Zainab Abdurrahman, BSc, MMath, MD, FRCPC (Paediatrics), FRCPC (Clinical Immunology and Allergy)

CLINICAL TOOLS

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Abstract: There are many concerns the general population has over the new mRNA vaccines that have been produced and are now being distributed in countries around the world to help curb the spread of COVID-19. This review helps to debunk the myths around some of the more common concerns.

Key Words: COVID-19, vaccines, mRNA, trials, studies.

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The mRNA vaccine is safe and effective for the prevention of COVID-19.

The two mRNA vaccines approved for use in Canada are the Pfizer-Biontech and the Moderna vaccine.

The Ministry of Health updated their guidelines indicating that the vaccine is still recommended for those with allergies.

It is important to discuss and dispel the myths that patients may have surrounding the mRNA vaccines.

The vaccine is safe and effective for the prevention of COVID-19.

Despite the safety and efficacy of the vaccine, patients who receive it should be reminded to continue wearing a mask and physically distance and follow public health guidelines.

To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.

A Diffuse Rash in a Patient Infected with HIV

Keywords: Syphilis; Treponema pallidum; HIV.

A 27-year-old MSM, presented to care with a rash. The rash appeared several weeks prior to presentation and involved the face, chest and back, arms and legs and was not accompanied by pruritus. He denied fever, chills, but complained of fatigue. No respiratory, gastrointestinal or urinary symptoms were present. He disclosed a diagnosis of HIV infection a year earlier, but has not kept his follow up appointments and was not receiving anti-retroviral medications or opportunistic infection prophylaxis. His most recent CD4 count was 109/mm³. He admitted sexual encounters with several male partners with inconsistent condom usage, and recalled a penile lesion that was present several weeks before the rash had appeared. The lesion has healed without specific therapy.

On physical examination: in no apparent distress, vital signs were within normal limits.

Notable finding on the examination included multiple small and non-tender anterior cervical, posterior cervical, axillary and inguinal lymph nodes. Genital examination revealed a healed lesion on the glans penis. A macular skin rash was widely distributed over face, trunk and extremities with several lesions on palms and soles (figure 1. and 2.)

1. What is your diagnosis?
2. Would you obtain a lumbar puncture?

Asymptomatic Bacteriuria: To Treat or Not to Treat

Dimitri M. Drekonja, MD, MS, Staff Physician, Minneapolis Veterans Affairs Medical Center; Assistant Professor of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA.

Urinary tract infections (UTIs) are a frequent diagnosis in older adults, leading to substantial antimicrobial use. Increased antimicrobial use is associated with higher rates of resistance, making future infections more difficult to treat. Unfortunately, many UTIs actually represent asymptomatic bacteriuria, which should not be treated in most cases. Adhering to clinical guidelines (based on high-quality evidence from randomized trials) would likely result in fewer UTI diagnoses, less antimicrobial use, and decreased antimicrobial resistance. Knowing when treatment for asymptomatic bacteriuria is recommended, and limiting therapy to these well defined circumstances is vital to appropriately managing a patient with a positive urine culture.
Key words: urinary tract infection, asymptomatic bacteriuria, catheter-associated bacteriuria, antimicrobial management.

Treatment and Prevention of Clostridium difficile Infection in the Long-Term Care Setting

Natasha Bagdasarian, MD, Department of Internal Medicine, Divisions of Infectious Diseases, University of Michigan Health System, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA.
Preeti N. Malani, MD, Department of Internal Medicine, Divisions of Infectious Diseases and Geriatric Medicine, University of Michigan Health System, Veterans Affairs Ann Arbor Healthcare System; Geriatric Research Education and Clinical Center, Ann Arbor, MI, USA.

The treatment and prevention of Clostridium difficile infection (CDI) in the long-term care (LTC) setting presents unique challenges. In this review, we offer an overview of CDI treatment along with a brief discussion of infection control strategies in the LTC setting. The approach to recurrent CDI is also addressed.
Key words: Clostridium difficile, aging, metronidazole, vancomycin, long-term care.

