IDSA News - October 1, 2007
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Thinking Outside the Box

Alternative Sources of Income

Infectious disease physicians can boost their income without working longer hours or increasing the number of patients they see. That was the message from Patrick Joseph, MD, FIDSA, at a session during IDSA 2007 titled “Thinking Outside the Box: Alternative Sources of Income.”

While infectious diseases physicians have seen a substantial boost in their Medicare payments this year, the outlook for future years is much less certain. As it becomes more difficult to make ends meet by seeing patients, Dr. Joseph emphasized that activities besides patient care can boost income for infectious diseases physicians..  Most other sources of income are reimbursed at a greater rate than patient care, but negotiation is a key skill.  

In a survey of 88 California infectious diseases physicians conducted by Dr. Joseph, lecturing, infection control, and antibiotic utilization programs were listed as the top means of supplemental employment.  Lab work or directorships, pharmacy administration, and private industry consultation ranked the lowest.  He emphasized continuously searching for opportunities as a means to ensure continued success, adding that for each problem in a hospital there is an opportunity for employment. 

Revisions to the rules governing physicians’ referrals to institutions where they are already working, commonly referred to as Stark II, allow more freedom for ID physicians to negotiate compensation for infection control activities. Compensation arrangements can still be scrutinized by the Office of the Inspector General (OIG), Dr. Joseph cautioned, but there are ways to prove your worth, including keeping track of invoices and W-2s. 

ART, Circumcision, STI Treatment as HIV Prevention

There is growing evidence to confirm what many already suspected: antiretroviral therapy (ART) significantly decreases the likelihood of HIV transmission from HIV-positive individuals to their HIV-negative partners. That was one of the promising findings on HIV prevention that Tom Quinn, MD, FIDSA, of Johns Hopkins University presented in his John F. Enders Lecture at the 45th Annual Meeting of IDSA, in San Diego. Dr. Quinn also highlighted evidence on the benefits of circumcision, and of treating sexually transmitted infections (STI), particularly herpes.

Dr. Quinn, who is also affiliated with the National Institute of Allergy and Infectious Diseases,  reviewed data presented at last year’s International AIDS Society (IAS) conference from the Rwanda Zambia HIV Research Group that demonstrated ART’s protective effect on HIV-negative partners in serodiscordant relationships. The study enrolled 1,034 serodiscordant couples in which the HIV-infected partners had a CD4 count < 200cells/mL and/or had advanced or severe symptoms by the World Health Organization classification. In 248 of these couples, the HIV-positive individual was on ART. Of the 42 seroconversions during the study period, only two were individuals whose partners were on ART.

Dr. Quinn also recapped a study from IAS 2007 in which 557 pregnant women received a three-drug ART regimen and were given the option before delivery to breastfeed or formula-feed. Breastfeeding mothers continued ART during the six months of breastfeeding and one month after. Half formula-fed their babies and 43 percent breastfed. Overall, six children (1.4 percent) were infected at birth and only one child was infected from breastfeeding.

HSV-2 and HIV

Dr. Quinn also spoke of the relationship between STIs and HIV transmission and acquisition. In particular, there seems to be a positive association between herpes simplex virus 2 (HSV-2) infection and HIV acquisition. A study demonstrated that those with HSV-2 were 1.7 times more likely to acquire HIV infection than those without HSV-2. Dr. Quinn added that acyclovir and valcyclovir for the treatment of HSV-2 is being studied as an effective way to reduce HIV acquisition in several populations.

Circumcision

Studies from Uganda, Kenya, and South Africa show male circumcision reduces HIV acquisition by 60 to 70 percent. Based on these results, the World Health Organization and the United Nations Programme on HIV/AIDS issued a statement in March regarding the efficacy of male circumcision in reducing female-to-male HIV transmission. Scaling up male circumcision in many countries would have an immediate effect, Dr. Quinn suggested. “No other piece of the body has the same amount of susceptible target cells,” he added.

Dr. Quinn concluded by emphasizing the importance of coupling circumcision and other biomedical interventions with behavioral ones. “Let me emphasize that [circumcision] needs to be integrated with behavioral interventions,” he said. “Otherwise the protective effect of circumcision could be abrogated completely if men increase risky sex activities.”

Global Surveillance, Vaccine Use Key to Controlling Seasonal Influenza

Teaser here

Pandemic influenza has garnered much attention in recent years, but the global burden of seasonal influenza is also significant. That was the key message from Kathryn M. Edwards, MD, FIDSA, professor of pediatrics at Vanderbilt University Medical School and keynote speaker for the Joseph E. Smadel Lecture on “Seasonal Influenza: Is It a Global Problem and What Can We Do About It?” 

