John A. Molinari, Ph.D.John A. Molinari, Ph.D.
Director of Infection ControlDirector of Infection Control
THE DENTAL ADVIS...
Major Immune SystemsMajor Immune Systems
Required for Host DefensesRequired for Host Defenses
Innate: non-specific, inborn...
Categories of Host Defects Associated withCategories of Host Defects Associated with
Impaired ResistanceImpaired Resistanc...
Early Immunoglobulin DevelopmentEarly Immunoglobulin Development
In Fetus & InfantIn Fetus & Infant
Congenital Immunodefic...
Immunodeficiency ClassificationImmunodeficiency Classification
Congenital:
- genetically inherited defects.
- recessive / ...
Representative Secondary (Acquired)Representative Secondary (Acquired)
Immune Deficiency ConditionsImmune Deficiency Condi...
Oral Infections / Manifestations OfOral Infections / Manifestations Of
HIV DiseaseHIV Disease
Fungal Lesions:
- Candidiasi...
Representative Secondary (Acquired)Representative Secondary (Acquired)
Immune Deficiency ConditionsImmune Deficiency Condi...
Representative Secondary (Acquired)Representative Secondary (Acquired)
Immune Deficiency ConditionsImmune Deficiency Condi...
NeoplasiaNeoplasia
Chronic Lymphocytic Leukemia:
- usually involves B - lymphocytes.
- affects humoral (Ab) immune respons...
AntiAnti--Neoplastic TherapyNeoplastic Therapy
Representative General Adverse Effects:
- bone marrow suppression
- general...
Representative Secondary (Acquired)Representative Secondary (Acquired)
Immune Deficiency ConditionsImmune Deficiency Condi...
Immunosuppression In DiabetesImmunosuppression In Diabetes
Est. 7% US adults (8 million).
Susceptible to many local & syst...
Infections In DiabeticsInfections In Diabetics
Head & Neck Infections:
Occurring Predominantly (>50%) in Diabetics:
- rhin...
Representative Secondary (Acquired)Representative Secondary (Acquired)
Immune Deficiency ConditionsImmune Deficiency Condi...
ID Contributary Factors In Transplant PtsID Contributary Factors In Transplant Pts
Transplant factors:
- type of transplan...
Representative Secondary (Acquired)Representative Secondary (Acquired)
Immune Deficiency ConditionsImmune Deficiency Condi...
SLE InfectionsSLE Infections
Main cause of hospital admission & principal
cause of death.
Susceptible to local & systemic ...
Infectious Complications In Asplenic PtsInfectious Complications In Asplenic Pts
Critical role in immune surveillance & re...
Representative Secondary (Acquired)Representative Secondary (Acquired)
Immune Deficiency ConditionsImmune Deficiency Condi...
Pain of ZosterPain of Zoster
•• Deep aching or burning painDeep aching or burning pain
•• Altered sensitivity to touch (pa...
3 Types of Varicella – Containing Vaccines:
Varicella vaccine (Varivax)
– approved for persons 12 months and older
Measles...
MethicillinMethicillin -- ResistantResistant
Staphylococcus aureusStaphylococcus aureus (MRSA)(MRSA)
•• Major transmission...
Representative Secondary (Acquired)Representative Secondary (Acquired)
Immune Deficiency ConditionsImmune Deficiency Condi...
Infections In Parenteral Drug AbusersInfections In Parenteral Drug Abusers
Other Skin & Soft Tissue Infections:
- skin ulc...
Representative Secondary (Acquired)Representative Secondary (Acquired)
Immune Deficiency ConditionsImmune Deficiency Condi...
Infections Related to Steroid UseInfections Related to Steroid Use
increased susceptibility to all types of
infection.
mos...
Hepatitis C, G, etcHepatitis C, G, etcHepatitis C, G, etc
S A R SS A R S
Emerging Infectious DiseaseEmerging Infectious Di...
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INFECTIONS IN IMMUNE INFECTIONS IN IMMUNE COMPROMISED ...

