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TRANSCRIPT
Ticked-off... Myths, Truths, and Realities of Tick-borne Infections
including Lyme, Babesia, and EhrlichiaVanessa Pomarico-Denino, MS, APRN, FNP-BC, FAANP
Interim Director/Lead Faculty SCSU FNP trackSenior Consultant
Fitzgerald Health Education Associates, LLC (FHEA) www.fhea.com
Disclosures
• No real or potential conflict of interest to disclose.
• No off-label, experimental or investigational use of drugs or devices will be presented.
2Fitzgerald Health Education Associates
Objectives
• At the end of the presentation, the participant will be able to:– Differentiate between types of
tick-borne diseases. – Recognize clinical presentation of
specific infections.
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Objectives(continued)
• At the end of the presentation, the participant will be able to: (cont.)– Understand current therapies to
treat specific tick-borne and vectorborne diseases.
– Interpret findings of laboratory testing.
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References
All references are listed in your program as well as at the end of
this presentation
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Tick-borne Pathogens
•Transmitted through bite ofinfected ticks–Bacteria, virus, protozoal– High risk
• Those who work outdoors, high grass, forestry, construction, landscaping, RR, wildlife or park management
– Peak season• April to October; highest in June to August
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Tick-borne Pathogens(continued)
•Transmitted through bite ofinfected ticks (cont.)– Are considered reportable diseases
to DPH– Consider widespread testing due to
concomitant infection risk
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Types
• Tick borne– Lyme– Babesia– Anaplasmosis
(also knownas Ehrlichia)
– Rocky Mountain spotted fever
– Powassan
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• Vector borne– West Nile Virus– Chikungunya– Zika Personal photo
The lifecycle of a tick.
• Lifecycle approximately 2 years• 4 life-stages
– Egg– Six-legged larva– Eight-legged nymph– Adult
• When eggs hatch, ticks must feedon a blood meal at every stage inorder to survive
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How Transmitted
• “Questing”• Ticks wait on ends of
blades of grass, leaves on hind legs
• Attach to suitable host aftermaking contact
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Source: CDC.gov. Public Health Image Library ID #10871
How Transmitted(continued)
• Front legs attach onto host to begin feed– Infection is transmitted
through tick saliva.
• Tick will feed thenfall off host untiltime to feed againin next lifecycle.
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Source: CDC.gov. Public Health Image Library ID # 8680. Photo by James Gathany
Lyme Disease (Borrelia Burgdorferi)
• Spirochete– Transmitted by infected
ticks, usually deer ticks
• Originated in Lyme, CT– Most common
tick-borne diseasein the country.
– Also found in Australia, Asia, Europe
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Lyme Disease (Borrelia Burgdorferi) (continued)
• Tick must generally be in place>24 hours in order to transmit infection to host.
• Different ticks – not all carry Lyme• Tick bite frequently unnoticed
– Tick may be in area that is not noticeable.– Can engorge itself and fall off without
ever being detected
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Tick vector Geographic location
Percentage of infection (dependent upon region)
Carrier
Ixodes scapularis
Northeastern, north central and mid-Atlantic regions of U.S.