Controlling the problem will take improved influenza surveillance and broader use of influenza vaccine across nations.

Scientists know surprising little about the global burden of influenza, Dr. Edwards said, although data from Hong Kong suggests that the burden may be greater in tropical and subtropical areas of the world, where influenza viruses circulate throughout the year. In 1999, the Hong Kong Government Virology Laboratory tested nearly 20,000 samples: From January to March, 35 percent of isolates were positive for influenza; from June to September, 15 percent were positive.

Compounding the problem, Dr. Edwards said, is the fact that viral respiratory infections have been shown to play a role in pneumonia and invasive pneumococcal disease (IPD). In lndia and large parts of Africa, 20 to 25 percent of childhood deaths are from pneumonia. (Williams BG. Lancet Infect Dis 2002; 2:25-32)  It’s not clear what portion of those deaths may be attributable to influenza—but Dr. Edwards believes that scientists need to know. 

Influenza vaccine is underutilized throughout the world, and some experts predict that the supply of vaccine will soon exceed demand. A study of influenza vaccination rates in 56 countries showed a correlation between a country’s gross national product and influenza immunization rates. Only Canada (with about 350 doses distributed per 1000 population) and the Republic of Korea (about 300 per 1000) have immunization rates surpassing the United States (under 300 per 1000), and all other countries are trailing far behind. Of the countries studied, 27 distribute fewer than 100 does per 1000. (Fedson, et al. Vaccine 2005; 23:5133-5143

According to a recent analysis, over 400 million doses of influenza vaccine were produced in 2006-2007, but the total capacity was 826 million doses. As new technologies are improved upon, the total capacity is projected to grow to 2 billion doses by 2013, including live vaccine and cell-based and egg-based inactivated vaccine. Some of the excess supply will be diverted to pandemic preparedness initiatives, but Dr. Edwards asserted that the excess supply should also be considered for seasonal vaccination in developing countries, who cannot afford to immunize their populations. 

Not only are the supplies adequate, Dr. Edwards said, but current influenza vaccines are effective, and newer adjuvanted vaccines offer even greater promise. 


For More Information: 

See IDSA’s principles for pandemic and seasonal influenza at http://www.idsociety.org/Content.aspx?id=5716

Slides from this session and many others from IDSA 2007 are available online.  

Audio files of individual sessions or a full-conference CD-ROM are available for purchase from Sound Images.   

Bad Bugs on the Run

The Society scored a victory recently on its “Bad Bugs, No Drugs” initiative (www.idsociety.org/badbugsnodrugs) when Congress reauthorized the Food and Drug Administration (FDA) Prescription Drug User Fee Act on Sept. 21. The new law includes several IDSA-backed provisions that would remove obstacles from antibiotic drug review and provide incentives to strengthen the drug pipeline.

Among other things, the law requires FDA to:

  1. establish and update clinical susceptibility concentrations—the breakpoints at which a bacterium is likely resistant to antibiotics
  2. hold a public meeting to discuss the eligibility of antibiotics for certain orphan drug incentives
  3. publish guidelines for anti-infective clinical trials by September 2008
  4. provide priority-review vouchers in exchange for drugs approved to treat tropical diseases

Unfortunately, lawmakers in the House of Representatives removed an IDSA-backed provision that would have granted new market exclusivity to some antibiotics. IDSA will continue to push for this incentive.

In another important development, the “Strategies To Address Antimicrobial Resistance” (STAAR) Act was introduced on Sept. 27 by Reps. Jim Matheson (D-UT) and Mike Ferguson (R-NJ). Co-sponsors include Reps. Tammy Baldwin (D-WI) and Henry Waxman (D-CA).

This IDSA-initiated bill would improve the nation’s capacity to control resistance by establishing a network of experts across the country to collaborate with the Centers for Disease Control and Prevention (CDC) and conduct regional monitoring of resistant organisms as they occur—a kind of “snapshot” to pick up on problems early.

Researchers in the network also would work with CDC and the National Institutes of Health to find ways to slow the development of resistance. They would test potential interventions and perhaps new drugs, diagnostics, and other products as they move through the pipeline.

The STAAR Act would create an advisory board of infectious diseases, public health, and veterinary experts to advise the federal government on reducing resistance.

It would create an Office of Antimicrobial Resistance in the Department of Health and Human Services to build upon existing efforts and to better coordinate, help plan, and guide the government’s response to resistance.


Read more about the new FDA law.

Find out more about the proposed STAAR Act.

For the latest data from CDC on methicillin-resistant Staphylococcus aureus, see Klevens RM, et al.  JAMA. 2007;298:1763-1771, http://jama.ama-assn.org/cgi/content/full/298/15/1763.