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  1. 1. John A. Molinari, Ph.D.John A. Molinari, Ph.D. Director of Infection ControlDirector of Infection Control THE DENTAL ADVISORTHE DENTAL ADVISOR Ann Arbor, MichiganAnn Arbor, Michigan INFECTIONS IN IMMUNEINFECTIONS IN IMMUNE COMPROMISED PATIENTSCOMPROMISED PATIENTS
  2. 2. Major Immune SystemsMajor Immune Systems Required for Host DefensesRequired for Host Defenses Innate: non-specific, inborn 1. Phagocytosis 2. Complement Acquired: specific, adaptive 1. Humoral immunity -- antibodies 2. Cellular immunity -- sensitized T cells Immune Compromised PersonImmune Compromised Person person with impairments in the body’s normal mechanisms of defense against infection. individual with 1 or more defects in body’s normal defense mechanisms that predispose them to infections, often opportunistic and life- threatening, that would otherwise not occur. increasing % of population. degree of immune deficiency can vary with time & therapy.
  3. 3. Categories of Host Defects Associated withCategories of Host Defects Associated with Impaired ResistanceImpaired Resistance 1. defects in cutaneous barriers: (severe dermatological conditions) 2. mucous membrane barrier defects: (mucositis; trauma, smoking) 3. conditions that cause obstruction of a natural body passage: (neoplasia; foreign bodies; cystic fibrosis) 4. abnormal number of functional granulocytes: (leukemia, anti- neoplastic chemo; aplastic anemia; diabetes; congenital disorders) 5. cell-mediated immunity abnormalities: (HIV; chemotherapy; aging; BM transplantation; corticosteroids; severe malnutrition) 6. humoral immunity abnormalities: (BM transplantation; aging; HIV; chronic lymphocytic leukemia; congenital deficiencies; acquired hypogammaglobulinemia) 7. pts with multiple immune defects: aging; severe trauma; alcoholism; obesity; splenectomy; corticosteroids; chemotherapy) APIC Text IC Epid (2009) Clinical Disease ManifestationsClinical Disease Manifestations May be different in immune compromised host vs. immune competent person: 1. accelerated pace of disease progression. 2. initial minor infections may become life- threatening. 3. granulocytopenic patients develop little purulence at localized infection sites. 4. elderly patients may only show confusion as infection sign. 5. patients on corticosteroids may have diminished fever response to infection. APIC Epid Text (2009)
  4. 4. Early Immunoglobulin DevelopmentEarly Immunoglobulin Development In Fetus & InfantIn Fetus & Infant Congenital ImmunodeficiencyCongenital Immunodeficiency Syndromes: Antibody SynthesisSyndromes: Antibody Synthesis Selective IgA Deficiency: - most common inherited specific Ab deficiency. - noted in 1 of 700 - 800 persons. - no obvious disease susceptibility. - occurs more commonly in people with chronic lung disease. - diminished secretory immune protection. - more common than diagnosed ? - increased susceptibility to acute GI, respiratory, oral infections.
  5. 5. Immunodeficiency ClassificationImmunodeficiency Classification Congenital: - genetically inherited defects. - recessive / autosomal; X chromosome mutations. - recessive defects cause disease when both X chromosomes have defect -- thus, males with genetic defect in single X chromosome will manifest disease. - females can be healthy carriers of a specific genetic abnormality. - before advent of antibiotics & fetal genetic testing, most individuals died in infancy or early childhood. Immunodeficiency ClassificationImmunodeficiency Classification Secondary (Acquired): - many extrinsic causes. - defects in T – cells, B – cells, or both. - can also develop as sequelae to initial microbial infection. - multiple immune defects can occur in same person (i.e. elderly cancer patient on cancer chemotherapy).
