomach problems from excess acid build-up, such as ulcers. It's reported that kombucha appears to protect the layer of the stomach which prevents acid erosion of stomach tissue. This results from reduced levels of stomach acid, and has been suggested as a support option for those with stomach ulcers.

10. Kombucha and the Kidneys

When researchers tested kombucha on kidneys damaged by environmental toxins, they found that the antioxidant potency of kombucha tea may repair damaged kidney tissue. These findings suggest kombucha tea has potential for many uses beyond the health-focused benefits advocated by traditional consumption and research supported by current research.

Do you make or drink kombucha? What tips do you have? What benefits have you noticed? Please leave a comment below and share your experience with kombucha with us!

References (15)

1. Hartmann AM, Burleson LE, Holmes AK, Geist CR. Effects of chronic kombucha ingestion on open-field behaviors, longevity, appetitive behaviors, and organs in c57-bl/6 mice: a pilot study. Nutrition. 2000 Sep;16(9):755-61.

2. Hauser SP. [Dr. Sklenar's Kombucha mushroom infusion--a biological cancer therapy. Documentation No. 18]. Schweiz Rundsch Med Prax. 1990 Feb 27;79(9):243-6.

3. Greenwalt CJ, Steinkraus KH, Ledford RA. Kombucha, the fermented tea: microbiology, composition, and claimed health effects. J Food Prot. 2000 Jul;63(7):976-81.

4. Vijayaraghavan R, Singh M, Rao PV, Bhattacharya R, Kumar P, Sugendran K, Kumar O, Pant SC, Singh R. Subacute (90 days) oral toxicity studies of Kombucha tea. Biomed Environ Sci. 2000 Dec;13(4):293-9.

5. Jayabalan R, Marimuthu S, Thangaraj P, Sathishkumar M, Binupriya AR, Swaminathan K, Yun SE. Preservation of kombucha tea-effect of temperature on tea components and free radical scavenging properties. J Agric Food Chem. 2008 Oct 8;56(19):9064-71. doi: 10.1021/jf8020893. Epub 2008 Sep 10.

6. Cetojevic-Simin DD, Bogdanovic GM, Cvetkovic DD, Velicanski AS. Antiproliferative and antimicrobial activity of traditional Kombucha and Satureja montana L. Kombucha. J BUON. 2008 Jul-Sep;13(3):395-401.

7. Wang Y, Ji B, Wu W, Wang R, Yang Z, Zhang D, Tian W. Hepatoprotective effects of kombucha tea: identification of functional strains and quantification of functional components. J Sci Food Agric. 2013 May 28. doi: 10.1002/jsfa.6245.

8. Murugesan GS, Sathishkumar M, Jayabalan R, Binupriya AR, Swaminathan K, Yun SE. Hepatoprotective and curative properties of Kombucha tea against carbon tetrachloride-induced toxicity. J Microbiol Biotechnol. 2009 Apr;19(4):397-402.

9. Pauline T, Dipti P, Anju B, Kavimani S, Sharma SK, Kain AK, Sarada SK, Sairam M, Ilavazhagan G, Devendra K, Selvamurthy W. Studies on toxicity, anti-stress and hepato-protective properties of Kombucha tea. Biomed Environ Sci. 2001 Sep;14(3):207-13.

10. Fu NF, Luo CH, Wu JC, Zheng YY, Gan YJ, Ling JA, Liang HQ, Liang DY, Xie J, Chen XQ, Li XJ, Pan RH, Chen ZX, Jiang SJ. Clearance of free silica in rat lungs by spraying with chinese herbal kombucha. Evid Based Complement Alternat Med. 2013;2013:790792. doi: 10.1155/2013/790792. Epub 2013 Aug 19.

11. American Lung Association. Understanding Silicosis. (last accessed 2013-12-05)

12. Bhattacharya S, Gachhui R, Sil PC. Effect of Kombucha, a fermented black tea in attenuating oxidative stress mediated tissue damage in alloxan induced diabetic rats. Food Chem Toxicol. 2013 Oct;60:328-40. doi: 10.1016/j.fct.2013.07.051. Epub 2013 Jul 29.

13. Aloulou A, Hamden K, Elloumi D, Ali MB, Hargafi K, Jaouadi B, Ayadi F, Elfeki A, Ammar E. Hypoglycemic and antilipidemic properties of kombucha tea in alloxan-induced diabetic rats. BMC Complement Altern Med. 2012 May 16;12:63. doi: 10.1186/1472-6882-12-63.