IDSA Advocacy Update

IDSA works at the state and federal levels to ensure that public health policies are based on a sound scientific foundation. Here is a sample of IDSA’s recent policy activities:

Help IDSA Get Home Infusion Therapy Legislation Introduced in the Senate  
The Medicare Home Infusion Therapy Coverage Act of 2007 (H.R. 2567) would guarantee seniors access to antimicrobial infusion therapies that are provided at home. The bill, which was recently introduced in the U.S. House of Representatives, would require Medicare to cover the related services, including pharmacy and care coordination services, supplies, and equipment.  IDSA needs your help to lobby the Senate to introduce similar legislation.

IDSA Outlines Negative Consequences of Legislation Banning Thimerosal in Vaccines  
IDSA sent letters to the National Governors Association (NGA) and the National Conference of State Legislatures (NCSL) to warn about the harmful consequences of banning thimerosal from use in vaccines.


Visit the
Policy & Advocacy section of the IDSA website to learn more about IDSA’s policy activities and how you can get involved.

HIV PrEP: Should We or Shouldn’t We?

Here’s Robert M. Grant, MD, MPH, of the Gladstone Institutes in San Francisco, on why HIV prevention strategies so far have failed: Abstinence programs? “My kids say it’s proof of adult stupidity.” Condoms? “Like showering with your socks on.” Male circumcision? Well, he said, considering it involves removing a significant area of the penis, “It’s no wonder that women are more interested in male circumcision than are men.”

The point is, he said, “Prevention concepts have not worked because people don’t use them. They interfere or alter sex in some way that people care about.”

That’s why Dr. Grant backed pre-exposure prophylaxis (PrEP) during the “Clinical Controversies” session at IDSA 2007 this month in San Diego. Antiretroviral drugs work without altering sex, he noted. They’re ready to prescribe now. They’re already prescribed for post-exposure prophylaxis and against mother-to-child transmission. And they are “at least as female-controlled as a microbicide—and more easily concealed,” he said.

And so far, at least, they appear to work. Tenofovir studies in non-human primates, health care workers following needle sticks, and discordant couples seeking to have children have shown promising results, Dr. Grant said. And in a phase II study in West Africa he co-authored, tenofovir PrEP appeared safe and there is a promising trend toward efficacy, although efficacy has not yet been established.

Wrong Idea, Wrong Time

For the sake of this debate, Willard Cates, MD, of Family Health International and senior author of the West African phase II tenofovir study, set himself up as the “con man”—saying there are biological, behavioral, economic, and societal reasons not to endorse PrEP.

The biological data are weak, he said. Animal models have yielded mixed and uninterpretable results, and human trials have a long way to go. The West African tenofovir study “is somewhat encouraging,” he acknowledged, “but as you all know, we need much more data from thousands of people before we can really give any of these antiretrovirals in uninfected people a clean bill of health.”

“The big threat, of course, is resistance,” he added. In animal models tenofovir-resistant strains developed rapidly, even under high doses. Explosive transmission of resistant HIV during the early, acute phase of infection would be a disaster. “We’re really setting ourselves up for the next Andromeda Strain of HIV,” he said.

Behaviorally, Dr. Cates said PrEP will encourage people to engage in riskier sex and forego proven prevention methods like condoms, circumcision, and limiting sex partners. In the United States, he noted, there are already reports of people at dance clubs using tenofovir before engaging in high-risk sexual activity. Scaling that up to all the beer halls in Africa would create what he called “a continental powder keg.”

Furthermore, he said, PrEP carries costs. Even at deep discounts from the manufacturer, tenofovir PrEP costs $20 a month, well out of reach for people in most developing countries. There are societal costs as well, he added. Consider the societal perceptions of “allowing or even encouraging illicit behaviors by passing out pills to make unsafe sex or drug use even easier,” he said.

“Lastly, the public health impact is, indeed, questionable,” he concluded. Under realistic assumptions, modeling studies show a modest impact at best—and resistance is a big issue.

“PrEP is the wrong idea, at the wrong time,” Dr. Cates “concluded.”

Offstage, however, the two actually agree: It would be a mistake to let fears about possible risks interfere with studies to answer these questions. Nor should ideology get in the way. Let the evidence decide, they say, whether PrEP is the right idea at the right time.


Slides from this session and many others from IDSA 2007 are available online.

Audio files, including a full-conference CD-ROM, are available for purchase from Sound Images.

Keep Up with Drug Approvals, Recalls, Adverse Events

IDSA offers a new, members-only service that e-mails ID-related messages from the Food and Drug Administration on label changes, adverse events, newly approved drugs, and other safety information on FDA-approved drugs and biologics.  Recent alerts have included:

To sign up for this service, IDSA members can visit http://www.idsociety.org/Content.aspx?id=4250.