  6. 6. Representative Secondary (Acquired)Representative Secondary (Acquired) Immune Deficiency ConditionsImmune Deficiency Conditions - Malnutrition - Transplantation - Neoplasia - Parenteral Drug Abuse - Anti-neoplastic therapy - Diabetes - Effects of aging - Alcoholic cirrhosis - Asplenia - Chronic hepatitis B or C - Trauma - Arthritis - Autoimmune conditions - HIV / AIDS - Other chronic infections - End stage renal disease (uremia & dialysis) HIV / AIDSHIV / AIDS Debilitated Cellular Immunity Defenses: - Kaposi’s sarcoma & other neoplasms - opportunistic fungal & viral infections - severe viral recurrences ( i.e. herpesviruses) - intracellular bacterial infections (i.e. TB) - condyloma acuminatum (maxillofacial; genital) - rapidly progressing periodontal diseases - other unusual microbial & parasitic infections
  7. 7. Oral Infections / Manifestations OfOral Infections / Manifestations Of HIV DiseaseHIV Disease Fungal Lesions: - Candidiasis Bacterial Lesions: - Linear Gingival Erythema (HIV-gingivitis) - Necrotizing Ulcerative Gingivitis (NUG), Periodonitis (NUP), & Stomatitis (NUS) Viral Lesions: - Oral Hairy Leukoplakia - CMV Infection - HSV Infection - Papillomavirus Infection Changing Patterns of HIV / AIDSChanging Patterns of HIV / AIDS Opportunistic InfectionsOpportunistic Infections Widespread use & success of combination antiretroviral therapy (beginning in 1996): - observed PCP decline, disseminated M. avium complex (MAC), & invasive cytomegalovirus disease decreases. - HIV – related immune suppression impt. - respiratory illness: TB & endemic fungal infections (histoplasmosis, coccidiomycocis). - 100x greater risk invasive pneumococcal disease.
  8. 8. Representative Secondary (Acquired)Representative Secondary (Acquired) Immune Deficiency ConditionsImmune Deficiency Conditions - Malnutrition - Transplantation - Neoplasia - Parenteral Drug Abuse - Anti-neoplastic therapy - Diabetes - Effects of aging - Alcoholic cirrhosis - Asplenia - Chronic hepatitis B or C - Trauma - Arthritis - Autoimmune conditions - HIV / AIDS - Other chronic infections - End stage renal disease (uremia & dialysis) Acquired Immunodeficiencies Are More Than AIDS Mycotic Infections: Indicators OfMycotic Infections: Indicators Of Primary or Secondary DeficiencyPrimary or Secondary Deficiency Candida albicans: common opportunistic pathogen in many immune compromised persons. Selective Infection Pressures: - immunosuppression (CA, HIV, diabetes) - changes in normal flora - antibiotic chemotherapy - prolonged steroid therapy
  9. 9. Representative Secondary (Acquired)Representative Secondary (Acquired) Immune Deficiency ConditionsImmune Deficiency Conditions - Malnutrition - Transplantation - Neoplasia - Parenteral Drug Abuse - Anti-neoplastic therapy - Diabetes - Effects of aging - Alcoholic cirrhosis - Asplenia - Chronic hepatitis B or C - Trauma - Arthritis - Autoimmune conditions - HIV / AIDS - Other chronic infections - End stage renal disease (uremia & dialysis) NeoplasiaNeoplasia Acute Leukemia: - infection major cause of death. - mostly opportunistic infections. - gram-bacilli, fungi, herpesviruses. - severe decrease in mature functioning granulocytes purulence in infections can be diminished or absent. - neutrophils show impaired ability to migrate. - diminished bactericidal chemotaxis.