14. Banerjee D, Hassarajani SA, Maity B, Narayan G, Bandyopadhyay SK, Chattopadhyay S. Comparative healing property of kombucha tea and black tea against indomethacin-induced gastric ulceration in mice: possible mechanism of action. Food Funct. 2010 Dec;1(3):284-93. doi: 10.1039/c0fo00025f. Epub 2010 Nov 3.

15. Gharib OA. Effects of Kombucha on oxidative stress induced nephrotoxicity in rats. Chin Med. 2009 Nov 27;4:23. doi: 10.1186/1749-8546-4-23.

†Results may vary. Information and statements made are for education purposes and are not intended to replace the advice of your doctor. Global Healing Center does not dispense medical advice, prescribe, or diagnose illness. The views and nutritional advice expressed by Global Healing Center are not intended to be a substitute for conventional medical service. If you have a severe medical condition or health concern, see your physician.

This entry was posted in Foods, Gut and Digestive Health, Gut Flora, Health, Healthy Foods, Healthy Probiotic Foods, Nutrition, Whole Body Wellness

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Dr. Edward Group DC, NP, DACBN, DCBCN, DABFM

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What is Kombucha? The 10 Facts You Need to Know

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If you're into health food, you may have heard of kombucha. Kombucha is a lightly fermented tea which has achieved considerable popularity among the healthy eating crowd. Advocates claim it enhances cognition, stimulates immune function, supports weight loss, can be applied as a therapy for almost any ailment, and even promotes longevity.

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Prevention and management of neonatal herpes simplex virus infections 4/19/2014

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Prevention and management of neonatal herpes simplex virus infections 4/19/2014

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All infants are potentially at risk for HSV (herpes simplex virus).

In Canada, HSV infection occurs in 6 of every 100,000 live births

In most cases of NHSV (neonatal HSV), the mother had no signs or symptoms of HSV infection (studies show that 75%-90% of HSV-2 positive women have no symptoms).

Women with recurrent genital HSV are given acyclovir prophylactically from 36 weeks gestation until birth.

Acyclovir is the primary treatment for NHSV

60 mg/kg/day, divided into 3 doses given Q8hr.

For Skin, Eye, and Mucous Membrane (SEM) infection, duration is 14 days

For disseminated (involving multiple organs, commonly lungs and liver) or CSF infection, duration is 21 days.

Dose can be immediately discontinued if all swabs for HSV is negative.

Oral route is contraindicated for acute treatment of HSV, as dose concentration would be too low.

Oral route used in cases of CSF involvement for 6 months as suppressive treatment.

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Language: English | French

Abstract

Human herpes simplex virus (HSV) infection in neonates can result in devastating outcomes, including mortality and significant morbidity. All infants are potentially at risk for neonatal HSV infection. This position statement reviews epidemiology, transmission and risk factors, with a focus on intrapartum infection. It considers diagnosis and prognosis according to infection category, along with testing modalities and limitations. Recommendations for managing newborns known to have been exposed intrapartum to HSV are based on expert opinion because a randomized trial to compare management options is not feasible. Guidance is provided for the empirical management of infants with suspected clinical sepsis, including those who do not respond to antibacterial therapy. The present statement replaces a 2006 position statement by the Canadian Paediatric Society.

Keywords: Acyclovir, CNS, Encephalitis, SEM, Sepsis

Résumé

Chez les nouveau-nés, l'infection par le virus de l'herpès simplex humain (VHS) peut avoir des conséquences cliniques dévastatrices, y compris la mortalité et une importante morbidité. Tous les nourrissons sont vulnérables à l'infection par le VHS néonatal. Le présent document de principes contient une analyse de l'épidémiologie, de la transmission et des facteurs de risque et s'attarde tout particulièrement sur l'infection intrapartum. Il présente une évaluation du diagnostic et du pronostic selon la catégorie d'infection, de même que les modalités et les limites des examens. Les recommandations relatives à la prise en charge des nouveau-nés dont l'exposition au VHS intrapartum est confirmée se fondent sur des avis d'experts, car il est impossible de procéder à un essai aléatoire pour comparer les possibilités thérapeutiques. Des conseils sont donnés pour la prise en charge empirique des nourrissons chez qui on craint un sepsis clinique, y compris ceux qui ne répondent pas à la thérapie antibactérienne. Le présent document de principes remplace celui que la Société canadienne de pédiatrie a publié en 2006.