Lyme Disease: When Symptoms Don’t Improve

Risks Associated with Long-term Antibiotic Therapy

Long-term antibiotic therapy for patients with purported chronic Lyme disease or post-Lyme disease symptoms can cause considerable harm for patients and public health, such as:

  • adverse reactions following ceftriaxone administration, including life-threatening anaphylaxis and biliary complications requiring cholecystectomy
  • infection of the intravenous catheter, including Candidemia, which can result in death
  • fostering the development of other drug-resistant infections

 

The vast majority of patients with Lyme disease can be treated with a short course of antibiotic therapy and will recover fully. But for the small percentage of patients whose symptoms don’t improve (roughly 5 percent by some estimates), what is an ID clinician to do?

Noted experts Allen C. Steere, MD, FIDSA, of Harvard Medical School and Gary P. Wormser, MD, FIDSA, of New York Medical College offered their advice during a Meet–the-Professor session on Lyme disease. Both speakers were authors of IDSA’s 2006 practice guidelines on Lyme disease as well as a recent review article in the New England Journal of Medicine on “A Critical Appraisal of ‘Chronic Lyme Disease.’” (N Engl J Med 2007;357:50-58)

Different terms have been used to describe patients who continue to experience symptoms (see sidebar). According to Drs. Steere and Wormser, the term “chronic Lyme disease,” which implies chronic infection with Borrelia burgdorferi, is a misnomer, and the use of prolonged antibiotic treatments is unwarranted and can cause patients significant harm. Nevertheless, physicians and laypeople who believe in the existence of chronic Lyme disease have been vocal in championing their cause.

In patients with newly diagnosed Lyme disease, Dr. Wormser noted that it’s important to provide anticipatory counseling, so that patients understand that it may take several weeks to months for symptoms to resolve. Patients should be told that the internet contains many sources of misinformation. Many patients with post-Lyme disease symptoms fear that their symptoms indicate that they have a chronic infection that could cause neurologic damage, he said. It’s important to address those concerns.

The speakers offered the following advice to clinicians who are referred a patient who is purported to have chronic Lyme disease:

  • Review the symptoms, tick exposure, and lab data.
  • Emphasize the non-specific nature of symptoms.
  • Discuss the risks of unnecessary antibiotic treatment (see sidebar).
  • Thoroughly evaluate the patient for other medical conditions that could explain the symptoms.
  • If there is no specific treatment indicated, provide emotional support and symptomatic management
  • Explain in clear and empathetic language that there is no medication such as an antibiotic to cure the condition.

Caring for a patient who has no objective manifestations of an infection can be frustrating for an ID clinician. Still, Dr. Wormser urged his audience, “Don’t abandon these patients.” Doing so leaves them vulnerable to misinformation and a treatment plan that is expensive, unnecessary, and potentially dangerous.


Post-Lyme or Chronic Lyme?

post-Lyme disease symptoms: fatigue, musculoskeletal pain, difficulties with concentration or short-term memory, or all of these symptoms when experienced by patients despite resolution of the objective manifestations of infection by Borrelia burgdorferi after antibiotic treatment. Seen in a minority of patients.

post-Lyme disease syndrome: symptoms above lasting longer than six months

chronic Lyme disease: The term has been applied to patients in a variety of contexts, including those with objective late manifestations (such as arthritis) and those with purely subjective complaints after antibiotic therapy. It is also applied to those with unexplained subjective symptoms without credible laboratory evidence for Borrelia burgdorferi infection irrespective of exposure to an endemic area. The term has also been applied to patients with other identifiable conditions such as multiple sclerosis.

Source: G. Wormser


Also see IDSA resources on Lyme disease at www.idsociety.org/lymedisease.htm.  

Slides from this session and many others from IDSA 2007 are available online.

Audio files, including a full-conference CD-ROM, are available for purchase from Sound Images.

Alternative Approaches, Possible Vaccines Against MRSA Infections

With the news this month that methicillin-resistant Staphylococcus aureus (MRSA) infections appear to be more prevalent than previously believed, a symposium at the 45th Annual Meeting of IDSA, in San Diego, on management and control of Staphylococcus aureus couldn’t have been more timely.

According to an October 17 study in the Journal of the American Medical Association (2007;298:1763-1771), most infections remain in the health care setting. Maureen K. Bolon, MD, of Northwestern University, discussed options for surgical antimicrobial prophylaxis in the context of increasing infections due to MRSA.

