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• Manual for outpatient clinics (a draft by Department of Pediatrics, Osaka University School of Medicine)
• To prevent secondary infection in a household
• Necessary caution to avoid secondary intrahospital infection

Manual for outpatient clinics (a draft by Department of Pediatrics, Osaka University School of Medicine)

This manual of patientsŐ care and instruction is written based on limited experience toward o-157 infection. Nobody has enough experience, and many physicians seem to have some degree of difficulty caring those patients. This manual can be used as a desk reference. Please feel free to make any comments.

At outpatient clinic (primary care and secondary care(referral) medical facility)

1. Early stage of the disease

b) diarrhea without bloody stool/mild bloody stool
Apply drip infusion (option), FOM plus LacBR (Most appropriate antibiotics need to be discussed)
Indication of follow-up visit: Continuous diarrhea for more than two days, vomiting, loss of appetite, oligourea, and bloody stool.
Day 4: Routine urinalysis for all family members. In case proteinuria ++ or more, blood test must be done. Other test (option)
Day 6, 8, 10: Make sure that patients visit clinics on those days to check the followings:
Crnn, BUN, platelet, urinalysis test. Blood test must be done several times at least after the onset.
Even if occult blood is negative, symptomatic patients should be hospitalized.

2. Subacute stage

b) Patients with severe symptoms in early stage but showing improved appetite and stool condition
Urinalysis (dipstick, sediment)
Blood test (option)

c)Patients with severe symptoms in early stage still have diarrhea and abdominal pain.
Patients with severe symptoms in early stage and have recurrence of abdominal pain and diarrhea, although recovered transiently with good stool condition.
Patients with severe symptoms in early stage, have vomiting and headache, though look better.
(Patients with ecchymosis, petechia, icteric ocular conjunctiva, oligouria, palpebral edema, pale complexion)
must be observed intensively---Blood test and urinalysis are indispensable.

3. patients suspicious for secondary infection or patient with late onset

4. Instruction to the patients after recovery

List of necessary blood test

CBC, BUN, Cr, LDH, T.Bil., GOT, CRP, Na, K, Cl, Ca, TP, Coagulation study and blood type in severe case.

Criteria for transfer to tertiary care medical facility

CNS symptoms, macroscopic heamturea, BUN>30, Plt<50,000 to 100,000, LDH>1000
(Any change of these values must be noted)

Criteria for an admission

Although BUN is lower than 30, elevated LDH(>600), thrombocytopenia(200,000), leukocytosis, CRP>1.0, T.Bil (>1-2), proteinuria and/or hematuria

When abnormal blood test in only one test (e.g. mild to moderately elevated LDH, mild proteinuria (1+))

Follow up by quantitative urinalysis (dipstick testing) or returning to clinic on the following day or day after.

If you have any question concerning this manual, contact us at 06-879-3939 (fax), or e-mail.

We have had the following comments to our manual.

1. There are patients with hemolytic uremic syndrome only showing positive occult blood without proteinuria.
2. Proteinuria should be checked within 3 days. it is late to check it after 4 days.
3. There are patients with HUS only showing thrombocytopenia.
4. HUS has been seen in patients whose early manifestation was mild.

To prevent secondary infection in a household

Infection by o-157, enteropathogenic E. coli, is spread mostly through the oral route. It can be sterilized by heat (75 ° C, 1 min) like other bacteria causing food poisoning.

You can minimize the infection when you pay attention to the following----most of these points are common knowledge, but need to be followed very closely in order to prevent the spread of infection.

1. Keep your hands clean.

2. Bathroom

3. Bathing

4. Laundry of the patients

5. Tableware

6. Bedclothes

7. Food

The key points are:

to wash your hands thoroughly
to use disposable gloves
and to avoid being close with babies and infants.

Necessary caution to avoid secondary intrahospital infection

1. Patients' room

   1. Minimize the frequency of trip to the patients' room. Private room is ideal.
      Staff members should be arranged to care same patients.
      Visitors should be limited to the family members.
   2. Emphasize hand wash, to wear mask and robe.
      After hand wash with soap at nursing station, sterilization with wellpass before entering the room.
      Sterilization with wellpass upon exiting the room (Sterilize well up to the elbow in case of contact with patient). Undress robe without touching external surface/ discard the mask at the exit.
      In case of developing reaction to wellpass, isodine can be used (Take longer time with isodine than ethanol. Gloves are also acceptable)

2. Management of patients' excretion

   It is principally desirable to use bedpan. Use stool bag special for bedpan. (The stool bags are managed temporarily by nursing department or chief-nurse on call). After bowel movement, 1/5 to 1/10 amount of Texant is poured into the bag with gentle shaking, and the bag should be placed duplicated black plastic bag to be discarded in the excretion management room. Toilet seat should be sprayed or wiped with 70% ethanol.

3. In case non-disposable plates are used

   they should be soaked in Milton solution more than one hour. New Milton solution should be used each time. Patients' clothes should be washed with water followed by soaking in either 0.1% Hyamine or 0.1-1% Texant solution over an hour. New batch of sterilizer should be used each time.

4. Management of blankets and sheets

   Used blankets and sheets should be placed in black plastic bag and sprayed with 70% ethanol. In case of contamination with stool, the contaminated area should be wiped 10 minutes after the decontamination with spray.

5. Bathing

   Patient should bathe at the end of the bathing turn. The bath tub and floor should be sterilized and cleaned.

6. Garbage disposal

   Paper diaper and other disposable materials should be treated well with Texant solution and placed in duplicated black plastic bag.

7. Hospital employee should wash hands and take shower well at home.

8. In case of appearance of signs and symptoms of infection in employee

   It should be reported to chairman of infection prevention control, and necessary tests should be performed. it is ideal to place the individual free of duty until the test results come back.

9. In case of appearance of signs and symptoms of infection in patients' aid

   The necessary tests such as stool culture should be performed immediately. (It is advisable to stop patients' aid)

Acknowledgement

Tomoko Maeda
Kristin E Allen
Toru Shoji*

Department of Dermatology, Boston University School of Medicine
*Department of Dermatology, Dermatopathology Section, Boston University School of Medicine