EPIDEMIOLOGY

Estimated rates of neonatal human herpes simplex virus (NHSV) infection vary across different regions of the world.( 1, 2) In Canada, the infection occurs in approximately one per 16,500 newborns, which corresponds to approximately six per 100,000 live births. ( 1) Transmission to newborns can occur with either genital herpes simplex virus (HSV) type 1 (HSV-1) or HSV type 2 (HSV-2). Worldwide, an estimated 75% of NHSV cases are caused by HSV-2 and 25% by HSV-1.( 3) One Canadian prospective study analyzing reports in the period between 2000 and 2003 found that 63% of cases were due to HSV-1.( 1) Studies from Ontario (conducted in 2000 to 2001)( 4) and British Columbia (in 1999)( 5) investigating infants potentially at risk for HSV-2 detected HSV-2 antibodies in 10% and 17% of pregnant women, respectively.

Many factors influence the transmission of HSV infection to newborns, including the nature of maternal infection, the mode of delivery, the duration of rupture of membranes and the use of intrapartum instrumentation.

Maternal genital HSV cases may be classified as follows:( 6)

Newly acquired

○ First-episode primary infection (mother has no serum antibodies to HSV-1 or -2 at onset);

○ First-episode nonprimary infection (mother has a new infection with one HSV type in the presence of antibodies to the other type); or

Recurrent (mother has pre-existing antibodies to the HSV type that is isolated from the genital tract).

The most common and important category of NHSV acquisition is intrapartum. Even for HSV-1, >75% of cases of NHSV are acquired during delivery from genital disease that is often newly acquired and asymptomatic.( 7) Newborns may also acquire HSV infection through in utero or postnatal transmission. Although rare, in utero HSV infection can have teratogenic effects such as skin lesions or scars, central nervous system (CNS) disorders and chorioretinitis. ( 8) Postnatal infection can be acquired from the infant's mother or from nonmaternal sources (eg, relatives or hospital personnel with orolabial herpes or asymptomatic shedding of HSV-1). ( 3, 9)

In most cases of NHSV infection, there is no known history of maternal genital HSV because mothers have never had or have never noticed external genital lesions. Studies show that 75% to 90% of individuals who are seropositive for HSV-2 were unaware of their infection.( 10) All infants, therefore, must be considered to be potentially at risk for NHSV infection. Seropositive women intermittently shed HSV in their genital tracts, with 10% to 20% of individuals with HSV-2 shedding on any given day, as detected by polymerase chain reaction (PCR) testing.( 11)

The category of maternal infection at time of delivery influences the likelihood of NHSV acquisition, presumably because mothers who have had an HSV infection transmit HSV-neutralizing antibodies to their infant across the placenta, provided that their infant is not born before 32 weeks' gestation. ( 7, 12- 14) Thus, infants born to mothers who have a first-episode primary infection at time of delivery are at the highest risk for acquiring HSV, with transmission rates of up to 60%, because their mother had no pre-existing neutralizing antibodies to transmit.( 3) For infants born to mothers who have first-episode nonprimary infections, the transmission rates are in the order of ≤30% because crossreactive antibodies are present. The lowest risk of neonatal transmission occurs with maternal recurrent infection (at <2%) because type-specific antibodies are present.( 4)

Delivery by elective Cesarean section markedly reduces but does not eliminate the risk for newborn infection.( 15, 16) Women with recurrent genital HSV are commonly prophylaxed with acyclovir (ACV) or valacyclovir from 36 weeks' gestation until delivery. In this context, antiviral therapy near the end of pregnancy can lower recurrence of genital HSV and shedding at delivery;( 17) however, it is not clear whether this prophylaxis translates to a reduced risk for NHSV infection. Guidelines regarding the role of Cesarean delivery and the indications for acyclovir are published( 16, 18, 19) but are not specifically addressed in the present statement.

Obstetrical procedures that can cause scalp abrasions or a break in the infant's skin during labour and delivery may increase risk of NHSV transmission to a newborn infant. Fetal scalp sampling and monitoring, use of forceps and vacuum-assisted deliveries( 16, 19- 23) should be avoided if possible when maternal genital lesions are present.( 16) Early or prolonged rupture of membranes may also increase risk.

CATEGORIES AND OUTCOMES OF NHSV INFECTION

Classifying NHSV infections can help to guide diagnosis and management, and is important for assigning prognosis.( 24) Intrauterine NHSV infections are rare, accounting for <5% of cases. The classification of infection acquired in the perinatal, natal and post-natal periods is as follows:

There may be overlap among the different syndromes. Disseminated disease involves multiple organs, notably the liver and lungs.

In most cases, the initial symptoms of NHSV infection present within the first four weeks of life. Occasionally, disease presents for the first time between four and six weeks after birth;( 4) therefore, infants up to 42 days of age should be fully evaluated for NHSV when clinical features are consistent with NHSV. Newborns with intrauterine infection present at birth or shortly thereafter.