Options include replacing cephalosporin with vancomycin for selected surgical procedures, or adding vancomycin to a cephalosporin regimen. Guidance published in the December 2006 The Medical Letter recommends vancomycin for cardiac, orthopedic, thoracic, neurosurgery, and vascular procedures in hospitals in which MRSA is a frequent cause of postoperative wound infection or in patients previously colonized with MRSA. Other guidance emphasizes the use of vancomycin as prophylaxis in the presence of MRSA clusters or for patients susceptible to colonization, and only after a review of infection prevention practices. Most guidelines emphasize that vancomycin should not be used as routine antimicrobial prophylaxis.

Thinking Outside of the Box

Dr. Bolon discussed options beyond systemic antimicrobial prophylaxis for the prevention of infections in surgical settings. A study of chlorhexidine gluconate oral rinse and nasal ointment versus placebo showed a significant reduction in nosocomial infections, while studies looking at the effectiveness of mupirocin nasal ointment versus placebo demonstrated no difference in occurrence of surgical site infection (SSI).

Andrew E. Simor, MD, of the University of Toronto, said that drugs with marginal activity or that induce resistance (e.g., ciprofloxacin and fusidic acid) may fail to eradicate MRSA colonization, and intranasal therapy is ineffective for the GI reservoir of the organism. 

Targeted approaches may be one way to ward off MRSA infections in hospitals. Carriers could be identified by active surveillance, Dr. Bolon said, and these patients could be selectively treated using glycopeptide as an adjunct to surgical prophylaxis and/or mupirocin for decolonization. Alternatively, hospitals could adopt a more universal approach by evaluating MRSA-related SSI rates and using glycopeptide as an adjunct to surgical prophylaxis for procedures found to have high rates of MRSA SSI. 

Hope for a Vaccine?

A study evaluating a vaccine candidate offered a glimmer of hope when it was published in 2002, according to Stan Deresinski, MD, at Stanford University. In that study, StaphVAX (from Nabi Biopharmaceuticals) was 57 percent effective against S. aureus bacteremia in patients with end-stage renal disease at weeks 37-40. A Phase III confirmatory trial demonstrated efficacy to week 35 but failed to meet the study’s primary endpoint of significantly reducing the number of S. aureus infections compared with placebo. In 2005, StaphVAX was put on hold pending further partnership and funding. A subsequent analysis found that the vaccine used in the confirmatory trial was less immunogenic than the first.

Other vaccine candidates are in early trials. Merck’s 0657nl has been studied in a Phase I trial of more than 120 healthy volunteers. It was safe and generally well tolerated. A Phase II trial of Intercell’s V710 is set to begin in December. It will look at the safety and efficacy of preventing serious S. aureus infections after elective cardiothoracic surgery.


Slides from this session and many more can be found on the IDSA website.

Audio files of individual sessions or a full-conference CD-ROM are available for purchase from Sound Images

New Hope for Viral Suppression in All HIV Patients

New agents for treatment-naïve individuals offer the promise of well-tolerated, convenient, and highly active therapy for all patients with HIV, according to Joseph Eron, Jr., MD, professor of medicine at the University of North Carolina. Speaking at the “State of the Art in HIV Care and Treatment” symposium at the 45th Annual Meeting of IDSA, in San Diego, he said for all patients, there should be “zero tolerance” for virologic failure. 

Dr. Eron emphasized the importance of using at least two fully active agents. Clinicians should draw upon newly approved agents, including the integrase inhibitor raltegravir and the entry inhibitor maraviroc, as well as enfuvirtide (T-20) and medications in expanded access, with choices dependent on treatment history, resistance testing, and tolerability, he said.

New Agents, New Strategies

In another presentation, Joel Gallant, MD, MPH, of the Johns Hopkins School of Medicine, said maraviroc is highly effective in treatment-experienced patients with R5-tropic virus—virus that enters cells through the CCR5 receptor. However, approximately half of treatment-experienced patients are not candidates for maraviroc because of the presence of X4-tropic virus, which enters the cell using the CXCR4 coreceptor. The tropism assay (Trofile) required to identify whether the patient is infected with R5-, X4-, or dual/mixed (D/M)-tropic virus is expensive and can sometimes miss the presence of X4- or D/M-tropic virus present at low levels. 

Because of the dosing inconvenience of enfuvirtide, most patients with suppressed viral loads on this agent will want to substitute a new agent, Dr. Gallant said. Raltegravir is probably the best drug to replace enfuvirtide, although this strategy has not been formally studied.  Substitution with maraviroc is rarely possible, since tropism testing requires a viral load of at least 1000 copies/mL.  