  10. 10. NeoplasiaNeoplasia Chronic Lymphocytic Leukemia: - usually involves B - lymphocytes. - affects humoral (Ab) immune responses. - secondary hypogammaglobulinemia, with secondary bacterial infection. - primarily respiratory bacterial infections. - encapsulated bacteria: pneumococci, H. influenzae, group A streptococci. Representative Secondary (Acquired)Representative Secondary (Acquired) Immune Deficiency ConditionsImmune Deficiency Conditions - Malnutrition - Transplantation - Neoplasia - Parenteral Drug Abuse - Anti-neoplastic therapy - Diabetes - Effects of aging - Alcoholic cirrhosis - Asplenia - Chronic hepatitis B or C - Trauma - Arthritis - Autoimmune conditions - HIV / AIDS - Other chronic infections - End stage renal disease (uremia & dialysis)
  11. 11. AntiAnti--Neoplastic TherapyNeoplastic Therapy Representative General Adverse Effects: - bone marrow suppression - generalized edema - alopecia - cystitis - pulmonary fibrosis - bleeding tendencies (due to thrombocytopenia) - ulceration of mucosa tissues - allergic reactions to prolonged drug regimens AntiAnti--Neoplastic TherapyNeoplastic Therapy Representrative Maxillofacial / Intra-oral Adverse Effects: - allergic reactions to anti-neoplastic agents - intra-oral ulceration - gingival tissue edema - decreased tolerance of stress of dental visits (due to steroid therapy) - opportunistic fungal infections ( Candida sp.)
  12. 12. Representative Secondary (Acquired)Representative Secondary (Acquired) Immune Deficiency ConditionsImmune Deficiency Conditions - Malnutrition - Transplantation - Neoplasia - Parenteral Drug Abuse - Anti-neoplastic therapy - Diabetes - Effects of aging - Alcoholic cirrhosis - Asplenia - Chronic hepatitis B or C - Trauma - Arthritis - Autoimmune conditions - HIV / AIDS - Other chronic infections - End stage renal disease (uremia & dialysis) Representative Secondary (Acquired)Representative Secondary (Acquired) Immune Deficiency ConditionsImmune Deficiency Conditions - Malnutrition - Transplantation - Neoplasia - Parenteral Drug Abuse - Anti-neoplastic therapy - Diabetes - Effects of aging - Alcoholic cirrhosis - Asplenia - Chronic hepatitis B or C - Trauma - Arthritis - Autoimmune conditions - HIV / AIDS - Other chronic infections - End stage renal disease (uremia & dialysis)
  13. 13. Immunosuppression In DiabetesImmunosuppression In Diabetes Est. 7% US adults (8 million). Susceptible to many local & systemic infections. Certain infections tend to be more common. Impaired Innate Cellular Defenses: - PMN abnormalities - adherence, chemotaxis, phagocytosis, intracellular microbial killing. - prolonged, less effective, pathogen response. - susceptible to metastatic acute infections. - abnormalities in maocytes / macrophages . Immunosuppression In DiabetesImmunosuppression In Diabetes Humoral Immunity: - normal Ab levels & vaccination responses. Cellular Immunity: - decreased T- lymphocyte responses. - abnormal Type IV (delayed) hypersensitivity.
  14. 14. Infections In DiabeticsInfections In Diabetics Head & Neck Infections: Occurring Predominantly (>50%) in Diabetics: - rhinocerebral mucormycosis - severe otitis externa (multiple causes) Increased Incidence in Diabetics: - oral candidiasis - esophageal candidiasis - surgical / wound infection Mucormycosis (Phycomycocis)Mucormycosis (Phycomycocis) Rare, often fatal, opportunistic fungal infection. Etiologic agents: Rhyzopus; Absidia, Mucor sp. “common bread molds” Infections most often associated with immune compromised persons (uncontrolled diabetes, liver cirrhosis, cancer, transplant patients). Increased # reported cases in recent years ! Clinical Forms: - Rhinocerebral - Pulmonary - Gastrointestinal - Disseminated
  15. 15. Representative Secondary (Acquired)Representative Secondary (Acquired) Immune Deficiency ConditionsImmune Deficiency Conditions - Malnutrition - Transplantation - Neoplasia - Parenteral Drug Abuse - Anti-neoplastic therapy - Diabetes - Effects of aging - Alcoholic cirrhosis - Asplenia - Chronic hepatitis B or C - Trauma - Arthritis - Autoimmune conditions - HIV / AIDS - Other chronic infections - End stage renal disease (uremia & dialysis) ID Contributary Factors In Transplant PtsID Contributary Factors In Transplant Pts Infection 2nd most impt problem post-transplantation Pre-transplant Host Factors: - ongoing medical conditions (HBV, HCV, diabetes) - lack of specific immunity ( susceptible to primary EBV, VZV, CMV, etc) - prior MO colonization ( Candida, staph, VRE) - prior latent infection (TB, CMV, HSV, VZV) - prior medications (i.e. immunosuppressives, antibiotics)
  16. 16. ID Contributary Factors In Transplant PtsID Contributary Factors In Transplant Pts Transplant factors: - type of transplant (common infection site) - surgery trauma Immunosuppression: - immunosuppressive drugs Allograft Reactions: - graft-vs-host reaction (cofactor in CMV & fungal infection) - host-vs-graft reaction ? Common Microbial Etiologies PostCommon Microbial Etiologies Post-- TransplantationTransplantation Bacteria: common gm+ & gm- flora - local contaminant infections & can spread Fungi: Candida sp.; Aspergillus sp.; Pneumocystis - superficial mycoses which can metastizize - Candida common in liver transplant pts - Aspergillosis airborne from environment Viruses: Herpesviruses; Papillomaviruses - many donors latently infected Most Common Infection Source: Other people !
