Infectious Disease — Advanced Nursing Guide

01Resistance Mechanisms

BETA-LACTAMASES & ESBL

ESBL — Extended-spectrum beta-lactamases; hydrolyse penicillins + cephalosporins. Treat with carbapenems.
AmpC — Cephalosporinases; resist cephalosporins + beta-lactamase inhibitors.
Plasmid — transferable resistance; horizontal gene transfer between organisms.

CARBAPENEMASES (LAST-LINE RESISTANCE)

NDM

New Delhi Metallo-beta-lactamase
Colistin only option

KPC

Klebsiella pneumoniae Carbapenemase
Ceftazidime-avibactam

OXA-48

Oxacillinase-48
Common in Middle East

MRSA, VRE & C. DIFF

MRSA — mecA gene; vancomycin or linezolid. Screen high-risk admissions. Contact precautions.

VRE — vanA/vanB genes; linezolid/daptomycin. Contact precautions. No alcohol hand gel — soap and water.

C. difficile — toxin-producing; antibiotic-associated. Oral vancomycin or fidaxomicin. Spore-forming — soap + water ONLY, hypochlorite disinfection. Contact precautions.

02Stewardship Principles

💊

Right Drug

Narrow spectrum when possible. Culture-guided.

⚖️

Right Dose

Weight-based dosing. Renal/hepatic adjustment.

⏱️

Right Duration

Shortest effective course. Stop when resolved.

🔄

Right Route

IV-to-oral switch when tolerating PO & improving.

48-72 HOUR REVIEW (MANDATORY)

✓ Review blood culture results — narrow or de-escalate
✓ Reassess clinical response — is patient improving?
✓ Consider IV-to-oral switch criteria
✓ Document indication, planned duration in notes
✓ Consult Infectious Disease/Pharmacy if uncertain

Blood cultures BEFORE antibiotics: Obtain 2 sets from different sites before first antibiotic dose. Each set = aerobic + anaerobic bottle. Label correctly with time and site. Allows targeted therapy and de-escalation.

Empirical vs Targeted Therapy & De-escalation

EMPIRICAL THERAPY

• Broad-spectrum initial coverage
• Based on likely pathogens + local resistance
• Start within 1 hour in sepsis
• Follow local antibiogram guidelines
• Always document indication

TARGETED THERAPY

• Culture + sensitivity results available
• Narrow to most specific agent
• De-escalate from broad-spectrum
• Confirm susceptibility pattern
• ID consultation for complex cases

ID CONSULTATION TRIGGERS

• Bacteraemia / fungaemia

• MRSA / ESBL / carbapenem-resistant

• Endocarditis / osteomyelitis

• CNS infections

• Immunocompromised host

• Failure to respond at 72h

• Tropical / travel infections

• HIV with OI

Pharmacy Collaboration & Guidelines

PHARMACIST ROLE IN STEWARDSHIP

Therapeutic drug monitoring (vancomycin, aminoglycosides — trough levels)
Renal dose adjustment review — creatinine clearance calculation
Drug interaction screening — especially antifungals (azole/CYP450)
IV-to-oral switch counselling and assessment
Allergy reconciliation — penicillin allergy assessment/de-labelling

Guideline Adherence: Follow institution-specific antibiograms. National guidelines (Saudi MOH, UAE DOH) for empirical therapy. WHO AWaRe classification — Access/Watch/Reserve antibiotics. Document deviation reasons in notes.

CEREBRAL MALARIA

Altered consciousness, seizures, coma. GCS <11. Urgent IV artesunate. Protect airway — consider intubation. Seizure precautions.

SEVERE ANAEMIA

Hb <7 g/dL. Haemolysis — dark urine (haemoglobinuria). Transfusion threshold Hb <7. Monitor fluid balance closely.

JAUNDICE & AKI

Bilirubin >50 μmol/L. Creatinine >265 μmol/L. Hepatic failure possible. Hourly urine output monitoring. Avoid nephrotoxins.

TREATMENT: ACT (Artemisinin-Based Combination Therapy)

Severe malaria: IV artesunate (preferred over IV quinine). Transition to oral ACT when tolerating PO.

Uncomplicated P. falciparum: Artemether-lumefantrine (Coartem) OR artesunate-amodiaquine.

Monitoring: Check parasitaemia at 0h, 12h, 24h, 48h, 72h via thick film.