15–65% Mammals, birds, reptiles, amphibians (snakes, frogs)
Ixodes pacificus
West coast 2% adult ticks2–15% nymph ticks
Lizards, birds, mammals
Ixodes ricinus
Europe 4–16% Wood mice, cattle, deer, small rodents
Ixodes persulcatus
Asia 27% Sheep, cattle, horse, dog
Transmission
• Spread through the bite of an infected tick
• Most common areas– Groin– Axillae– Scalp
• Most common timeof year– Spring and summer
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Source: CDC.gov Public Health Image Library ID #2417
Transmission(continued)
• Ticks not known to transmit Lyme disease include– Lone star ticks (Amblyomma americanum)– American dog tick (Dermacentor variabilis)– Rocky Mountain wood tick (Dermacentor
andersoni)– Brown dog tick
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Source: https://www.cdc.gov/lyme/resources/reportedcasesoflymedisease_2015.pdf
Incidence of RecentlyConfirmed Lyme Cases
• CT: 1873 • CA: 83• MA: 2922• NJ: 3932• NY: 3252
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• PA: 7351 • TN: 6• AK, CO, HI, WY: 0
– Source: https://www.cdc.gov/lyme/stats/tables.html
Clinical Presentation
• Flu-like symptoms (“summer flu”) and possibly a rash
• Stage 1: Early localized infection– Approximately 3–30 days after initial tick bite– Erythema migrans
• Localized erythema at site of insertion
– Target lesion with central area of clearing• 10–20% of patients do not develop rash or lesion
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Source: CDC.gov. Public Health Image Library ID # 14476
Source: CDC.gov. Public Health Image Library ID # 14481
Clinical Presentation(continued)
• Stage 2: Early disseminated infection– Weeks to months after initial infection– 50–60% of patients with EM
become bacteremia– Malaise, fatigue*, fever, HA (sometimes
severe), neck pain, generalized myalgia/arthralgia
– *Fatigue can persist for months
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Clinical Presentation(continued)
• Stage 2: Early disseminated infection (cont.)– Cranial nerve VII
palsy or meningitis(10–15%)• Rare complication:
AV block (~4–10%) or myopericarditis, panophthalmitis
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Clinical Presentation(continued)
• Stage 3: Late, persistent infection– Can occur months to years after
initial infection– Moderate to severe generalized
arthralgias (60%)– Monarticular or oligoarticular arthritis
involving the knee or hip usually self-limiting• Joint aspiration yields a mean WBC 25,000/mcL
with predominance of neutrophilsFitzgerald Health Education Associates 23
Clinical Presentation(continued)
• Rare neurologic manifestations– Subacute encephalopathy, sleep
disturbance, memory loss, mood changes, intermittent paresthesias, ataxia, spastic paraparesis, bladder dysfunction
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Clinical Presentation(continued)
• If patient presents with symptoms of Bell’s palsy, heart block or myopericarditis, test for Lyme!
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Source: CDC.gov. Public Health Image Library ID # 6633
ECG courtesy of Nick Tullo, MD
Differential Diagnosis
• Bell’s palsy• Contact dermatitis• Tinea corporis• Herpes zoster• Fibromyalgia• Arthritis
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Diagnosis and Treatment
• National surveillance case definition– 30-day window of exposure prior to onset
of symptoms– Erythema migrans as diagnosed by HCP– At least one late manifestation of disease– Confirmatory lab testing
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• True incidence unknown due toseveral factors.– Serologic testing is not standardized.– Clinical manifestations are not specific and
can mimic other illness or infection.– Serology is not sensitive enough in early
stage of disease leading to false negative readings.
– Source: Papadakis, M., & McPhee, S. (2017). Current medical diagnosis & treatment. (56th ed). New York, NY: McGraw-Hill
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Incidence of Lyme
Lab Testing
• ELISA two step testing (EIA)• If ELISA is +, Western blot assay to detect
both IgM and IgG antibodies• IgM + within 2–4 weeks (~70%); can
seroconvert to IgG after 6 weeks• IgM Western blot (IFA) must have two of the
following three bands present: 23, 39, and 41kDa for diagnosis
• IgG must have 5/10 bands + for diagnosis– ESR may be elevated.– LFT abnormalities, shift in WBC
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Treatment: Prevention
• Caveats– Known tick bite <72 h– Tick is identified as an adult or nymph
scapularis tick estimated to have been attached for ≥36 h.
– Prophylaxis can be started within 72 h of the time that the tick was removed.
