Infection and Human Immunodeficiency Virus Infection

KEY POINTS

INFECTIONS
An infection is an invasion of the body by a pathogen (any microorganism that
causes disease) and the resulting signs and symptoms that develop in response to the
invasion.
Infections can be divided into localized, disseminated, and systemic disease.

TYPES OF PATHOGENS
The most common types of pathogens are bacteria, viruses, fungi, and protozoa.
Agents cause infection in two ways: They grow inside human cells, causing
damage, or they secrete toxins that damage cells.

EMERGING INFECTIONS
An emerging infection is an infectious disease whose incidence has increased in
the past 20 years or threatens to increase in the immediate future. Examples include
Ebola, MERS, H1N1, SARS, West Nile virus, and Zika.
Emerging infectious diseases can originate from unknown sources, contact with
animal or insect vectors, changes in known diseases, or biologic warfare. Global travel,
population density, encroachment into new environments, misused antibiotics, and
bioterrorism have contributed to the increased risk of emerging infections.
Drug resistance occurs when pathologic organisms change in ways that decrease
the ability of a drug (or a family of drugs) to treat disease.
Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant
enterococci (VRE), and penicillin-resistant Streptococcus pneumoniae are three of the
most troublesome drug resistant bacteria currently causing problems in North America.

HEALTH CARE-ASSOCIATED INFECTIONS

Health care-associated infections (HAIs) are infections that are acquired as a
result of exposure to a microorganism in a hospital setting and typically occur within 72
hours of hospitalization.
Approximately one third of HAIs are preventable through the implementation of
health care precautions.

GERONTOLOGIC CONSIDERATIONS: INFECTION IN OLDER ADULTS

The rate of HAIs is two to three times higher for older adult patients than for
younger patients.
Common infections in older adults include pneumonia, urinary tract infections
(UTIs), and skin infections.

INFECTION PREVENTION AND CONTROL

 The Occupational Safety and Health Association (OSHA) mandates that any
employer whose employees could be exposed to potentially infectious materials
implement standard policies and procedures for protection of those employees.
The Centers for Disease Control and Prevention (CDC) developed guidelines with
two levels of precautions: standard precautions (designed for use during the care of all
patients in hospitals and health care facilities) and transmission-based precautions
(designed for specific diseases).

HUMAN IMMUNODEFICIENCY VIRUS INFECTION

Human immunodeficiency virus (HIV) infection is a global pandemic.
HIV can only be transmitted under specific conditions that allow contact with
infected body fluids, including blood, semen, vaginal secretions, and breast milk.
Sexual contact with an HIV-infected partner is the most common mode of
transmission.

Pathophysiology
HIV is a ribonucleic acid (RNA) virus, which replicates by using its RNA as a
template to produce deoxyribonucleic acid (DNA), which is then integrated into the
human genome.
Immune dysfunction in HIV infection is caused by damage and destruction of
CD4 T cells (also known as T helper cells or CD4+ T lymphocytes).
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The major concern related to immune suppression is the development of

opportunistic diseases (infections and cancers that occur in immunosuppressed patients
that can lead to disability, disease, and death).

Clinical Manifestations and Complications

HIV infection is divided into different stages, including acute, asymptomatic,
symptomatic, and AIDS.
Acute HIV infection occurs 2 to 4 weeks after the initial infection and is
often accompanied by a mononucleosis-like syndrome that may be mistaken for
the flu.
Asymptomatic infection is the interval between untreated HIV infection
and a diagnosis of acquired immunodeficiency syndrome (AIDS). Although called
asymptomatic, symptoms (e.g., fatigue, headache, low-grade fever, night sweats)
often occur.
Symptomatic infection occurs as the CD4+ T-cell count drops to 200 to 500
cells/L, and the viral load increases. Symptoms seen in earlier phases tend to
become worse and other problems, including infections, lymphadenopathy, and
nervous system manifestations, may occur.
AIDS is characterized by severe immune system suppression and CD4+ T-
cell counts of less than 200 cells/L.

Diagnostic Studies
 The most useful screening tests for HIV are those that detect HIV-specific
antibodies and/or antigens.
The progression of HIV infection is monitored by two important laboratory
assessments: CD4+ T-cell counts and HIV viral load.

Interprofessional Care
Interprofessional management of the HIV-infected patient focuses on (1)
monitoring HIV disease progression and immune function, (2) initiating and monitoring
antiretroviral therapy (ART), (3) preventing the development of opportunistic diseases,
(4) detecting and treating opportunistic diseases, (5) managing symptoms, (6) preventing
or decreasing the complications of treatment, and (7) preventing further transmission of
HIV.
The goals of drug therapy in HIV infection are to decrease the viral load, maintain
or raise CD4+ T-cell counts, prevent the development of HIV-related symptoms and
opportunistic diseases, and delay disease progression.
The major drug classifications for HIV include nucleoside/nucleotide reverse
transcriptase inhibitors (NRTIs), integrase strand transfer inhibitors (INSTIs), protease
inhibitors (PIs), non-nucleoside reverse transcriptase inhibitors (NNRTIs), and
entry/fusion inhibitors.
Treatment regimens can have side effects and frequently interact with
other medications.
Management of HIV is complicated by the many opportunistic diseases that can
develop as the immune system deteriorates.
Examples of opportunistic diseases include Pneumocystis jiroveci pneumonia
(PCP), Mycobacterium avium complex (MAC), and Kaposi sarcoma.

NURSING MANAGEMENT: HIV INFECTION

Since HIV infection can be prevented, nursing care for individuals not known to
be infected with HIV should focus on preventing disease transmission.
The first step is to assess the patients individual risk behaviors,
knowledge, and skills.
Based on the assessment, nursing interventions can then encourage the
patient to adopt safer, healthier, and less risky behaviors, particularly in regard to
sexual intercourse, drug use, perinatal transmission, and work issues.
The overriding goals of therapy for infected individuals are to keep the viral load
as low as possible for as long as possible, maintain or restore a functioning immune
system, improve the patients quality of life, prevent opportunistic disease, reduce HIV-
related disability and death, and prevent new infections.
Nursing interventions are based on and tailored to patient needs at every stage of
HIV disease and can be instrumental in improving the quality and quantity of the
patients life.
Nursing care can assist the patient to (1) adhere to drug regimens; (2) promote a
healthy lifestyle that includes avoiding exposure to other sexual and blood-borne
diseases; (3) protect others from HIV; (4) maintain or develop healthy and supportive
relationships; (5) maintain activities and productivity; (6) explore spiritual issues; (7)
come to terms with issues related to disease, disability, and death; and (8) cope with the
frequent symptoms caused by HIV and its treatments.
Teach patients and families about treatment options: (1) advantages and
disadvantages of new treatments, (2) dangers of nonadherence to therapeutic regimens,
(3) how and when to take each drug, (4) drug interactions to avoid, and (5) side effects
that must be reported to the HCP.
While HIV-infected patients share problems experienced by all individuals with
chronic diseases, these problems are exacerbated by negative social attitudes and stigma
associated with HIV. Discrimination related to HIV infection can lead to social isolation,
dependence, frustration, low self-image, loss of control, and economic pressures.
Should the nurse be exposed to HIV-infected fluids, postexposure prophylaxis
(PEP) with combination ART can significantly decrease the risk of infection.