Long-term Care for Older Adults: Reservoirs of Methicillin-Resistant Staphylococcus Aureus and Vancomyin-Resistant Enterococi

D.F. Gilpin, PhD, Research Fellow, School of Pharmacy, Queen’s University, Belfast, Northern Ireland.
M.M. Tunney, PhD, Senior Lecturer, School of Pharmacy, Queen’s University, Belfast, Northern Ireland.
N. Baldwin, PhD, Research Fellow, School of Pharmacy, Queen’s University, Belfast, Northern Ireland.
C.M. Hughes, PhD, Professor, School of Pharmacy, Queen’s University, Belfast, Northern Ireland.

Methicillin-resistant Staphlyococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) are responsible for substantial morbidity and mortality in acute care settings. Older residents in long-term care (LTC) facilities possess many of the risk factors for colonization with these antibiotic resistant bacteria, and the potential exists for both transmission, via transiently colonized staff, within LTC, and subsequent reintroduction into hospitals. Infection control policies in LTC are primarily based on those used in acute care and may not be appropriate for this unique environment. Studies to determine which infection control procedures are effective at reducing the prevalence and transmission of MRSA and VRE in LTC are required.
Key words: long-term care, MRSA, VRE, colonization, infection control.

Treating Infectious Disease in the Older Adult

Sir William Osler referred to pneumonia as “the old man’s friend,” correctly realizing that infection is a common cause of death in old age. Some hundred years later, even in this age of potent antimicrobial agents, Osler’s assessment still holds true. Disease frequently presents in an atypical manner in old age, and often fever in bacterial infections is a late manifestation, following delirium, falls, or “taking to bed.” Delay in treatment may result in poor outcomes but, on the other hand, overtreatment may be likely to harm an older person. One of the most difficult environments in which to accurately diagnose infection is the long-term care (LTC) facility. The residents tend to be more frail and more likely to be cognitively impaired than community-dwelling patients coming to their family doctor’s office; therefore, the utility of the history is much decreased. As well, the vast array of diagnostic tools available in the acute hospital is relatively inaccessible in LTC, and the transfer to acute care from LTC often results in deleterious consequences to the patient.

Our focus in this issue is infectious disease in the older adult, and our CME article addresses a major public health concern: “Long-term Care for Older Adults: Reservoirs of Methicillin-Resistant Staphylococcus Aureus and Vancomyin-Resistant Enterococci” by Drs. D.F. Gilpin, M.M. Tunney, N. Baldwin, and C.M. Hughes. We all know that we should not treat asymptomatic bacteriuria, but most of us are unsure whether our patients are truly asymptomatic or not. The article “Asymptomatic Bacteriuria: To Treat or Not to Treat” by Dr. Dimitri M. Drekonja will address this clinical conundrum. I still remember treating my first case of severe antibiotic-induced colitis as an intern. It was in the wife of my physician-in-chief and occurred two months before clindamycin-associated pseudomembranous colitis was first described in a classic article in the Annals of Internal Medicine. Since then, C. difficile infection has become a major problem in older patients, particularly for those in acute hospital or LTC. This important topic is addressed in the article “Treatment and Prevention of Clostridium difficile Infection in the Long-Term Care Setting” by Dr. Natasha Bagdasarian and Dr. Preeti N. Malani.

Further, we offer our usual collection of important and informative articles on medical care of older people. In geriatric medicine, it has been frequently noted that the risk factors for each of the “geriatric giants” overlap to a great degree. In our Cardiovascular column, our frequent and much valued contributor, Dr. Wilbert S. Aronow, asks the question “Bone Mineral Density: What Is Its Relationship to Heart Disease?” Our Dementia column reviews the difficult area of screening in the article “Screening for Dementia: First Signs and Symptoms Reported by Family Caregivers” by Dr. Mary Corcoran. There is more evidence arriving on a regular basis to show how important our teeth are for both quality of life and for good health, so it is very appropriate that our Biology of Aging column by Dr. Gregory An discusses “Normal Aging of Teeth.” Our Falls and Fitness column, “Psychoactive Medications and Falls” is written by Dr. James Cooper and Dr. Allison Burfield. Our featured geriatrician this month is Dr. Angela Juby, the president of the Canadian Geriatrics Society.