NURSING MONITORING PRIORITIES

🩸 Hypoglycaemia — BGL hourly (quinine stimulates insulin); glucose infusion if <3.5 mmol/L
💧 Fluid balance — avoid over-hydration (pulmonary oedema risk); strict I&O
🌡️ Temp cycles — chart fever pattern; paracetamol (not NSAIDs)
🔬 Diagnostics — Thick & thin blood film; RDT (rapid diagnostic test); repeat if initial negative

Dengue Fever

WARNING SIGNS (Hospitalise Immediately)

⚠ Abdominal pain / tenderness

⚠ Persistent vomiting

⚠ Clinical fluid accumulation

⚠ Mucosal bleeding

⚠ Lethargy / restlessness

⚠ Rapid BP drop

⚠ Liver >2cm enlarged

⚠ Rising haematocrit + falling platelets

DENGUE SHOCK SYNDROME

Rapid fluid resuscitation: Crystalloid (Hartmann's/Normal Saline) 5-10 mL/kg/hr. Titrate to haematocrit. Avoid excessive fluids. Monitor pulse pressure — narrowing indicates impending shock. Colloids for refractory shock.

DIAGNOSTICS & KEY NURSING POINTS

• NS1 antigen: Day 1-5 (early viraemia)
• IgM antibody: Day 5+ (secondary response)
• Platelet count 8-hourly during critical phase
• STRICTLY NO aspirin or NSAIDs — haemorrhage risk
• Paracetamol only for fever management
• Tourniquet test: >20 petechiae/inch² = positive

Typhoid Fever

CLASSIC CLINICAL FEATURES

Rose Spots

Faint salmon-pink maculopapular rash on trunk. Days 7-12. Blanching. 30% of patients.

Relative Bradycardia

Heart rate lower than expected for temperature (Faget's sign). Pulse-temp dissociation.

Step-ladder Fever

Progressive rise each day. Peaks at week 1-2. Persistent if untreated.

Complications

Intestinal perforation (week 3), haemorrhage, hepatosplenomegaly.

TREATMENT

First-line: Ciprofloxacin 500mg BD × 10-14 days (check fluoroquinolone sensitivity — South Asian strains often resistant)
Alternative: Azithromycin 1g stat then 500mg OD × 6 days
MDR Typhoid: Ceftriaxone IV or azithromycin

Enteric Precautions: Contact precautions. Strict handwashing. Private toilet or bedpan. Food handlers excluded from work until 3 negative stool cultures.

ISOLATION TYPE

Airborne + Contact precautions. Negative pressure room (AIIR). Keep door closed.

PPE REQUIRED

N95/FFP3 respirator + gown + gloves + eye protection (goggles/face shield).

TRANSMISSION

Dromedary camels to humans. Human-to-human (close contact). Healthcare-associated transmission documented.

TREATMENT

No specific antiviral approved. Supportive care. Oxygen therapy. ECMO in severe cases. Notify public health immediately.

GCC Context: MERS-CoV is endemic in Saudi Arabia and UAE. Exposure risk at camel farms, souqs, and veterinary settings. Hajj/Umrah gatherings increase transmission risk. Case fatality rate ~35%. Immediate notification to MOH required. All HCW contacts must be traced and monitored 14 days.

Brucellosis

EXPOSURE HISTORY (Key in GCC)

• Raw/unpasteurised camel or goat milk consumption
• Direct livestock/animal contact (slaughterhouses, farms)
• Laboratory exposure to Brucella cultures
• GCC context: rural camel herders, Bedouin communities

CLINICAL FEATURES

• Malta fever / undulant fever (waves of pyrexia)
• Profuse night sweats, arthralgia, hepatosplenomegaly
• Complications: spondylitis, endocarditis, neurobrucellosis
• Diagnosis: serology (Rose Bengal, SAT) + blood culture

Treatment: Doxycycline 100mg BD + Rifampicin 600-900mg OD × 6 weeks minimum. Combination mandatory to prevent relapse. Monitor LFTs (rifampicin hepatotoxicity). Not transmitted person-to-person — standard precautions only.

Crimean-Congo Haemorrhagic Fever (CCHF)

HIGH-RISK TRANSMISSION ROUTES

• Hyalomma tick bite (livestock areas — Saudi Arabia, Oman)
• Direct blood/tissue contact (slaughterhouse workers, butchers)
• Nosocomial transmission: needlestick, blood/body fluids without PPE
• No airborne transmission documented

Nosocomial Risk: CCHF has caused major healthcare outbreaks. Strict contact + droplet precautions. Dedicated nursing team. PPE for all patient contact. Sharps discipline essential.

Treatment: Ribavirin (IV/oral) — antiviral. Supportive care: FFP, platelet transfusions for haemorrhage. Strict isolation. Notify MOH immediately.

Leishmaniasis

TRANSMISSION

Female Phlebotomus sandfly bite. Protozoan parasite — amastigote form in macrophages. Zoonotic reservoir: dogs, rodents. GCC: endemic in Yemen, parts of Oman/Saudi Arabia.

VISCERAL (KALA-AZAR)

Fever, massive splenomegaly, hepatomegaly, weight loss, pancytopenia, hypergammaglobulinaemia. Fatal if untreated. Diagnosis: bone marrow/splenic aspirate, serology (rK39 test).