Those with R5 virus and/or virus susceptible to darunavir, tipranavir, or etravirine may not need enfuvirtide. However, enfuvirtide will still be necessary in some highly treatment-experienced patients with cross-resistance to the second generation non-nucleoside reverse transcriptase inhibitors and protease inhibitors and with and D/M- or X4-tropic virus. 

When to Start?

There is growing evidence of benefit with earlier initiation of ART, according to Dr. Gallant. Although the magnitude of additional benefit achieved with earlier therapy is smaller than for later therapy, he said the risk-to-benefit ratio favors earlier initiation now that therapy is more convenient, better tolerated, and less toxic. 

Furthermore, he added, a modeling approach that compared starting ART with a CD4 count greater than 350 cells/mm3 versus 200 to 350 cells/mm3 found that starting earlier is a cost-effective strategy in the United States. Dr. Gallant’s opinion, which he emphasized is not necessarily consistent with evolving treatment guidelines, is to treat anyone with a CD4 count of less than 350 cells/mm3, anyone with hepatitis B virus (HBV)/HIV co-infection needing treatment for HBV, pregnant women, and patients with conditions that require ART, such as HIV-associated nephropathy or neurocognitive dysfunction. 

He said he would defer treatment for patients in the setting of some acute opportunistic infections (to avoid immune reconstitution inflammatory syndrome), long-term non-progressors (or those who might be), and patients who are not ready, motivated, or likely to be adherent.  Dr. Gallant said that therapy could be considered in motivated, adherent patients with clear evidence of immunologic progression regardless of CD4 count, or in patients at high risk of transmitting HIV infection. However, he pointed out that a thorough discussion of the pros and cons of early therapy is especially important in patients starting therapy earlier than is recommended by current treatment guidelines.  


Slides from this session and many others from IDSA 2007 are available online.

Audio files of individual sessions or a full-conference CD-ROM are available for purchase from Sound Images.

Resistant Staph: Use One Drug or a Combination?

“Vancomycin as a single agent against [methicillin-resistant Staphylococcus aureus (MRSA)] is dead,” declared Dennis L. Stevens, MD, PhD, FIDSA, of the Boise, Idaho Veterans Affairs Medical Center. Today’s serious MRSA infections call for combinations of antibiotics, he argued during the “Clinical Controversies” session at IDSA 2007 this month in San Diego.

Resistance to vancomycin is increasing rapidly, as manifested by minimum inhibitory concentration (MIC) creep, vancomycin-resistant Staphylococcus aureus (VRSA), vancomycin-intermediate (VISA), hetero-resistance, vancomycin tolerance, and slow bacterial killing. Dr. Stevens also noted reports of treatment failure are on the rise. He cited research showing the rate of clinical failure increased as the MIC went up, reaching more than 50 percent when the MIC topped 2 mg/ml (J Clin Microbiol. 2004;42:2398-402).

“Antibiotic susceptibility does not predict success, but it certainly does predict failure,” Dr. Stevens said, adding that failure rates of 50 percent with vancomycin alone are just not acceptable.

Since vancomycin blocks cell-wall synthesis, the drug works best when bacteria are growing rapidly. But he noted that in serious MRSA infections, the bacterial loads are high and these bacteria are not growing rapidly or are in the stationary phase of growth.  Treatment fails as a result. 

“Furthermore,” he added, “vancomycin fails against these toxin-producing bacteria because many bacterial toxins are produced late in the bacterial life cycle (early stationary phase) and drugs such as vancomycin are therefore less effective.” When these drugs do kill bacteria, the bacteria lyse, releasing their toxins. And, Dr. Stevens said, his research has found that drugs active against cell wall production actually increase toxin-gene expression and also increase toxin production.  In sharp contrast drugs like linezolid and clindamycin markedly suppress toxin production at the ribosomal level. (Stevens et al., J Infect Dis. 2007;195:202-211).

Therefore, he concluded, these serious MRSA infections should be treated with a combination of drugs—a protein synthesis inhibitor such as clindamycin, linezolid, or possibly tigecycline; plus either a cell wall agent such as a glycopeptide, or ceftobiprole or daptomycin.

Single Drug Can Still Get Job Done

“Yes, there are a lot of bad diseases that we’re seeing as a result of the newer Staphylococci,” agreed A. W. Karchmer, MD, FIDSA, of Beth Israel Deaconess Medical Center in Boston, in his counterpoint, “but how common are they? They’re just case reports.” While major studies of S. aureus infections have noted increases in MRSA cases, these studies have reported relatively few cases of necrotizing fascitis (Miller et al., NEJM. 2005;352:1445-53) or deaths from invasive disease (Kaplan et al., Clin Infect Dis. 2005;40:1785-91).