  17. 17. Representative Secondary (Acquired)Representative Secondary (Acquired) Immune Deficiency ConditionsImmune Deficiency Conditions - Malnutrition - Transplantation - Neoplasia - Parenteral Drug Abuse - Anti-neoplastic therapy - Diabetes - Effects of aging - Alcoholic cirrhosis - Asplenia - Chronic hepatitis B or C - Trauma - Arthritis - Autoimmune conditions - HIV / AIDS - Other chronic infections - End stage renal disease (uremia & dialysis) Autoimmune Diseases:Autoimmune Diseases: Systemic Lupus Erythematosus (SLE)Systemic Lupus Erythematosus (SLE) Multiple infection risk factors: 1. functional defect in phagocytic cells. 2. CMI defects: lymphopenia, CD4 - cell lymphopenia, & decreased cytokines. 3. reduced Ab levels & low complement levels. 4. low capacity to eliminate microbes -- due to functional asplenia. 5. also, corticosteroids & immunosuppressives increase infection risks.
  18. 18. SLE InfectionsSLE Infections Main cause of hospital admission & principal cause of death. Susceptible to local & systemic infections. Related to immune defects & disease therapy. Viral: VZV, Cytomegalovirus, EBV, Parvovirus B19. Bacterial: Salmonella, S. pneumoniae, Mtb, Nocardia, various gram- bacteria. Mycotic: Candida, Pneumocystis carinii. Representative Secondary (Acquired)Representative Secondary (Acquired) Immune Deficiency ConditionsImmune Deficiency Conditions - Malnutrition - Transplantation - Neoplasia - Parenteral Drug Abuse - Anti-neoplastic therapy - Diabetes - Effects of aging - Alcoholic cirrhosis - Asplenia - Chronic hepatitis B or C - Trauma - Arthritis - Autoimmune conditions - HIV / AIDS - Other chronic infections - End stage renal disease (uremia & dialysis)
  19. 19. Infectious Complications In Asplenic PtsInfectious Complications In Asplenic Pts Critical role in immune surveillance & response. Asplenic pts: lower C3 levels & defective responses to encapsulated bacterial pathogens - decreased phagocytosis & destruction of microbes. - failure to recognize polysaccharide Ag’s. - impaired IgM synthesis early in infection. - failure to remove Ab - coated bacteria. - prone to post-splenectomy sepsis (PSS). - S. pneumoniae (#1), H influenzae (#2), N. meningitidis (#3) Streptococcus pneumoniae (#1): - etiology in 50 – 90% PSS cases. - age major factor - % cases increase with age. - high mortality rate in children. Haemophilus influenzae (#2): - 32% of PSS mortality. - decreased incidence with conjugated Hib vaccine use (important to vaccinate pts!!). Neisseria meningitidis (#3): - greater risk for meningococcemia (?) Microbiology of PSSMicrobiology of PSS
  20. 20. Representative Secondary (Acquired)Representative Secondary (Acquired) Immune Deficiency ConditionsImmune Deficiency Conditions - Malnutrition - Transplantation - Neoplasia - Parenteral Drug Abuse - Anti-neoplastic therapy - Diabetes - Effects of aging - Alcoholic cirrhosis - Asplenia - Chronic hepatitis B or C - Trauma - Arthritis - Autoimmune conditions - HIV / AIDS - Other chronic infections - End stage renal disease (uremia & dialysis) Effect of Aging On Immune CompetenceEffect of Aging On Immune Competence Declining Innate, Humoral & Cellular ImmuneDeclining Innate, Humoral & Cellular Immune ResponsesResponses Increased Susceptibility to Pneumonias & CertainIncreased Susceptibility to Pneumonias & Certain Chronic InfectionsChronic Infections DEPRESSING !!!DEPRESSING !!! How old is old ?How old is old ? Diminished vaccineDiminished vaccine responsesresponses
