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May 1, 2008
In the IDSA Journals

New Studies on When to Start ART Suggest Earlier is Better 

Two new studies in the April 15 issue of The Journal of Infectious Diseases provide new insights on the risk-benefit calculation of when to start antiretroviral therapy (ART). In one study, patients who initiated or restarted ART below 250 CD4+ cells/mL were more than four times as likely to die or experience opportunistic diseases or serious non-AIDS events than those who started at or above 350 cells/mL. (The Strategies for Management of Antiretroviral Therapy (SMART) Study Group, J Infect Dis. 2008;197:1133-1144; editorial commentary by Hughes and Ribaudo, J Infect Dis. 2008;197:1084-1086.)

An accompanying study by the same group showed that the risks of opportunistic disease and death were higher the longer virus replication went unchecked, even among those with higher CD4+ cell counts. (SMART Study Group, J Infect Dis 2008;197:1145–1155.) The authors said their new results should be verified in a larger randomized trial on when to start therapy.

Varicella Vaccination May Require Second Dose 

Outbreaks of chickenpox among vaccinated children may be the result of lower-than-expected vaccine effectiveness. Of 148 healthy children receiving one dose of varicella vaccine at a median age of 12.5 months, one in four had no detectable antibodies an average of four months later. This is significantly lower than the 86 percent to 96 percent seroconversion rate reported in other studies. These results support the recent recommendation by the Centers for Disease Control that a second dose of varicella vaccine be routinely given to all children.. (Michalik et al., J Infect Dis. 2008;197:944-949; editorial commentary by Shapiro, J Infect Dis. 2008;197:935-937.)

Pneumococcal vaccine in the elderly population

The authors of this study compared the immunogenicity and safety of 7-valent conjugate vaccine (7vPnC) with that of the polysaccharide vaccine (PPV) in elderly adults who had not been previously vaccinated. One year after the initial vaccination, 7vPnC recipients received a booster dose of either PPV or 7vPnC, whereas PPV recipients received a booster dose of 7vPnC. An initial dose of 7vPnC was found to elicit higher and potentially more effective levels of antibodies, compared with an initial dose of PPV, and antibody titers were maintained through subsequent administration of either 7vPnC or PPV. (de Roux et al., Clin Infect Dis. 2008;46:1015-1023.) 

Clarithromycin for the therapy of ventilator-associated pneumonia (VAP) and sepsis  

Patients with sepsis and VAP were given clarithromycin (1 g) or placebo daily for 3 days, and their outcomes were compared in a randomized trial. The median time required for resolution of VAP was 10 days for clarithromycin-treated patients and 15.5 days for placebo-treated patients, whereas the median time required for weaning from mechanical ventilation was 16 and 22.5 days, respectively. Among the patients who died due to sepsis, time to death was significantly prolonged in clarithromycin-treated subjects. These results suggest a benefit associated with the adjunctive use of clarithromycin for patients with VAP and sepsis. (Giamarellos-Bourboulis et al., Clin Infect Dis. 2008;46:1157-1164.)

Outcome of prosthetic joint infection

The extent of adherence to recently recommended treatment modalities for prosthetic joint infection was analyzed in a group of 68 patients at a Swiss hospital. The chosen surgical strategy was in agreement with the recommendations in 88% of the cases, and the antimicrobial regimen was in agreement with the recommendations in 84%. The risk of treatment failure was significantly higher for patients in whom the surgical strategy or antibiotic treatment did not correspond with the recommendations. (Betsch et al., Clin Infect Dis. 2008;46:1221-1226.)

More from the literature…

Don’t miss a new feature to help you stay up to date on the infectious diseases literature: Each month, IDSA News will feature brief summaries of key infectious diseases studies in the previous month’s major journals chosen by the new IDSA Literature Review Panel. [[LINK]]

In addition, the “In This Issue” section of each issue of Clinical Infectious Diseases highlights several important studies from that journal. (Click for May 1 or May 15.)

For a review of other recent research in the infectious diseases literature, see “In the Literature,” by Stanley Deresinski, MD, in each issue of Clinical Infectious Diseases.

May 1

  • Syphilis: Old and New World
  • The Risk of Stroke Decreases Rapidly after the Initiation of Effective Antibiotic Therapy for Endocarditis
  • High-Dose Isoniazid (INH) for Multidrug-Resistant Tuberculosis (MDR-TB)
  • The Genetic Basis of Job's Syndrome  

May 15

  • Is It Time for Vancomycin in Surgical Prophylaxis?
  • Do Serum Concentrations of Antituberculous Drugs Matter?
  • Tuberculosis in the United States: Down, but Definitely Not Out

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