Infectious Disease

Definitions

• HAART: Antiretrovirals are a combination of medications that are typically used for reducing viral infections. Highly Active Antiretroviral Therapy is a combination of antiretrovirals that target the entire life cycle of HIV. 

• CD4: Also known as T helper cells they are cell receptors that are a primary target for HIV infection. HIV uses CD4 to gain entry into T-cells. CD4 mediates cell recognition and help direct immune activities to target foreign antigens, promote the differentiation of B cells and cytotoxic T cells, and activate macrophages. HIV

• VL: Viral load measures the amount of virus found in the blood and gives an estimate of how severe a viral infection is. 

Anatomy/Physiology

Briefly discuss the functions of the immune system

The immune system is made up of cells, tissues, and molecules which are designed to protect the body from infection and disease. The immune system fights off infections through both innate and adapt immunity. Innate immunity is the body's first line of defense against microbial attack. It both blocks infection through epithelial barriers and fights off infection by eliminating microbes with phagocytes and natural killer cells. Adaptive immunity defends the body against infection after infection already ocurred. After the body has been exposed to microbes, antibodies block subsequent infections and along with T lymphocytes they eliminate microbes. The immune system is made up of several cells including: B lymphocytes, T lymphocytes, natural killer cells, dendritic cells, macrophages, follicular dendritic cells, macrophages, and granulocytes

What are some micronutrients that are important in immunity?

Selenium, zinc, iron, copper, beta-carotene, and vitamins A, C, E, B6, and B12. 

What are some of the metabolic abnormalities that can occur in patients treated with HAART?

Hypertriglyceridemia, insulin resistance, increased serum cholesterol, lactic acidosis, andhyperlipidemia. 

What are some of the physical changes that can occur in patients treated with HAART?

Loss of fat in the extremities with simultaneous increase of visceral and abdominal fat, breast hypertrophy, and development of a dorsocervical fat pad.

Pathophysiology

What are some opportunistic infections commonly seen with HIV infection?

Tuberculosis, fungal infections such as candidiasis (Thursh) and pneumocystis pneumonia, Herpes Simplex, toxoplasmosis, cytomegalovirus, meningitis, and mycobacterium avium complex.

How do these impact nutritional status?

Opportunistic infections may trigger weight loss and further decline health. This occurs because of increased energy expenditure, malabsorption, loss of appetite, and in some cases reduced intake because of pain and difficulty eating. 

Drug Therapy

Discuss the use of the following classifications of drugs. Include indication for use with AIDS patients, and pertinent drug/nutrient interactions. 

• Appetite Stimulants: Many HIV patients suffer from a lack of appetite because of complications with their medication and condition. Apptetite stimulants are often prescribed to prevent patients from decreasing weight as a decrease in weight is strongly associated with a decline in health status and increases the probability of death. Blood sugar fluctuations may result from taking these medications which is a particular problem for diabetic patients.

• Protease Inhibitors: These medications interrupt the viral replication cycle by inhibiting protease enzymes that allow the viral proteins to be cleaved for reassembly into viral cores. Avoid St. Johns wart, grapefruit, and garlic.

• Nucleoside Reverse Transcriptase Inhibitors: These medications interrupt the viral replication cycle by inhibiting reverse transcriptase enzymes that allow the girl RNA to be transcribed to DNA before being integrated into the host cell DNA. Avoid alcohol.

• Non-nucleoside Reverse Transcriptase Inhibitors: These differ from their nucleoside counterparts in that they non competitively bind directly to the enzyme downstream from the active catalytic site. Avoid alcohol and St. Johns Wart.

• Fusion Inhibitors: These medication interrupt the viral replication cycle by inhibiting fusion of the HIV virus to the target cell. 

• Anabolic Agents: Synthetic steroids that are used to increase lean body mass, increase muscle strength, and increase appetite. 

Nutritional Management

Discuss the importance of educating immunosuppressed patients on safe food handling techniques.

Immunosuppresed patients are at increased risk of developing food borne illnesses. By maintaining proper food sanitation a person can protect themselves against microbial and fungal infections.

 Click here to view the Infectious Disease chart review.

INTERN’S NAME: Melissa Cannon

INSTITUTION: Cooler-Goldwater

ROTATION AREA: Infectious Disease/HIV

CHARTING TYPE: Not specified 

PRECEPTOR’S COMMENTS / CORRECTIONS OF CHARTING

Mention in the nutritional comments section that the patient agreed to have one can of ensure plus removed

Always mention that education was provided in the progress note and indicate the topic as well as the expected level of compliance

INTERN’S COMMENTS ABOUT NUTRITIONAL INTERVENTION(S):

The patient was very receptive to removing one can of Ensure Plus in order to prevent weight gain. However, the patient was not willing to remove both. We were able to come to a compromise that we would remove one can and assess him later to see if his weight was decreasing and if not then we would remove both. 

WAS THE NUTRITION INTERVENTION SUCCESSFUL? WHY/WHY NOT?:

The assessment was completed on November 25th, 2011 and his December weights would not likely show the effect of removing one can of Ensure Plus. His weight will be taken again in January. However, I will be unable to assess the patient’s weight status as I will be out of the unit.