  21. 21. Pain of ZosterPain of Zoster •• Deep aching or burning painDeep aching or burning pain •• Altered sensitivity to touch (paresthesia)Altered sensitivity to touch (paresthesia) that may be painful (dysesthesia)that may be painful (dysesthesia) •• Exaggerated responses to stimuliExaggerated responses to stimuli (hyperesthesia)(hyperesthesia) •• Electric shockElectric shock--like painlike pain Zoster in Immunocompromised PtsZoster in Immunocompromised Pts •• More severe than in normal personsMore severe than in normal persons •• Lesion formation may continue for up to 2 wks,Lesion formation may continue for up to 2 wks, scabbing may not occur until 3scabbing may not occur until 3--4 weeks into the4 weeks into the disease coursedisease course •• Frequent infection in HIV ptsFrequent infection in HIV pts •• Chronic herpes zoster may occurChronic herpes zoster may occur
  22. 22. 3 Types of Varicella – Containing Vaccines: Varicella vaccine (Varivax) – approved for persons 12 months and older Measles-mumps-rubella-varicella vaccine (ProQuad) – approved for children 12 months through 12 years Herpes zoster vaccine (Zostavax) – approved for persons 60 years and older Vaccine Recommendations for Adolescents & Adults: All persons 13 years of age and older without evidence of varicella immunity 2 doses separated by at least 4 weeks Do not repeat 1st dose because of extended interval between doses Herpes Zoster Vaccine*Herpes Zoster Vaccine* •• Approved for a single dose among personsApproved for a single dose among persons 60 years and older whether or not they60 years and older whether or not they report a prior episode of shinglesreport a prior episode of shingles •• Persons with a chronic medical conditionPersons with a chronic medical condition may be vaccinated unless amay be vaccinated unless a contraindication or precaution existscontraindication or precaution exists for the conditionfor the condition
  23. 23. MethicillinMethicillin -- ResistantResistant Staphylococcus aureusStaphylococcus aureus (MRSA)(MRSA) •• Major transmission modes:Major transmission modes: 1.1. via infected /colonized patientsvia infected /colonized patients 2.2. dissemination by infected/ colonizeddissemination by infected/ colonized HCWsHCWs •• Within a facility:Within a facility: -- HCW hands after contact with infected pt.HCW hands after contact with infected pt. •• Between hospitals & institutions:Between hospitals & institutions: -- pt transfers & new carrier HCWpt transfers & new carrier HCW employees.employees. Staphylococcal Nasal CarriageStaphylococcal Nasal Carriage •• Chronic carriageChronic carriage •• Periodic bacterialPeriodic bacterial sheddingshedding •• Infectious to othersInfectious to others •• Source of healthSource of health--carecare acquired infectionsacquired infections •• Special risks forSpecial risks for compromised personscompromised persons who arewho are exposedexposed
  24. 24. Representative Secondary (Acquired)Representative Secondary (Acquired) Immune Deficiency ConditionsImmune Deficiency Conditions - Malnutrition - Transplantation - Neoplasia - Parenteral Drug Abuse - Anti-neoplastic therapy - Diabetes - Effects of aging - Alcoholic cirrhosis - Asplenia - Chronic hepatitis B or C - Trauma - Arthritis - Autoimmune conditions - HIV / AIDS - Other chronic infections - End stage renal disease (uremia & dialysis) Infections In ParenteralInfections In Parenteral Drug AbusersDrug Abusers Skin & Soft Tissue Infections: - Staphylococcus aureus: - abscesses - staph colonization universal in PDAs - most common etiology - Group A & G streptococci: - bacteremia - cellulitis - associated with long Hx drug abuse (?)
