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September 2015
IDSA Journal Club
In this feature, a panel of IDSA members identifies and critiques important new studies in the current literature that have a significant impact on the practice of infectious diseases medicine.
Click here for the previous edition of Journal Club. For a review of other recent research in the infectious diseases literature, see “In the Literature,” by Stanley Deresinski, MD, FIDSA, in each issue of Clinical Infectious Diseases.

Antibiotic Treatment of CAP in Children: Do We Adhere to National Guidelines?
Reviewed by Terri Stillwell, MD

In 2011, IDSA, in conjunction with the Pediatric Infectious Diseases Society, published a clinical practice guideline for the management of community-acquired pneumonia (CAP) in children older than 3 months of age. For healthy, fully immunized children with uncomplicated CAP, the guideline recommends ampicillin, or penicillin G, as first-line treatment, perhaps a more narrow-spectrum antimicrobial than was the practice at the time. A recent Pediatrics article looked at the impact this guidance has had on prescribing practices at three major U.S. children’s hospitals. 

Analyzing prescribing data from 20 months prior to and nine months after guideline publication, the authors assessed the monthly percentage of CAP treated with a third-generation cephalosporin versus the percentage treated with ampicillin/penicillin. The study included 2,121 children: 1,303 in the pre-guideline cohort, and 772 in the post-guideline cohort. Third-generation cephalosporin use was consistent throughout the pre-guideline period, with a monthly median of 52.8 percent of children with CAP receiving this type of antibiotic; ampicillin/penicillin use was steady at a monthly median of 2.7 percent. After the guideline was published, third-generation cephalosporin use decreased 12.4 percent, with ampicillin/penicillin use increasing 11.3 percent.

Two hospitals involved in the study proactively disseminated information regarding guideline recommendations; in those institutions, a statistically significant decline in third-generation cephalosporin use was seen, with absolute declines of 27.6 percent and 17.3 percent, respectively. The remaining hospital saw a decline in use, but it was not statistically significant. Despite these decreases, at the end of the study, third-generation cephalosporins continued to be prescribed for 44.8 percent of children with CAP.

National guidelines can help lessen variations and reinforce best practices. However, these findings suggest acceptance of these recommendations into day-to-day practice may be slow and could benefit from proactive dissemination of the guidelines at the local, hospital level.

(Williams et al. Pediatrics. 2015;136(1):44-52.)

Does C. difficile Colonization Increase the Risk for C. difficile Disease?
Reviewed by Jennifer Brown, MD

Clostridium difficile is a significant cause of health care-associated infections. The impact of asymptomatic C. difficile colonization on the risk for C. difficile disease development is not well understood.

In the July issue of Infection Control and Hospital Epidemiology, investigators described the results of a single-center, prospective study that assessed the development of C. difficile disease in adult patients with, and without, asymptomatic C. difficile colonization. Rectal swab specimens were obtained from patients upon admission to the intensive care unit (ICU), and weekly thereafter, until ICU discharge. Polymerase chain reaction (PCR), followed by toxigenic bacterial culture for all PCR-positive specimens, was performed on the rectal screening specimens as well as on stool specimens submitted for clinical care. Patients were monitored for the development of C. difficile disease during their hospital stay and for up to one month after hospital discharge.

At admission, there were 17 (3.1 percent) patients with asymptomatic toxigenic C. difficile colonization and 525 (96.9 percent) without colonization. Three additional patients were found to be colonized during hospitalization via weekly surveillance swabbing. C. difficile disease developed in eight (1.5 percent) patients during hospitalization and four (0.7 percent) patients within one month of discharge. After multivariable analysis, colonization with C. difficile on admission was an independent risk factor for development of C. difficile disease (relative risk, 8.62 [95 percent CI, 1.48-50.25], P = .017). Colonization during hospitalization was also an independent risk factor (relative risk, 10.93 [95 percent CI, 1.49-80.20], P = 0.19).

One limitation of the study is the low prevalence of patients colonized with toxigenic C. difficile on hospital admission. Also, the diagnosis of symptomatic C. difficile disease was determined by retrospective clinical chart review, thus actual rates may have been skewed. Nonetheless, the results of this paper are intriguing and may have implications for infection prevention and antimicrobial stewardship measures. 

(Tschudin-Sutter et al. Infect Control Hosp Epidemiol. 30 July 2015. [Epub ahead of print])

Addressing Gonorrhea: Screening for Asymptomatic Pharyngeal Infection Among MSM and Expedited Partner Therapy
Reviewed by Michael T. Melia, MD

Two recent articles highlight underutilized practices in the prevention and treatment of gonorrhea: screening for asymptomatic pharyngeal gonococcal infection and expedited partner therapy (EPT).

In a Sexually Transmitted Infections article, the authors conducted a case-control study of men who have sex with men (MSM) who sought care at a sexually transmitted disease (STD) clinic between 2001 and 2013. Approximately 5,300 cases of symptomatic urethritis were diagnosed based upon the presence of urethral discharge, dysuria, or other urethral discomfort plus ≥5 WBC/HPF on urethral discharge Gram stain. Patients were diagnosed with non-gonococcal, non-chlamydial urethritis (NGNCU) if they had a diagnosis of urethritis but negative testing for gonorrhea and chlamydia.