The absence of skin lesions does not negate the possibility of an NHSV diagnosis. One study showed that 39% of infants with disseminated disease did not have skin lesions at any time during their illness, while 32% with CNS disease and 17% with SEM disease did not develop skin lesions.( 25) NHSV infection should be considered in neonates with sepsis syndrome, particularly when this condition is accompanied by liver dysfunction and even when there is no known history of maternal HSV and the infant has no skin vesicles. One study reviewed 32 infants with perinatal HSV, noting that 50% of cases came to medical attention with non-specific complaints and 75% of these had fever alone. Nonspecific presentation occurred primarily in infants whose symptoms started at <21 days of age.( 26) Also, HSV should be considered in neonates with fever, irritability and abnormal cerebrospinal fluid (CSF) findings, particularly when accompanied by seizures. However, a normal initial CSF examination does not necessarily exclude the diagnosis of an NHSV CNS infection.( 26)

Infants who present with disseminated disease are less likely to survive than infants with SEM or CNS disease. Data suggest that dissemination is more common with newly acquired maternal HSV, presumably because there has not been sufficient time to transfer neutralizing antibodies in utero.( 27, 28) Before antivirals, an estimated 85% of infants with disseminated HSV disease and 50% with CNS disease died.( 29) Treatment with ACV (60 mg/kg/day) has resulted in one-year mortality rates from disseminated and CNS disease of 29% and 14%, respectively.( 30) A mortality rate of 15.5% was reported in a Canadian study that documented cases occurring over a three-year period (October 2000 to September 2003).( 1)

Among survivors enrolled in two studies of parenteral ACV for which follow-up data were available at 12 months of age, 25% of patients with disseminated disease exhibited neurological complications, compared with 70% with CNS infection alone.( 25) Among neonates with SEM disease (without apparent CNS disease), long-term neurological sequelae have also been documented.( 28, 31) However, more recent studies demonstrate no sequelae; therefore, it appears likely that those infants with sequelae had unrecognized CNS infection.( 32)

LABORATORY DIAGNOSIS

It is important for the clinician to speak with a laboratory specialist or infectious disease consultant when NHSV is suspected, particularly in settings where testing for NHSV is performed less frequently. Expert consultation is important because the utility of testing modalities varies according to sample type, and the laboratory must provide general as well as centre-specific advice on the types of specimens to send for testing. Each specific laboratory test for HSV has important limitations. Therefore, test results should be interpreted with careful consideration of the clinical context and results from nonspecific investigations including an electroencephalogram, computed tomography or magnetic resonance imaging, liver transaminase levels and platelet count.

HSV may be detected using the following tests:

Viral cultures from the oropharynx, nasopharynx, skin lesions, mucous membrane (eye and mouth) swabs, rectal swabs, blood buffy coat and CSF;

PCR testing of CSF, skin lesions, mucous membranes and blood;

Direct immunofluorescent antibody staining of skin lesions;

Enzyme immunoassays for HSV antigens in skin lesions.

When skin lesions are present, rapid diagnostic techniques, such as direct immunofluorescence of virus-infected cells for the presence of HSV antigens, are of value. Direct immunofluorescence staining is not reliable unless the sample was obtained from a skin lesion (as opposed to a mucous membrane or oropharyngeal swab).( 4)

The isolation of HSV by culture is still regarded as the definitive diagnostic method for establishing HSV disease outside of the CNS.( 33) Some centres now only offer PCR because it is believed to be more sensitive. The detection of the virus in superficial cultures may, however, represent skin contamination by intrapartum exposure if samples are obtained within the first 24 h after birth. ( 4) When samples obtained >24 h after birth are positive, they are more likely to represent active viral replication than contamination. Prospective studies regarding the utility of periodic surveillance cultures in the early diagnosis of NHSV infection are lacking for infants exposed to active genital lesions.

For patients with CNS HSV, PCR is a critically important diagnostic test because it is more sensitive than culture.( 34) As with any PCR test, false positive and false negative test results can occur. Caution should be exercised when using a negative CSF HSV PCR to rule out CNS HSV, particularly when the sample is obtained in the early stages of illness (the first 24 h to 48 h). Because CNS disease can be very subtle, any patient with suspected NHSV infection should have a lumbar puncture performed for CSF DNA PCR testing as soon as it is clinically feasible to do so, unless there is a contraindication to performing a lumbar puncture. CNS NHSV infection may occur despite 'normal' CSF cell counts and biochemical features, particularly in the early stages of infection. Therefore, the CSF DNA PCR test should be performed even when these parameters are normal.