  25. 25. Infections In Parenteral Drug AbusersInfections In Parenteral Drug Abusers Other Skin & Soft Tissue Infections: - skin ulcers: staph; strept; gram-negative rods - septic thrombophlebitis: staph & streptococci - necrotizing fasciitis: gram-negative bacilli - candidiasis: mycotic infections - wound botulinum: not common Ocular Infections Pulmonary Infections Infective Endocarditis Let Us Not Forget OneLet Us Not Forget One TransientTransient Cause of SecondaryCause of Secondary Immune DeficiencyImmune Deficiency EMOTIONAL DISCOMFORTEMOTIONAL DISCOMFORT STRESSSTRESS
  26. 26. Representative Secondary (Acquired)Representative Secondary (Acquired) Immune Deficiency ConditionsImmune Deficiency Conditions - Malnutrition - Transplantation - Neoplasia - Parenteral Drug Abuse - Anti-neoplastic therapy - Diabetes - Effects of aging - Alcoholic cirrhosis - Asplenia - Chronic hepatitis B or C - Trauma - Arthritis - Autoimmune conditions - HIV / AIDS - Other chronic infections - End stage renal disease (uremia & dialysis) Infections Related to Steroid UseInfections Related to Steroid Use Dramatic increase in corticosteroid use c/in last decade. Anti-inflammatory &/or immunosuppressive. Chronic steroid use predisposes to variety of infections by interfering c host defenses. Affect most aspects of immune system. Infections dependent on route of administration, dose, & duration of therapy. Most common: oropharyngeal candidiasis.Most common: oropharyngeal candidiasis. Prolonged CMI suppression important forProlonged CMI suppression important for opportunistic infection to occur.opportunistic infection to occur. Klein, et al. IDCNA (2001)Klein, et al. IDCNA (2001)
  27. 27. Infections Related to Steroid UseInfections Related to Steroid Use increased susceptibility to all types of infection. most infections caused by pyogenic bacteria. pts on chronic steroid use at increased risk of surgical wound infections & delayed wound healing: steroids interfere with fibroblaststeroids interfere with fibroblast proliferation & collagen synthesis.proliferation & collagen synthesis. Klein, et al. IDCNA (2001)Klein, et al. IDCNA (2001) Misuse of Topical CorticosteroidsMisuse of Topical Corticosteroids can cause transient immune suppression in otherwise healthy persons mainly act on CMI can interfere with macrophage phagocytosiscan interfere with macrophage phagocytosis & antigen& antigen--processing during immuneprocessing during immune responsesresponses when mistakenly applied topically ontowhen mistakenly applied topically onto superficial infectionssuperficial infections -- can inhibit hostcan inhibit host immune responses to microbial pathogensimmune responses to microbial pathogens JAM (2009)JAM (2009)
  28. 28. Hepatitis C, G, etcHepatitis C, G, etcHepatitis C, G, etc S A R SS A R S Emerging Infectious DiseaseEmerging Infectious Disease ChallengesChallenges DrugDrug--Resistant HIV / AIDSResistant HIV / AIDS PrionsPrions MDRMDR -- TuberculosisTuberculosis Diarrheal DiseasesDiarrheal Diseases MalariaMalaria West Nile VirusWest Nile Virus Waterborne DiseasesWaterborne Diseases Acute Lower Respiratory Tract InfectionAcute Lower Respiratory Tract Infection Compromised PatientsCompromised Patients Antimicrobial ResistanceAntimicrobial Resistance THANKTHANK YOUYOU

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