TREATMENT

Visceral: Liposomal amphotericin B (first-line, lower toxicity). Monitor renal function, electrolytes.
Cutaneous: Sodium stibogluconate IM/IV or miltefosine oral.

CD4 <500

HIV+

• Recurrent bacterial pneumonia
• Tuberculosis (any count)
• Herpes zoster
• Oral candidiasis

CD4 <200

AIDS-defining

• PCP (Pneumocystis pneumonia)
• Cryptococcal meningitis
• Chronic cryptosporidiosis
• Prophylaxis: Co-trimoxazole

CD4 <100

Severe

• MAC (M. avium complex)
• CMV retinitis / colitis
• Cerebral toxoplasmosis
• Prophylaxis: Azithromycin (MAC)

CD4 <50

Critical

• Disseminated MAC
• CMV encephalitis
• Progressive multifocal leukoencephalopathy (PML)
• Disseminated fungal infection

HIV Transmission, Diagnosis & Staging

PrEP & PEP PROTOCOLS

PrEP (Pre-Exposure)

Tenofovir/emtricitabine (TDF/FTC) daily. For HIV-negative high-risk individuals. Renal monitoring. High adherence essential.

PEP (Post-Exposure)

Start within 72 hours (ideally <2 hours). TDF/FTC + raltegravir × 28 days. Baseline HIV test. Follow-up at 6 weeks, 3 months.

DIAGNOSIS

• 4th Gen Ag/Ab test: detects p24 antigen + antibodies (window 14-21 days)
• Viral Load (RNA PCR): quantifies virus; goal <50 copies/mL on ART
• CD4 Count: immune staging; baseline + every 3-6 months on ART
• Confirmatory Western Blot / second Ag/Ab test required

WHO CLINICAL STAGING

Asymptomatic

Mild symptoms

III

Advanced disease

AIDS-defining illness

ART & Drug Classes

U = U: Undetectable = Untransmittable. Viral load <200 copies/mL = no sexual transmission risk. Major adherence motivation tool.

NRTI (Backbone)

TDF, FTC, 3TC, ABC. Side effects: nephrotoxicity (TDF), lactic acidosis, lipoatrophy.

NNRTI

Efavirenz, nevirapine, rilpivirine. Side effects: CNS (EFV), hepatotoxicity (NVP), rash.

PI (Protease Inhibitors)

Lopinavir/r, atazanavir/r. Metabolic: dyslipidaemia, GI upset, drug interactions (CYP3A4).

INSTI (Preferred)

Dolutegravir, raltegravir, bictegravir. Well-tolerated. High barrier to resistance. Weight gain noted.

IRIS — Immune Reconstitution Inflammatory Syndrome: Paradoxical worsening after ART initiation as immune system recovers. Occurs in 10-25%. Management: continue ART, steroids for severe cases.

ADHERENCE COUNSELLING POINTS

• Take every dose — even one missed dose can cause resistance
• Pill-taking routine: tie to daily activity (brushing teeth, meals)
• Disclose to trusted family member if possible
• Address stigma concerns — confidentiality is legally protected
• Community/peer support groups in GCC available anonymously

DONNING (PUTTING ON)

1Hand hygiene (soap and water or ABHR)

2Gown (fluid-resistant, tie at back)

3N95/FFP3 respirator (fit check — seal test)

4Eye protection (goggles or face shield)

5Gloves (over cuffs of gown)

DOFFING (REMOVING) — Highest Risk Step

1Gloves (roll off — don't snap — hand hygiene)

2Gown (untie, roll inward, do not touch outside)

3Hand hygiene

4Eye protection (handle by straps/band only)

5Respirator (handle by straps, do NOT touch front) → hand hygiene

Key Rule: Never touch the front of the mask or outside of the gown. Doffing should be supervised by a trained observer. All PPE is single-use unless otherwise specified. Perform hand hygiene at every step.

Ebola & Marburg (VHF)

CATEGORY A BIOTERRORISM AGENT HCID DESIGNATION

Transmission: Direct contact with blood/bodily fluids of symptomatic patients. No airborne transmission. Infectious after death — safe burial practices essential.

NURSING PRECAUTIONS

• Full-body PPE: coverall/gown + N95 + face shield + double gloves + boot covers
• Dedicated nursing teams — minimise number entering room
• STRICT no-touch principle for patient's body fluids
• No aerosol-generating procedures without additional precautions
• Contact tracing of all HCW exposures

Psychological Impact: Nursing HCID patients causes significant moral distress, fear, and burnout. Debriefing, peer support, occupational health referral, and psychological first aid are essential for HCW wellbeing.