– Source: Wormser, et al. (2006)
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Treatment: Prevention(continued)
• Caveats (cont.)– Local rate of infection of these ticks with
B. burgdorferi is ≥20%.– Doxycycline treatment is not
contraindicated.• Doxycycline 200 mg PO single dose
– Source: Wormser, et al. (2006)
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Outpatient Treatment of Lyme Disease: One of the following regimens
• Doxycycline 100 mg PO BID × 21 d– Do not use in pregnancy, ? lactation OR
• Amoxicillin 500 mg PO TID × 21 d– Safe for pregnancy/lactating women OR
• Cefuroxime axetil 500 mg PO BID × 21 d OR
• Erythromycin 500 mg PO QID × 14–21 d– Use of probiotic to prevent C-diff. colitis
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Inpatient treatment of Lyme disease with cardiac complications
• Ceftriaxone: drug of choice: 10-28 days of therapy– Pedi: 50-100 mg/kg/day IV once daily– Adults: 2 g IV once daily
• PCN G potassium: 10-28 days of therapy– Pedi: 200,000-400,000 million units/kg/day in
divided doses every 4 hours– Adult: 18-24 million units/kg/day IV every 4
hours
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Outpatient Treatment: PediOne of these regimes
• Pedi– Amoxicillin 50 mg/kg PO QD in 3
divided doses• Maximum of 500 mg per dose
– Cefuroxime axetil 30 mg/kg PO QD in2 divided doses• Maximum of 500 mg per dose • Age >8 years: Age ≥8 years, doxycycline PO
(4 mg/kg per day in 2 divided doses [maximum of 100 mg per dose])
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Treatment Alternatives
• To be used if PCN allergic or intolerant of other recommended medications
• Azithromycin– 500 mg PO daily × 7–10 days
• Clarithromycin– 500 mg PO BID × 14–21 days
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Post-TreatmentLyme Disease Syndrome
• Formerly referred to as chronic Lyme– Controversial– No documentation or studies to
prove/disprove its existence
• Refer to infectious disease specialist if symptoms persist beyond treatment
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Source: CDC.gov. Public Health Image Library
Babesiosis
• Protozoan parasitic infection transmitted by ticks, usually on cattle, wild animals
• Generally found in the coastal northeastern U.S.– 95% of the cases were reported by 7
states: CT (205), MA (537), NJ (159), NY(471), RI (172)• Total for U.S. in 2014= 1744
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Babesiosis
• Causes B. microti or B. divergens• Infected by same ticks carrying
B. burgdoferi– Nymph ticks the size of a poppy seed– People rarely know they were bitten by
a tick.– + vertical transmission from mother
to fetus
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Clinical Presentation of Babesia
• Flu-type symptoms gradually worsening– Fever, HSM
• Arthralgias, myalgias– May not have any rash
• Hemolytic anemia and thrombocytopenia
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Clinical Presentation of Babesia(continued)
• Symptomatic within a week but may be asymptomatic for many months
• Can be fatal in elderly or peoplewithout spleen
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Diagnosing Babesia
• Detailed history of high risk exposure and high index of suspicion
• Labs– CBC with anemia due to RBC destruction
and low platelets– Proteinuria– Hemoglobinuria– Elevated LFTs, BUN/creatinine
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Diagnosis(continued)
• Manual peripheral blood smear– Can need more than one sample to
detect parasites– Must request manual reading!
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Diagnosis(continued)
• Indirect immunofluorescent antibody– Anti-babesia IgG titers >1:64– Antibodies detected 2–4 weeks
after infection– Titers generally rise to ≥1:1024 during
the first weeks of illness and decline gradually over 6 months
– Can remain detectable at low levels fora year or more
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Outpatient Treatment
•First-line–Atovaquone 750 mg PO BID plus
azithromycin 500–1000 mg PO on day 1 then 250–1000 mg PO for 7–10 days
•Alternative–Clindamycin 600 mg PO TID + quinine 650
mg PO TID for 7–10 days• Higher adverse effect profile
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Blood Donation
• Patients diagnosed with Babesia are indefinitely deferred from donating blood
• Currently, no routine screening for Babesia with blood donation exists
• Patients should be advised to refrain from blood donations unless their specimen is screened for Babesia
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Medication Risks
• Antimalarials• Pregnancy category C• Use with caution if breast feeding• Pedi patients must weigh >11 lbs (5 kg)
– Azithromycin• Safe for pregnancy, lactation and pedi patients
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Medication Risks(continued)
• Antimalarials (cont.)– Clindamycin
• Pregnancy category B• Is excreted in breast milk but is compatible
with breast feeding• Contains benzyl alcohol, which has been
associated with a fatal "gasping syndrome" in premature infants
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Source: Used with permission from Graham Hickling, PhD, University of Tennessee.
Ehrlichiosis or Anaplasmosis
• Human monocytic ehrlichiosis (HGE) caused by Ehrlichia chaffeensis from the Lone Star tick from white-tailed deer
• Became reportable in 1999– <1000 cases reported in 2008
• Now known as human granulocytic anaplasmosis (HGA)
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Ehrlichiosis or Anaplasmosis(continued)
• More prevalent Northeastern and Midwestern U.S.
