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April 1, 2008
ID Literature Review: March 2008

In this new feature, a panel of IDSA members identifies and critiques important new infectious diseases studies in the current literature that have a significant impact on the practice of infectious diseases medicine.

For more from Clinical Infectious Diseases and The Journal of Infectious Diseases, see the "In the IDSA Journals" section of IDSA News.

 Two Studies on Screening Patients for MRSA Reach Conflicting Conclusions

Sara E. Cosgrove, MD, MS

In the March 12 issue of the Journal of the American Medical Association, Harbarth et al. found no differences in the rates of nosocomial MRSA infection or MRSA surgical site infection when surgical patients in one institution were screened for MRSA carriage on admission. In contrast, in a study in the March 18 issue of Annals of Internal Medicine, Robicsek et al. showed a reduction in hospital-associated MRSA infections when all admitted patients at three hospitals were screened for MRSA.

It is important to note that both studies had an intervention component that went beyond obtaining cultures and placing MRSA carriers in contact isolation; rather, both had arms in which rapid testing for MRSA with direct feedback to providers about results occurred, both had good compliance with contact isolation and both employed decolonization strategies with mupirocin and chlorhexidine baths for MRSA carriers. Thus, in the positive Robicsek study, understanding the independent benefit of obtaining MRSA surveillance cultures relative to other interventions is challenging. On the other hand, the negative result in the Harbarth study may be partially attributed to the fact that almost one third of patients did not have MRSA surveillance culture data available before surgery to allow for adjustments in antimicrobial prophylaxis.

Although both groups used advanced analytic techniques to minimize potential confounding factors, neither study is a cluster-randomized trial where different units or institutions are randomized to receive a particular intervention, which would be the most robust study design to avoid confounding. Harbarth et al. used a crossover design with concomitant control units in each intervention period which strengthens the results. There was no control group in the Robicsek study..

In summary, these studies provide differing results with regard to the effect that screening patients for MRSA carriage has on prevention of subsequent MRSA infection in hospitals, demonstrating that successful approaches to MRSA prevention differ among patient populations and institutions. (Harbarth et al., JAMA. 2008;299:1149-1157. Robicsek et al., Ann Intern Med. 2008;148:409-18.)

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 Airborne Varicella-Zoster Virus from Patients With Shingles?

Jason B. Weinberg, MD

Two reports in the March 1 issue of The Journal of Infectious Diseases highlight the potential for herpes zoster (HZ) to serve as a source for varicella outbreaks via airborne transmission.

In the first, Lopez et al. describe an outbreak of varicella in a long-term care facility in which the index case patient was an individual with HZ, suggesting possible airborne transmission from isolated cutaneous disease. Despite seemingly appropriate precautions (lesions were covered for the duration of the rash), high concentrations of varicella zoster virus (VZV) DNA were detected in environmental samples, and three other individuals in the facility became infected. Identical VZV strains were detected in all environmental isolates and in isolates from case patients.

In a second article in the same issue, Mehta et al. demonstrated the presence of VZV DNA in the saliva of all 54 patients with acute herpes zoster tested. Together, these two studies indicate that contrary to current opinion, aerosolized VZV may be transmitted from patients with herpes zoster.

In an accompanying editorial, Bauer notes that the potential for airborne transmission raises questions about the overall effectiveness of current isolation guidelines for HZ patients. These guidelines are primarily focused on covering cutaneous lesions but do not recommend respiratory isolation of all HZ patients, and probably need modification. (Lopez et al., J Infect Dis. 2008; 197:646-53. Mehta et al., J Infect Dis. 2008;197:654-657. Breuer, J Infect Dis. 2008;197:635-637.)

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 Circumcision Lowers Rates of HPV in Men

Melinda M. Pettigrew, PhD

Human papillomavirus (HPV) was detected in the glans penis or corona sulcus in 46 percent of uncircumcised men and 29 percent of circumcised men in this study in the March 15 issue of The Journal of Infectious Diseases. Uncircumcised men also were 2.5 times more likely to have high-risk HPV types and 3.5 times more likely to have more than one HPV type. This study is noteworthy because the authors sampled multiple genital sites and controlled for potential confounders. These data add significantly to our knowledge of HPV in men. The study suggests male circumcision may prevent genital warts and penile cancer in men and may reduce HPV transmission and related cancers in the sex partners of HPV infected men. Male circumcision may provide an important tool for HPV prevention in addition to condoms and vaccines. Prospective studies are needed to clarify the role of circumcision in HPV incidence, transmission, and cancer. (Hernandez et al., J Infect Dis. 2008;197:787-94.)

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 PIs Associated with Elevated Fibrinogen Levels

Sabrina R. Kendrick, MD

Use of protease inhibitors (PI) was associated with higher fibrinogen levels, while use of non-nucleoside reverse transcriptase inhibitors (NNRTI) were associated with lower fibrinogen levels in a study in the March 30 issue of AIDS. Elevated fibrinogen levels may contribute to the elevated risk of coronary artery disease in HIV-infected patients.

The analysis sought to identify factors associated with elevated fibrinogen levels in HIV infected patients compared to controls. Subjects were drawn from a study to evaluate the correlates of changes in fat distribution and other atherosclerosis markers.

After adjusting for adipose tissue volume, which is associated with fibrinogen levels, the authors found patients on PI drugs had 11 percent higher fibrinogen levels compared with those not on PIs. Elevation was seen with all PIs studied and suggested a class effect, which may contribute to atherosclerosis risk.

PIs and C-reactive protein were independently associated with elevated fibrinogen levels, suggesting that PIs may directly alter fibrinogen levels independent of acute inflammation as a mechanism.

The results should be interpreted with some caution, however, because the study’s cross-sectional design was unable to prove causality between antiretroviral therapy, alteration in fibrinogen levels, and subsequent cardiovascular events. Also, the present study did not assess effects of more recently introduced PI drugs. (Madden et al., AIDS. 2008; 22:707-715.)

Negligible Public Health Risk from Cardiovascular Complications of HAART

In contrast, all three classes of antiretroviral therapy provided a survival benefit and no significant increase in the rate of cardiovascular events in a large, 11-year retrospective cohort of HIV-infected patients at US Veterans Affairs facilities, published in the March issue of the Journal of Acquired Immune Deficiency Syndromes. (Bozzette et al., JAIDS. 2008;47:338-341.)

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