MSM were grouped into four categories based upon self-reported behavior during the previous 60 days: (1) insertive oral sex only; (2) always-protected insertive anal sex plus oral sex; (3) unprotected or inconsistently protected insertive anal sex with or without oral sex; (4) no sex. The risk of acquiring symptomatic urethritis through oral sex was estimated by behavioral categorization and by calculating the population-attributable risk percent.

Based upon self-reported sexual behaviors, 27.5 percent of symptomatic gonococcal urethritis was acquired through oral sex, as was 31.4 percent of symptomatic chlamydial urethritis and 35.9 percent of symptomatic NGNCU. Similar estimates were obtained by calculating the population-attributable risk percent for symptomatic gonococcal (33.8 percent) and NGNCU (27.1 percent), although the calculated estimate for symptomatic chlamydial urethritis was only 2.7 percent. These data suggest that over one-third of symptomatic gonococcal and NGNCU may be attributable to oral sex, highlighting the importance of pharyngeal screening for gonorrhea among MSM, as well as the potential role of the oropharynx in causing a substantial proportion of NGNCU.

The partners of patients diagnosed with gonorrhea are permitted to receive EPT in a majority of states.  EPT has been associated with increased rates of partner treatment and reduced rates of recurrent gonorrhea for patients, and it is recommended by the Centers for Disease Control and Prevention for sex partners of heterosexuals with uncomplicated gonorrhea when there is concern that partners may not promptly seek medical attention. The frequency with which EPT is utilized, however, is not known.

A recent article in Sexually Transmitted Diseases reviewed data from seven U.S. jurisdictions participating in the STD Surveillance Network. A random sample of 23,363 gonorrhea cases reported between 2010 and 2012 was reviewed. Overall, only 5.4 percent of patients eligible for EPT—those who reported ≥1 sex partners during the 60-90 days prior to their gonorrhea diagnosis—reported receiving EPT to treat their sex partners, including 6.6 percent of heterosexual patients and 2.6 percent of MSM.

While EPT for MSM with gonorrhea is not currently recommended owing to a high risk of coinfection, including undiagnosed HIV, among patients’ sex partners, these data highlight how infrequently it is implemented across diverse populations. When considered with data suggesting individual and population-level benefits of EPT, this study suggests that additional efforts to increase EPT would be associated with significant benefit and reduced morbidity.

(Barbee et al. Sex Transm Infect. 2015 Aug 21. [Epub ahead of print] and Stenger et al. Sex Transm Dis. 2015;42(9):470-4.)

Universal Glove and Gown Use Within the ICU: An Annoyance or a Benefit?
Reviewed by George R. Thompson III, MD

Contact precautions (glove and gown use prior to entry to a patient’s room) are recommended by the Centers for Disease Control and Prevention for patients colonized or infected with antibiotic-resistant bacteria in an attempt to reduce transmission within the hospital setting. However, in prior studies, contact precautions have been shown to increase the frequency of adverse events, and health care workers visit patients on contact precautions less frequently than patients not on contact precautions.   

Universal glove and gown use (contact precautions for all patients) was examined in a recent cluster randomized trial to better assess the role confounding factors may have played in past studies. This study, described in an article published in Clinical Infectious Diseases, compared 900 patients in the intensive care unit (ICU) under universal gown and glove use to 900 patients in a control ICU (patients received contact precautions only if they were known to be colonized or infected with an antibiotic-resistant organism).

Overall, adverse events were not associated with universal glove and gown use. In fact, an increased number of infectious (P<0.001), cardiovascular (P=0.02), and surgical adverse events (P=0.001) occurred in the control group. The reasons for the latter two complications are not clear from the results but bear further study in future trials.

These results are of great interest in the fight against hospital-acquired infections and will likely soon be adopted within the ICU setting. Adoption of universal glove and gowns to all hospitalized patients initially seems similarly prudent and offers the advantage of avoiding delays with hospital admissions while awaiting a “contact isolation” room. However, these results will need to be validated in the non-ICU setting and potentially for a longer period of time to avoid a Hawthorne effect and to ensure provider “fatigue” does not set in during adoption of potentially new standard practices.

(Croft et al. Clin Infect Dis. 2015;61(4):545-553.)

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

September 15
  • Eosinophilia as a Predictor of Hypersensitivity Reactions in Outpatients Receiving Parenteral Antibiotics
  • Failure of Ethanol Lock to Prevent Infection of Temporary Hemodialysis Catheters
  • Case Vignette: A Lethal Common Cold Viral Infection
  • Case Vignette: Fever in a Visitor From India (With a Side Trip to Massachusetts)
September 1
  • Colorado Tick Fever
  • Trimethoprim-Sulfamethoxazole Versus Vancomycin for MRSA Infections

August 15

  • Treatment of Pyogenic Vertebral Osteomyelitis—6 Weeks is Enough
  • Herpes Zoster Vaccination and Corticosteroid Use

August 1

  • Cryptococcal Infection in Patients With Hepatic Cirrhosis, Including Transplantation Candidates
  • A Genetic Defect Accounting for Susceptibility to Lethal Influenza Virus Infection
  • Case Vignette: Arcobacter Bacteremia in a Patient With Diarrhea and Chronic Lymphocytic Leukemia

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