The evaluation of HSV viremia using DNA PCR is less well established than CSF DNA PCR testing. ( 35- 37). One study that evaluated HSV viral load in serum and CSF using a real-time PCR assay found that patients with disseminated disease had higher viral loads in their sera, while patients with CNS infection had higher viral loads in their CSF.( 35) Viral loads were also higher in patients who succumbed to HSV disease, suggesting that this measure may be useful for assessing prognosis in NHSV cases. A poorer prognosis has also been associated with persistence of HSV DNA in the CSF of patients on acyclovir.( 35)

Infant serology is not useful for diagnosing NHSV for three main reasons. First, transplacental immunoglobulin (Ig) G antibodies cannot be differentiated from IgG produced by the infant. Second, the ability of some severely affected infants to make antibodies is impaired. Third, the commercially available assays for HSV IgM antibodies have only variable and limited reliability.

MANAGING NHSV INFECTIONS

Intravenous acyclovir is the treatment of choice for treating NHSV. The dose is 60 mg/kg/day in three divided doses administered every 8 h, assuming that renal function is normal.( 30) The duration of therapy is dictated by the category of disease. For SEM disease, the duration of therapy is 14 days, while for disseminated or CNS disease, the minimum duration of treatment is 21 days. Oral ACV has limited bioavailability, resulting in inadequate drug levels for treatment;( 38) consequently, parenteral therapy is required. The use of higher doses of ACV is associated with neutropenia and adequate hydration is necessary to reduce the risk of nephrotoxicity.( 30) A topical agent (eg, 1% trifluridine) is recommended for use with parenteral ACV in neonates with ocular disease.( 3)

Given the potential for significant neurological sequelae in survivors of NHSV infection, affected infants should have a structured follow-up program that allows for neurodevelopmental, ophthalmological and hearing assessments.

There has been research into the role of suppressive antiviral therapy in infants with NHSV infections. A recent randomized, double-blinded, placebo-controlled trial evaluated infants with CNS HSV or disseminated HSV with CNS involvement, while a second, parallel trial evaluated infants with SEM HSV disease. The study demonstrated improved developmental outcome in infants with CNS involvement who were randomly assigned to receive six months of treatment with oral ACV versus placebo. ( 32) For infants with SEM disease, the only benefit was a decreased incidence of skin recurrences.( 39, 40)

RECOMMENDATIONS

Laboratory diagnostics for NHSV infections

Whenever a diagnosis of NHSV is being considered, it is essential to order laboratory testing for HSV in addition to performing skin and mucous membrane examinations:

○ The standard tests for HSV include CSF PCR and swabs of vesicular lesions and mucous membranes (tested by the method recommended by the local laboratory). Also, blood for HSV PCR may be tested, if available.

○ Serum hepatic transaminase levels should be measured to provide supporting evidence for disseminated HSV infection.

When evaluating NHSV infection in exposed asymptomatic infants, mucous membrane swabs should be obtained from the mouth, nasopharynx and conjunctivae at least 24 h after delivery. Additional swabs may be obtained (eg, from sites of scalp electrodes, if present).

PCR testing for CSF HSV DNA is the diagnostic method of choice for CNS HSV.

For all the above tests, clinicians and laboratory staff should work together to minimize the turn-around time for test results.

Managing asymptomatic term infants whose mothers have active lesions at delivery ( and )

Antibodies to HSV-1 or HSV-2 (type-specific HSV antibodies) take approximately three weeks to develop following infection. ( 41) Their identification is useful in managing NHSV and testing should be performed if available. When a mother has active lesions at time of delivery but does not have type-specific antibodies, clinicians should presume it is a newly acquired first-episode primary infection. When she only has antibodies to the HSV type other than the type she is shedding, assume it is a first-episode nonprimary disease. When she has antibodies to both HSV-1 and HSV-2, this is likely to be a case of recurrent disease.

Evaluation and treatment at birth is indicated for exposed newborns with symptoms of NHSV.

Presumed first-episode primary or first-episode nonprimary infection, when an infant is delivered by Cesarean section before rupture of membranes

The risk for NHSV is very low. Assuming that the infant is well, mother and child can be discharged pending results of the mucous membrane and nasopharyngeal swabs taken at 24 h of life. Reliable caregivers should be made aware of the signs of NHSV infection. Some experts also recommend testing blood with PCR, if the test is available. If HSV is detected on a swab or in blood PCR, the infant should be managed as a case of NHSV.

Note: Some experts recommend performing CSF cell count, chemistries and PCR when mucous membrane swabs are taken (ie, a complete work-up).

Presumed first-episode primary or first-episode nonprimary infection, when an infant is delivered vaginally or by Cesarean section after rupture of membranes

Where available, approved type-specific HSV antibody testing can be used to confirm whether the mother has primary, nonprimary or recurrent HSV.( 42) Many women who are believed to be presenting with primary disease at delivery actually have recurrent disease.