Most importantly, he noted, there is limited evidence that using drug combinations improves outcomes. Dr. Karchmer cited a litany of studies in which various drug combinations were no more effective than single drugs, and in several cases the single drug even worked significantly better than the combination. Plus, the additional drug in some cases increased toxicity without improving the outcome.

Dr. Karchmer agreed in theory that combining a toxin-inhibiting drug with a bacteriocidal drug would be a good idea. “But what do we use?” he asked. “At this point in time,” he concluded, “single-drug therapy is…less likely to lead to antagonism, is not going to cause as much collateral damage, and is in all of our experience as efficacious as combination therapy.”


Slides from this session and many others from IDSA 2007 are available online. 

Audio files of individual sessions or a full-conference CD-ROM are available for purchase from Sound Images.

Congratulations to the 2007 Society Award Recipients

IDSA and the Education and Research Foundation offer awards to individuals to honor outstanding achievements in the field of infectious diseases and HIV/AIDS.  Award recipients are pioneers in the study of newly emerging emerging diseases, inspiring and supportive teachers and those who paved the way for life-saving vaccines.  The awards were presented during ceremonies at the 45th Annual meeting of IDSA in San Diego.

Alexander Fleming Award

The Alexander Fleming Award is granted in recognition of a career that reflects major contributions to the acquisition and dissemination of knowledge about infectious diseases.

Sherwood Gorbach, MD, FIDSA

Sherwood L. Gorbach, MD, FIDSA, a pioneering researcher, educator, mentor, and editor who has shaped the discipline of infectious diseases for more than 40 years, is the recipient of IDSA’s 2007 Alexander Fleming Award for Lifetime Achievement. Previously known as the Bristol Award and first bestowed in 1964, the Alexander Fleming Award is granted in recognition of a career that reflects major contributions to the acquisition and dissemination of knowledge about infectious diseases. Dr. Gorbach currently holds professorships in the Departments of Community Health, Medicine, and Molecular Biology and Microbiology at Tufts University School of Medicine. He also serves as professor in the university’ School of Nutrition Science and Policy.

Described as a remarkable physician whose ongoing contributions to the field of infectious diseases have been deep, diverse, and profound, Dr. Gorbach began his celebrated career upon graduating from Tufts University School of Medicine in 1962. After completing his internal medicine residency at Cornell-Bellevue Medical Center, he returned to the Tufts-New England Medical Center for a fellowship in infectious diseases and a stint as chief medical resident. Heading across the Pond for additional postgraduate work, Dr. Gorbach trained in parasitology and entomology at the London School of Hygiene and Tropical Medicine and in gastroenterology at the Hammersmith Royal Postgraduate Medical School in London. Back stateside, he held several prestigious academic and hospital appointments in Chicago and Los Angeles before returning “home” to the faculty of Tufts University School of Medicine, where he has made a celebrated impression for the past 32 years.

A testament to his exceptional research skills, Dr. Gorbach has been continuously funded as a principal investigator by the National Institutes of Health for research in infectious diseases and nutrition since 1969. Prominent among his many contributions was the seminal demonstration—through a series of meticulous studies carried out under difficult conditions in Calcutta in the 1960s—that enterotoxigenic E. coli was a major cause of life-threatening diarrheal disease in both adults and children, especially in the developing world. Following this pioneering work, he demonstrated that enterotoxigenic E. coli was also the cause of infantile diarrhea in Chicago—the first time the organism had been linked to severe pediatric diarrheal disease in the industrialized world.

Dr. Gorbach’s revered status as an investigator is matched by his passion and skill as a disseminator of scientific knowledge. Beloved by his students at Tufts University School of Medicine, he has received the Citation for Excellence in Teaching on 12 occasions and has twice been honored with the Special Faculty Recognition Award, which is bestowed on the single outstanding faculty member as judged by the graduating class. As a mentor, he has influenced the careers of many leading figures in the infectious diseases field. And lastly, as the editor of Clinical Infectious Diseases since 1999, Dr. Gorbach has been credited with using his scientifically sound and exceptionally user-friendly editorial style to garner increasing national and international respect for a publication that many now consider the most prestigious and competitive infectious diseases journal in the world.

Despite a career overflowing with laurels, Dr. Gorbach shows no sign of resting on any. He is presently the principal investigator on no fewer than five NIH research projects, and he continues to teach, mentor, publish, edit, and contribute daily to the infectious diseases field he helped define over the past four decades. As one prominent colleague noted, “He did it all, and he still does.” For his lifetime of achievements and the many still to come, IDSA is proud to honor Dr. Gorbach with the 2007 Alexander Fleming Award. 

Oswald Avery Award

The Oswald Avery Award recognizes outstanding achievement in an area of infectious diseases by an indvidual member or fellow of IDSA who is 45 or younger.