Rabies, Tetanus & Anthrax/Plague

RABIES — POST-EXPOSURE PROPHYLAXIS (PEP)

Step 1 — Wound care: Immediate wash 15+ minutes with soap and water. Flush with virucidal agent (povidone-iodine).
Step 2 — RIG: Human rabies immunoglobulin (HRIG) infiltrated at wound site on Day 0.
Step 3 — Vaccine: Rabies vaccine Days 0, 3, 7, 14 (IM deltoid). Pre-exposure vaccination for vets/lab workers.

TETANUS — WOUND CLASSIFICATION & PROPHYLAXIS

Clean

Minor wound, not contaminated. Td if no vaccine in 10 years.

Tetanus-Prone

>6h old, deep, contaminated. Td + HTIG if incomplete/unknown vacc.

High-Risk

Crush/ischaemic tissue. Td + HTIG always. Surgical debridement.

HTIG = Human Tetanus Immunoglobulin | Td = Tetanus + Diphtheria toxoid

Anthrax & Plague (Awareness): Category A bioterrorism agents. Anthrax: cutaneous/inhalational/GI; ciprofloxacin PEP. Plague: Y. pestis; bubonic/pneumonic/septicaemic; droplet + contact precautions (pneumonic); streptomycin/gentamicin. Report immediately to public health.

GCC-Specific Infectious Disease Context

MERS-CoV (Saudi Arabia / UAE): Endemic in Arabian Peninsula. Linked to dromedary camel contact. Hajj and Umrah pilgrimages intensify surveillance. Highest case burden in Saudi Arabia. Healthcare outbreak risk in hospitals — strict IPC protocols mandatory.

Imported Malaria: South Asian and African expatriate workers returning from home visits. P. falciparum most dangerous. Nurses must take thorough travel history. Blood film is gold standard — request thick + thin film.

Brucellosis: Rural GCC — raw camel and goat dairy products. Common in Bedouin communities. Significant underreporting. Nurses should educate patients about pasteurised dairy and livestock hygiene.

Dengue: Primarily imported from Yemen, Horn of Africa, South/Southeast Asia. Local Aedes aegypti mosquitoes present in some GCC areas — climate change expanding range. Vector control programmes in Saudi Arabia and UAE.

CCHF: Saudi Arabia and Oman during Eid al-Adha slaughter season — handling livestock without PPE. Hyalomma tick exposure. Nosocomial clusters documented in Saudi hospitals.

HIV in the GCC — Ethical Awareness

STIGMA AND ANONYMITY

HIV carries significant social stigma in GCC countries due to cultural, religious, and legal factors. Many patients present late due to fear of disclosure. Nurses must approach HIV testing and care with strict confidentiality, empathy, and non-judgement.

Anonymous and confidential testing is available in several GCC states. Encourage testing in all at-risk individuals regardless of perceived social barriers.

EXPATRIATE POLICIES (ETHICAL AWARENESS)

Some GCC states have historically required HIV testing for work visa/residency. HIV-positive expatriates may face deportation in certain jurisdictions. Nurses must be aware of these policies to counsel patients ethically, ensure access to care before repatriation, and advocate for patient rights. Maintain professional boundaries — never participate in discriminatory practices.

DHA/DOH Infection Control Competencies: All nurses licensed in Dubai (DHA), Abu Dhabi (DOH/HAAD), and Saudi Arabia (SCFHS/MOH) are assessed on infection prevention and control including standard precautions, transmission-based precautions, hand hygiene, PPE, and outbreak management.

DHA / DOH / SCFHS Exam Quick Reference

MERS-CoV PRECAUTIONS (High-Yield)

• Airborne + Contact precautions
• N95 (not surgical mask) + gown + gloves + eye protection
• Negative pressure / AIIR room
• Notify MOH immediately — notifiable disease
• 14-day monitoring of exposed contacts

MALARIA MANAGEMENT (High-Yield)

• Diagnosis: thick and thin blood film (gold standard)
• Severe malaria = IV artesunate (not quinine first)
• Monitor BGL hourly (hypoglycaemia — especially with quinine)
• Uncomplicated P. falciparum = ACT (artemether-lumefantrine)
• No specific isolation required (not person-to-person)

PEP PROTOCOL (High-Yield)

• Start PEP within 72 hours of exposure (ideally <2h)
• Duration: 28 days of ARV therapy
• Baseline HIV test before starting PEP
• Follow-up HIV testing: 6 weeks, 3 months post-exposure
• Report exposure via occupational health immediately

PPE DONNING SEQUENCE (High-Yield)

• Order: Hand hygiene → Gown → N95 → Eye protection → Gloves
• Doffing (reverse): Gloves → Gown → HH → Eye → N95 → HH
• Perform hand hygiene at EVERY step during doffing
• N95 fit test required annually for HCWs
• Doffing is highest risk — trained observer recommended

Interactive Tool: Isolation Precautions Selector

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