An infant's mucous membrane swabs should be obtained and ACV started. It remains controversial whether this testing should be performed at birth (with the risk being detection of surface contamination) or at 24 h of life. Some experts also recommend testing blood with PCR, if the test is available. If the infant's swabs or blood PCR are positive, CSF PCR must be obtained to determine the duration of ACV therapy. If the infant's swabs are negative, ACV can be stopped if type-specific serology testing shows that the mother has recurrent HSV. If type-specific serology testing is not available or shows the mother has first-episode HSV, the infant should receive ACV for 10 days despite negative swabs.

Note: Some experts recommend performing CSF cell count, chemistries and PCR when mucous membrane swabs are taken (ie, a complete work-up).

Recurrent HSV at delivery - Infant delivered by Cesarean section

Use the same approach as for first-episode infections before membrane rupture.

Recurrent HSV at delivery - Infant delivered vaginally

Obtain mucous membrane swabs at 24 h and the infant may be discharged pending results. Some experts also recommend testing blood for PCR, if the test is available. ACV therapy would only be indicated when the swabs or blood PCR are positive or when the infant develops signs and symptoms of NHSV infection.

Managing asymptomatic term infants whose mothers have no active lesions at delivery (including women on ACV prophylaxis)

An infant whose mother has a history of HSV but no active lesions at delivery should be observed for signs of NHSV but does not require ACV therapy. Mucous membrane swabs are not routinely recommended for this infant. In scenarios in which the first clinical evidence of HSV was documented during the third trimester or near delivery, clinicians may consider mucous membrane swabs. Parents and caregivers should be educated about the signs and symptoms of NHSV.

Managing the neonate with symptoms compatible with NHSV

Disseminated HSV can mimic bacterial sepsis, and clinicians need to consider possible NHSV infection in unwell infants <6 weeks of age. Pending laboratory confirmation, consider investigations and treatment of NHSV for the following at-risk patients:

Infants started on IV antibiotics for suspected sepsis (especially infants presenting with seizure or yielding abnormal CSF) who do not improve rapidly and have negative bacterial cultures at 24 h incubation.

Infants admitted with pneumonia of uncertain etiology who do not improve after 24 h on antibiotics, especially if the radiographic picture is consistent with viral pneumonia.

Infants with unexplained bleeding from venipuncture sites or an unexplained, documented coagulopathy.

Infants started on IV antibiotics for suspected sepsis who are found to have unexplained hepatitis.

Treatment and follow-up of infants with NHSV infections

Early therapy with intravenous (IV) ACV improves the prognosis for all three presentations of NHSV. Therefore, infants should be started on IV ACV before laboratory confirmation of NHSV, as soon as the infection is suspected clinically.

The dose is 60 mg/kg/day in three divided doses administered every 8 h, assuming that renal function is normal. Treatment duration should be 14 days if the disease is limited to the skin, eyes or mouth, and a minimum of 21 days if the infection involves the CNS or is disseminated.

For infants with CNS disease, CSF should be sampled near the end of a 21-day course of therapy. If the PCR remains positive, treatment should be extended with weekly CSF sampling and ACV stopped when a negative result is obtained.

In combination with parenteral ACV, neonates with ocular involvement should receive a topical ophthalmic agent such as trifluridine. An ophthalmology consultation is essential.

Oral ACV is contraindicated for the acute treatment of NHSV because drugs levels are too low. Levels from oral ACV are only high enough for suppressive therapy.

Suppressive therapy with oral ACV (300 mg/m ² per dose administered three times per day) should be given for six months to infants with CNS disease. A tool for calculating body surface area can be found at: www.csgnetwork.com/bsacalc.html. Data are less convincing for SEM or disseminated disease, but suppressive therapy may still be offered.

Follow-up is necessary to detect and manage adverse effects related to suppressive ACV treatment as well as for the neurodevelomental sequelae of NHSV. Complete blood count, and urea and creatinine levels should be checked monthly for adverse effects, and the dose of ACV adjusted for growth. Infants should be followed in a program that enables their evaluation for the neurodevelopmental, ophthalmological and aural consequences of NHSV infection.

Preventing NHSV infections

Strategies to prevent NHSV, including the identification of high-risk pregnancies, Cesarean delivery, maternal antiviral therapy, and anticipatory guidance for prospective mothers and partners, are largely beyond the scope of this statement. However, the following recommendations are especially pertinent to special care nurseries and neonatal intensive care units.

General infection control measures

Comprehensive infection control guidelines are available,( 43) but three specific target groups warrant attention here:

Acknowledgments

This position statement has been reviewed by the Fetus and Newborn and Community Paediatrics Committees of the Canadian Paediatric Society.