• Peaks June-December– May-August: Highest transmission time
• Short incubation: 9 days–2 weeks• Can be fatal in <1% of those who are
untreated
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Ehrlichiosis or Anaplasmosis
• Prodrome– Malaise, rigors, fever, HA, myalgia, N/V/D– Rash is rare.– Coinfection with Lyme, Babesia
not uncommon
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Diagnosis and Treatment
• Indirect immunofluorescence assay (IFA)-gold standard
• PCR assay• Enzyme immunoassay (EIA)
– Serologic only gives + or (-) result high false positive
• Peripheral blood smear
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Diagnosis and Treatment(continued)
• CBC/diff, LFTs– Can have thrombocytopenia,
leukopenia, transaminitis– Infect monocytes and granulocytes– Presence of morulae
– Source: American Academy of Pediatrics Committee onInfectious Diseases
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Diagnosis and Treatment(continued)
• Treatment– Doxycycline 100 mg PO BID × 10–14 days– Rifampin PO if pregnant/lactating or
pediatric patient– Use of antibiotics other than doxycycline
increases the risk of patient death– Source: American Academy of Pediatrics Committee on
Infectious Diseases
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Rocky Mountain Spotted Fever
• Causative organism– Rickettsia rickettsii
• Can be potentially fatal if not treated within the first few days
• Spread by dog tick or wood tick, fleas, lice and mice
• 5–14 day incubation period
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Clinical Presentation
• Fever• Rash: Appears 2–5 days after infection
in 90% of pts– Nonpruritic, erythematous macular rash
on wrists, forearms, ankles, trunk– Petechial rash generally not seen until
after day 6 of illness– Pedi pts will develop rash more quickly
than adults.
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Clinical Presentation(continued)
• HA• N/V/abdominal pain• Anorexia• Conjunctival irritation
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Pediatric Clinical Presentation
• More likely to present with headache• Earlier onset of rash than adults• Abdominal pain• Conjunctival injection• Altered mental status
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Diagnosis
• Important to diagnose and treat early if high index of suspicion
• Skin biopsy of rash quickest way to diagnosis due to rapid turnaround
• + antibodies after 7–10 days
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Diagnosis(continued)
• Gold standard: Indirect immunofluorescence assay (IFA) with R. rickettsii antigen– First sample within first week– Second sample 2–4 weeks after– Repeat 2–4 weeks
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Complications
• Vasculitis due to infection of endothelial cells
• Limb amputation due to decreased circulation
• Internal organ damage
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• Neurological deficits• Thrombocytopenia• Hyponatremia• Elevated LFTs
Treatment
• Doxycycline 100 mg PO BID x 7–14 days is treatment of choice– Fever generally subsides within 24–72
hours after initiation of treatment– Children <45 kg (<100 lbs): 2.2 mg/kg
body weight given twice a day
• Chloramphenicol if pregnant or allergic to doxycycline
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Outpatient Treatment of RSMF:Additional information for Pedi
• Doxycycline binds less readily to calcium and has not been shown to cause the same tooth staining as TCN
• Blinded study in 2013 revealed that no differences in tooth color, staining, or weakness were found between children < 8 yo who had received doxycycline and those who had not
• Source: https://www.cdc.gov/rmsf/doxycycline/index.html
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Source: CDC.gov. Public Health Image Library ID #14489
Powassan
• Found in Northwestern and Great Lakes region of the U.S.– Peak transmission: Late spring, early
summer, mid-fall
• Incubation: 1 week to 1 month– # of reported cases in 2013= 12
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Clinical Presentation
• HA• Fever• Vomiting• Weakness• Confusion• Loss of coordination• Seizures
– Indicative of meningitis or encephalitis
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Diagnosing• CSF
– <500 WBC/mm3; granulocytosis earlyin disease
• EEG– With slower brain wave activity
• Brain MRI– Consistent with microvascular ischemia or
demyelinating disease
• Viral testing during autopsyFitzgerald Health Education Associates 68
Treatment
•~50% will have permanent neuro deficits•Supportive measures
– Ventilator– Respiratory support– IVF– Medications to decrease brain swelling
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Prevention
• Adequate covering of all exposed skin
• DEET orpermethrinproducts
• Extensive skin checks if inexposed area