Enjoy this issue,
Barry Goldlist

Urinary Tract Infections in Older Adults: Current Issues and New Therapeutic Options

Sophie Robichaud, MD, FRCP(C), Medical Microbiology and Pediatric Infectious Diseases, Royal University Hospital and Saskatoon Health Region, and Departments of Microbiology and Immunology and Pathology, University of Saskatchewan, Saskatoon, SK.
Joseph M. Blondeau, MSc, PhD, RSM(CCM), SM(AAM), SM(ASCP), FCCP, Head of Clinical Microbiology, Royal University Hospital and Saskatoon Health Region, and Adjunct Professor of Microbiology and Immunology, Clinical Assistant Professor of Pathology, Departments of Microbiology and Immunology and Pathology, University of Saskatchewan, Saskatoon, SK.

Urinary tract infections (UTIs) are the most common infectious problem among older adults both in the community and institutional settings. With the expected increase in this population, UTI-related costs--both human and financial--will rise in a parallel fashion. The diagnosis of symptomatic UTI among older adults is complicated by the high prevalence of asymptomatic bacteriuria, which does not require any treatment, and the difficulty in interpreting the signs and symptoms of UTI in a population in which significant comorbidities can undermine the communication between the patient and the medical team. Another important issue is the constant increase in antimicrobial resistance, especially in long-term care facilities, where antimicrobial use is greater than in the community. Newer agents are now available for the treatment of UTI among older adults, targeting both the usual and the multiresistant uropathogens. Rational use of antimicrobials in the treatment of UTI in the older adult is important to both provide appropriate care and control the spread of resistant organisms in this population.
Key words: urinary tract infection, older adults, UTI management, antimicrobials.

Fever in the Returning Traveller

Alberto Matteelli, MD, Institute of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy.
Anna Cristina Carvalho, MD, Institute of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy.
Veronica Dal Punta, MD, Institute of Infectious and Tropical Diseases, University of Brescia, Brescia, Italy.

The number of international travellers is steadily increasing, paralleled by the number of persons with travel-related diseases. Fever in the returning traveller should always raise suspicion of severe and potentially life-threatening infections. Therefore, physicians should be familiar with the most common syndromes, relevant diagnostic procedures, optimal treatment regimens, and referral criteria. This review gives a general overview of the pathogens causing fever in the returning traveller, their clinical presentation, and standard management procedures.
Key words: fever, travel, older adults, tropical diseases, vaccination.

Aging in Africa

Irene Turpie, MB, ChB, MSc, FRCP(C), FRCP (Glas), Professor Emeritus, McMaster University, Hamilton, Ontario.
Leigh Hunsinger, BA, Medical Student, McMaster University, Hamilton, Ontario.

Africa, with its many countries and ethnic groups, has a population of 800 million people and the highest rate of growth of the older adult population in the world. Urbanization and the HIV/AIDS epidemic are changing the traditional role of older adults. The epidemiological transition from acute infections to chronic diseases is occurring more slowly in Africa than in other continents but it is occurring. Many older persons are malnourished and live in poverty. Hypertension, stroke, osteoarthritis, chronic respiratory and mood disorders are expected to increase in incidence and are increasingly being identified in a continent without the resources or infrastructure as yet to mount preventive campaigns and to treat chronic health conditions. What is known about many older Africans is that they have the capacity to age well through daily exercise and healthy diets low in processed sugar and saturated fats. Aging Africans are generally regarded with respect and dignity. There is much that needs to be done to prevent deleterious aging outcomes for older adults in that continent and there is much we can learn about healthy aging and lifestyle prevention.
Key words: aging, Africa, epidemiological transition, developing nations, HIV/AIDS.