Footnotes
CPS INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE
Members: Robert Bortolussi (past Chair); Natalie A Bridger MD; Jane C Finlay MD (past member); Susanna Martin MD (Board Representative); Jane C McDonald MD; Heather Onyett MD; Joan L Robinson MD (Chair); Marina I Salvadori MD (past member); Otto G Vanderkooi MD

Consultant: Noni E MacDonald MD

Liaisons: Upton D Allen MBBS, Canadian Pediatric AIDS Research Group; Michael Brady MD, Committee on Infectious Diseases, American Academy of Pediatrics; Janet Dollin MD, College of Family Physicians of Canada; Charles PS Hui MD, Committee to Advise on Tropical Medicine and Travel (CATMAT), Public Health Agency of Canada; Nicole Le Saux MD, Immunization Monitoring Program, ACTive (IMPACT); Dorothy L Moore MD, National Advisory Committee on Immunization (NACI); John S Spika MD, Public Health Agency of Canada

Principal authors: Upton D Allen MBBS; Joan L Robinson MD

The recommendations in this statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. All Canadian Paediatric Society position statements and practice points are reviewed on a regular basis. Retired statements are removed from the website. Please consult the Position Statements section of the CPS website ( www.cps.ca) for the full-text, current version.

REFERENCES

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Prevention and management of neonatal herpes simplex virus infections

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Language: English | French Human herpes simplex virus (HSV) infection in neonates can result in devastating outcomes, including mortality and significant morbidity. All infants are potentially at risk for neonatal HSV infection. This position statement reviews epidemiology, transmission and risk factors, with a focus on intrapartum infection.

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A young adult client's acne has responded well to treatment with tetracycline. However, the client has now returned to the clinic 6 weeks later with signs and symptoms of oral candidiasis. The nurse should recognize that this client's current health problem is likely attributable to which occurrence?

A.     a delayed (type IV) hypersensitivity reaction

B.     the fact that the client may have chewed the capsules prior to swallowing them

C.     superinfection following the eradication of normal oral flora

D.    a type I hypersensitivity reaction

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Answer: C

Candidal superinfections may result from the use of tetracycline. The superinfection results from the elimination of normal flora and is not a hypersensitivity reaction. This is not the result of physical contact between the drug and the oral mucosa. Type IV hypersensitivity is often called delayed-type hypersensitivity as the reaction takes 2 to 3 days to develop. A type I hypersensitivity reaction is triggered by an innocuous foreign substance (like dust, pollen, or animal dander) that would cause no problems in most people.

Reference: Karch, Amy M., Focus on Nursing Pharmacology, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 9: Antibiotics, p. 123.

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A 70-year-old man is being treated for herpes zoster virus. He has been prescribed acyclovir (Zovirax). The clinic nurse should prioritize assessments of which of the following?

A.      Neurologic function

B.      Renal function

C.      Cardiac function

D.     Respiratory function

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Answer: B

The risk for nephrotoxicity is higher in older patients because with advancing age, renal function diminishes and drug excretion becomes less effective. Serious adverse effects or cumulative toxicity can result. It is important for the nurse to be aware of and assess the older patient's neurologic, cardiac, and respiratory functions. However, they would not be as important as the renal function because of the medication being taken.

Reference: Karch, A.M. Focus on Nursing Pharmacology, 7th ed., Philadelphia: Wolters Kluwer Health, 2017, Chapter 10: Antiviral Agents, p. 144, box 10.2.

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An adult client, recently diagnosed with a tinea infection, has begun treatment with griseofulvin. During a scheduled clinic visit, the client states to the nurse, “I'm pretty good at reading my body's signals, so I make sure to take a bit extra when I think my infection is getting worse.” This client's statement is suggestive of what nursing diagnosis?

A.      deficient knowledge related to correct use of griseofulvin

B.      effective therapeutic regimen management related to symptom identification

C.      disturbed thought processes related to appropriate use of griseofulvin

ineffective coping related to self-medication

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Answer: A

In order to achieve maximum therapeutic benefit, it is important for the client to take the drug exactly as prescribed. The client's statement suggests that the client does not appreciate or understand this fact. There is no evidence of pathological thought patterns or ineffective coping. The statement reflects an inaccurate conclusion regarding the symptom management of this disorder.

Reference: Karch, Amy M., Focus on Nursing Pharmacology, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 11: Antifungal Agents, p. 171,175.

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An adult client has been admitted to the emergency department after deliberately overdosing on approximately 50 grams of Tylenol. The nurse should prepare for what intervention?