• Removal of tick inits entirety
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Source: CDC.gov Public Health image library
Case Study
• Gary, 56-year-old male patient• PMH: Obesity, HLD, HTN, gout• PSH: Splenectomy age 10• CC
– Fatigue– Arthralgias– Myalgias– “No energy”
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Case Study (continued)
• Medications– Valsartan-amlodipine-HCTZ 160 mg/5
mg/25 mg PO daily – ASA 81 mg PO daily– Glucosamine 500 mg PO TID
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Case Study (continued)
• SH –Non-smoker, social ETOH use–Avid golfer daily during the warmer
months–Walks the golf course with his dogs
daily–Married, real estate agent
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Case Study (continued)
• CC– “Summer flu”
• ROS– Worsening fatigue– Arthralgias and myalgias– Constant headache– Feels feverish but did not take his temp– Denies N/V/D
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Case Study – Labs(continued)
• WBC 3.2×1000/uL (4–10 ×1000 u/L)– Neutrophils 70% (37–84%)
• 0.7 proportion (0.37-0.84 proportion)
– Lymphs 16% (8–49%)• 0.16 proportion (0.08-0.49 proportion)
– Monos 14% (4–15%)• 0.14 proportion (0.04-0.15 proportion)
• RBC 3.9 M/uL (3.8–5.9 M/uL)• Hgb 11.6 g/dL (12.0–18.0 g/L)
– 1160 g/L (1200-1800g/L)• Hct 36.5% (37–52%)
– 0.365 proportion (0.37-0.52 proportion)
• Platelets (140–440 ×1000/uL) 157×1000/uL
• BNP 479 pg/mL (100–400 pg/mL)
• Lyme IgM: Positive 2/3 bands
• ANA/RA: Negative• ALT: 58 U/L (0–34 U/L)• AST: 63 U/L (0–34 U/L)• Urine: Moderate
protein
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Case Study (continued)
• Babesia PCR + for Babesia DNA:– Detectable parasites with distinct
morphology different from malaria– Rings with basophilic stippling
• Ehrlichia: Negative
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Case Study (continued)
• Treatment: Need both– Azithromycin 500 mg PO daily × 7‒10
days– Atovaquone 750 mg PO BID × 7‒10 days
• Alternative– Quinine 650 mg TID x 7‒10 days PO plus
clindamycin 600 mg PO TID x 7‒10 days• Higher adverse effect profile• Usually reserved for severe disease
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Follow-up
• Serial CBC/diff, CMP and Babesiaperipheral smear to determine eradication of parasites– If outpatient, weekly labs until negative
then one month after therapy has been completed
– Repeat labs if patient becomes symptomatic again
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Questions?
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End of Presentation.Thank you for your attention
Vanessa Pomarico-Denino,MS, APRN, FNP-BC, FAANP
www.fhea.com [email protected]
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References
• Buttaro, T., Trybulski, J., Polgar Bailey, J. (2016). Primary Care: A collaborative practice. (5th ed). St. Louis, Missouri: Elsevier
• Center for Disease Control (CDC): www.cdc.gov
• Evans, D. & Meires, J. (2016). Chikungunya Virus: A rising health risk in the United States and how nurse practitioners can help address and reduce the risk. Journal for Nurse Practitioners. 12(5): 289-298.
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References(continued)
• Mcneil, C., Shreve, M., Jarrett, A., & Perry, C. (2016). Zika: What providers need to know. The Journal for Nurse Practitioners. 12(6): 359-366.
• Moore, K. (2015). Lyme Disease: Diagnosis, treatment, guidelines, and controversy. The Journal for Nurse Practitioners. 11(1): 64-69.
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References (continued)
• Papadakis, M., & McPhee, S. (2017). Current medical diagnosis & treatment. (56th ed). New York, NY: McGraw-Hill
• Wooten, A. (2015). Zika Virus: An emerging threat to travelers. The Journal for Nurse Practitioners. 12(5): e237-238.
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References (continued)
• Wormser, G., Dattwyler, R., Shapiro, E., Halperin, J., Steere, A., Klempner, M., Krause, P., Bakken, J., Strle, F., Stanek, G., Bockenstedt, L., Fish, D., Dumler, J.S., & Nadelman, R. (2006). The Clinical Assessment, Treatment, and Prevention of Lyme Disease, Human Granulocytic Anaplasmosis, and Babesiosis: Clinical Practice Guidelines by the Infectious Diseases Society of America. Clinical Infectious Diseases. 43 (9): 1089-1134.
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Photo Credits
• Graham Hickling, PhD, University of Tennessee.
• CDC public health image library. https://phil.cdc.gov
• Pixnio. www.pixnio.com
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• Images/Illustrations: Unless otherwise noted, all images/ illustrations are from open sources, such as the CDC or Wikipedia or property of FHEA or author.
• All websites listed active at the time of publication.
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