The December 2014 issue of Mayo Clinic Proceedings featured an article that provided an overview of the recent Ebola outbreak in West Africa and included a section on infection control in health care facilities in the United States following the first case in this country and the transmission of Ebola virus disease (EVD) to healthcare workers who cared for the patient in Dallas.1 The article highlights several points important for infection preventionists and other hospital clinicians to keep in mind when interacting with patients who have recently arrived in the U.S. from countries experiencing outbreaks of life-threatening viral diseases, before and after their diagnoses. A response to the article published in the same journal the following month reiterates the importance of maintaining good antimicrobial stewardship practices when treating unidentified viruses.2
Infection Prevention Lessons
Because of the nature of EVD, some of the infection prevention lessons from the first U.S. case are very specific, but others apply to any virus with high mortality rates to which travelers may have been exposed. Currently, the Centers for Disease Control and Prevention advise hospitals to consider the possibility of three such viruses in patients in the U.S.:
- Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in travelers who have come from the Arabian Peninsula in the last 14 days and have fever and respiratory illness as well as those presenting with the same symptoms who have been in a healthcare facility in South Korea (as a visitor, patient or healthcare worker) in the last two weeks.3
- Avian influenza A (H7N9) for individuals who develop respiratory illness within 10 days of arriving from China4
- Ebola in patients who have traveled to Guinea or Sierra Leone in the last three weeks or been exposed to someone with EVD in that period and present with fever, severe headache, diarrhea, vomiting, abdominal pain or unexplained hemorrhage.1
All three viral diseases call for close communication among healthcare personnel once initial questions identify an individual as a patient under investigation (PUI). Clear documentation and communication are needed to ensure that healthcare workers and hospital departments implement appropriate infection prevention measures, including immediate isolation, and that local and state health departments receive immediate notification.
While the CDC initially believed all U.S. hospitals could safely care for patients with EVD, the transmission of Ebola to two healthcare workers changed the recommendation to advise that most hospitals stabilize infected patients and transfer them to a specialized center. Healthcare workers caring for patients suspected or confirmed to have Ebola must wear fluid-resistant, single-use personal protective equipment (PPE) that covers all exposed skin, demonstrate competency in PPE use and don and doff PPE in the presence of a trained monitor. Other administrative and environmental controls must be implemented as well.5
For patients who have or potentially have MERS-CoV, avian influenza and other potentially highly pathogenic avian influenza strains, the CDC recommends immediately isolating patients and implementing standard, contact and airborne precautions. PPE should include gloves, gowns, respiratory protection and eye protection. Patients should be placed in an airborne infection isolation room (AIIR) or transferred as quickly as possible to a facility that has an AIIR. Until the patient moves to an AIIR, he or she should wear a facemask. The CDC provides specific guidance on testing and environmental controls for MERS-CoV and avian influenza A.
Antimicrobial Stewardship Lessons
In his response to the Ebola outbreak overview, Emil Lesho, DO, of the Walter Reed Army Institute of Research noted that while much about EVD remains unclear, it is clearly caused by a virus--as are MERS-CoV and influenza. Therapies and prophylaxis, then, should be appropriate for a viral pathogen, not a bacteria. In his first visit to the hospital in Dallas, the initial U.S. Ebola patient was diagnosed with a “low-grade, common viral disease” and discharged--with antibiotics, according to an article in the Washington Post.6
As Lesho concluded, “it is important to remind ourselves that escalating antibiotic resistance and the lack of countermeasures is arguably a more urgent and imminent threat than Ebola for patients everywhere.” Whether a patient actually has a “common viral disease” or a viral disease no one at the hospital had ever previously seen, good antibiotic stewardship practices should have keep antibiotics from being prescribed.
1. Tosh PK, Sampathkumar P. What Clinicians Should Know about the 2014 Ebola Outbreak. Mayo Clinic Proceedings. December 2014. 89(12):1710-1717.
2. Lesho EP. US Ebola Case: An Example of the Misuse of Antibiotics and a Reminder for Better Stewardship. Mayo Clinic Proceedings. January 2015. 90(1):161.
3. Interim Infection Prevention and Control Recommendations for Hospitalized Patients with Middle East Respiratory Syndrome Coronavirus (MERS-CoV). CDC.gov.. http://www.cdc.gov/coronavirus/mers/infection-prevention-control.html Updated June 2015. Accessed August 24, 2015.
4. Interim Guidance for Infection Control Within Healthcare Settings When Caring for Confirmed Cases, Probable Cases, and Cases Under Investigation for Infection with Novel Influenza A Viruses Associated with Severe Disease. CDC.gov. http://www.cdc.gov/flu/avianflu/novel-flu-infection-control.htm Updated June 11, 2015. Accessed August 24, 2015.
5. Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in the U.S. Hospitals, Including Procedures for Putting on (Donning) and Removing (Doffing). CDC.gov. http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html Updated April 25, 2015. Accessed August 24, 2015.
6. Berman M., Nutt AE. Ebola patient was allowed to leave Dallas hospital last week. Washington Post. October 2, 2014. http://www.washingtonpost.com/national/health-science/ebola-patient-was-allowed-to-leave-the-dallas-hospital-last-week/2014/10/01/778f1276-49b4-11e4-891d-713f052086a0_story.html. Accessed August 24, 2015.