A.      Administration of acetylcysteine as prescribed

B.      Watchful waiting

C.      Administration of naloxone as prescribed

D.      Intravenous administration of Lactated Ringer’s

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Answer: A

Acetylcysteine is the antidote to acetaminophen overdose. Naloxone treats opioid overdoses. Given the high dose of acetaminophen, watchful waiting would be inadequate. Lactated Ringer’s would not be therapeutically beneficial.

Reference: Karch, Amy M., Focus on Nursing Pharmacology, 7th ed., Philadelphia, Wolters Kluwer, 2017, Chapter 16: Anti-Inflammatory, Antiarthritis, and Related Agents, p. 275.

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A male patient, 80 years old, visited primary care physician with complaints of breathlessness and a sore throat. He has a history of bronchiectasis and has been developing regular chest infections over the years. He was admitted 2 years ago with a DVT in the right calf. He also has a history of UTI’s and seasonal allergies. He claims that he experiences “occasional winter blues” and self medicates with non prescription herbal medication.

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It may not look like it sitting in that cute bear bottle, but honey is a supercharged bacteria-killing powerhouse! Learn more about hydrogen peroxide: https://www.youtube.com/watch?v=vVSC79nxCvI Hosted by: Hank Green ---------- Support SciShow by becoming a patron on Patreon: https://www.patreon.com/scishow ---------- Dooblydoo thanks go to the following Patreon supporters -- we couldn't make SciShow without them!

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Tamiflu Commercial

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Fever, aches, chills. Check your symptoms and learn more about a prescription flu treatment.

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Tamiflu® (oseltamivir phosphate) is an antiviral medicine for treatment of flu in people 2 weeks of age and older and for prevention of flu in people 1 year of age and older. Indications: Tamiflu is a prescription medicine used to treat the flu (influenza) in people 2 weeks of age and older who have had flu symptoms for no more than 2 days.

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What are Anti-infectives: Anti-infectives is a general term used to describe any medicine that is capable of inhibiting the spread of an infectious organism or by killing the infectious organism outright.

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The patient is on the following medications:

Ciprofloxacin 500mg P.O. 2x daily for 14 days

Men’s Daily Multivitamin P.O. 1x daily

Eliquis 2.5mg P.O. 2x daily

Loratadine 10mg P.O. 1x daily

St. John’s Wort 5-6 drops P.O. 3x daily

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At the same time Alexander Fleming noted that mold belonging to the genus Penicillium inhibited the growth of bacteria. Fleming called this unknown antibacterial substance penicillin. Ten years later, a group at Oxford University began to investigate penicillin in laboratory mice. Penicillin was hailed as a miracle drug and saved countless lives in World War II.

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The discovery of antibiotics in the 20th century helped humans to fight deadly diseases, but now  the more we use them, the greater the pressure becomes for bacteria to evolve.
So why do we become resistant?

When exposed to repeated cycles of antibiotics, within days bacteria can evolve a new adaptation, by remaining dormant for the treatment period to survive antibiotic stress. The results show for the first time that bacteria can develop a biological timer to survive antibiotic exposure

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The male patient calls his PCP, complaining “I must have bumped my leg off of the table because my right leg is aching very bad this morning”.

The doctor instructed him to take 500mg of acetaminophen every 6 hours as needed.

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Resist the Resistance: An Explanation of Beta-lactam Antibiotics

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The next day the patient called again and complained to the Physician’s Assistant that the pain is unbearable in his right leg and radiates from his heel to his knee, and that now his left leg is beginning to hurt as well. The PA reviewed the patient’s chart and said to go to an ER immediately.

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How should these patients be treated?

How could you – and patients – help to slow the development of resistant bacteria?

How can drug companies be encouraged to develop new treatments?

What role could better diagnostic tests play in reducing resistance?

Should antibiotic use be restricted?

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The patient arrived to the ER and the Dr. preformed a palpation exam. The examination revealed bilateral posterior calf tenderness. He then preformed a Thompson-Doherty test and it was positive bilaterally. A palpable gap was noted in the Achilles tendon bilaterally. MRI confirmed bilateral total Achilles tendon rupture.

Some things to know about Cipro:

·      Achilles tendon rupture is most common in people over the age of 60

·      Achilles tendon rupture is more common with groups of people who have pre-existing health problems such as diabetes mellitus, or prolonged steroid use for lung problems

·      Rupture can occur from the first dose or can be over long periods of time

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We have Narrow-spectrum anti-infectives – Which are agents that are so selective in their action that they are effective against only a few microorganisms

And Broad-spectrum anti-infectives are agents that interfere with biochemical reactions in many different kinds of microorganisms.