Pablo C. Okhuysen, MD, FIDSA

Pablo C. Okhuysen, MD, FIDSA, a nationally and internationally recognized expert in experimental models and the clinical manifestations, immunopathogenesis, and therapy of enteric infectious diseases, is the recipient of IDSA’s 2007 Oswald Avery Award for Early Achievement. Previously known as the Squibb Award, this honor has been granted since 1968 in recognition of outstanding achievement in an area of infectious diseases by an individual member or fellow of IDSA who is 45 years of age or younger. Dr. Okhuysen is professor of medicine at the University of Texas Medical School and School of Public Health at Houston, as well as clinical professor of medicine at Baylor College of Medicine.

Holding dual citizenship in the United States and Mexico, Dr. Okhuysen is a 1988 graduate of the Universidad Autónoma de Guadalajara Medical School. He completed his internship in internal medicine at the Cook County Hospital in Chicago and his internal medicine residency at the University of Texas Medical School at Houston. He remained at the latter institution for a fellowship in infectious diseases and joined the faculty upon its completion. Over the next decade, he progressed at an accelerated pace to the level of full professor of medicine—and has become one of the most respected academicians in Houston.

Described as enormously productive and successful in his research, Dr. Okhuysen has quickly become a recognized authority in cryptosporidiosis, volunteer studies with parasitic and bacterial pathogens, and enteric bacterial and parasitic immunity and pathogenesis and host genetics. He directs the clinical and volunteer aspects of the University of Texas research program dealing with the infectivity of Cryptosporidium, through which he has established the low infectious dose of Cryptosporidium infections and provided entirely new information on strain differences in both infectious dose and immune responses. The U.S. Environmental Protection Agency used data from these studies to develop nationwide safe drinking water regulations implemented in 2006. Dr. Okhuysen also is a leader in researching genetic polymorphisms that predispose to gastrointestinal infection, having created a large cohort (more than 1900 participants) of US travelers to Mexico from whom he has collected DNA and conducted groundbreaking investigations into the causes of travelers’ diarrhea.  

A natural leader and mentor, Dr. Okhuysen serves as program director for the combined M.D. Anderson Cancer Center and University of Texas infectious diseases fellowship program. In addition, he is co-director of the University of Texas NIH Center for Translational Science Award (CTSA), one of 12 recently funded “roadmap” programs nationwide. At the CTSA, he leads studies of HIV, AIDS, and cryptosporidiosis, as well as mentored training programs in both the hospital facility and in Hispanic communities in the lower Rio Grande Valley in South Texas. His career to date has produced some 70 peer-reviewed publications, as well as numerous awards for excellence in teaching, research, and clinical care. IDSA is pleased to add the 2007 Oswald Avery Award to Dr. Okhuysen’s rapidly growing list of accomplishments.

Mentor Award

IDSA’s Mentor Award was created to recognize individuals who have served as exemplary mentors and is presented to an IDSA member or fellow who has been exceptional in guiding the professional growth of infectious diseases professionals. Recipients are chosen based on their proven availability to provide counsel, assistance, and encouragement; their willingness to make serving as a mentor a priority; their ability to assist in solving problems and overcoming obstacles impeding career development; and important role model characteristics, such as integrity and compassion. This year IDSA is pleased to present Mentor Awards to two worthy recipients.

Stanley Falkow, PhD, FIDSA

Stanley Falkow, PhD, FIDSA, is the Robert W. and Vivian K. Cahill professor of microbiology and immunology and medicine at the Stanford University School of Medicine. Widely regarded as the foremost bacteriologist in the United States for more than a generation, his discoveries and contributions to the field of microbiology have been enormous. He is recognized throughout the world for his observations related to molecular mechanisms of bacterial pathogenesis. But he is also recognized by his colleagues and trainees as the supreme example of a mentor: an inspiring, selfless, empathetic, and brilliant counselor.

Dr. Falkow earned his PhD from Brown University in 1961. He began his career as a microbiologist at the Walter Reed Army Institute of Research in the Department of Bacterial Immunology. He subsequently held academic positions at Georgetown University Medical School and the University of Washington Medical School before arriving at Stanford in 1981. He pioneered infectious disease research through his recognition of the role of plasmids in the development of antibiotic resistance and by originating the field of molecular pathogenesis. His most renowned discoveries include the identity of Bartonella henselae and T. whippelli and virulence pathways in Salmonella, E. coli, plague, and Helicobacter.

Beyond these storied accomplishments, Dr. Falkow has served as a highly regarded mentor for generations of microbiologists and infectious diseases physicians, many of whom have continued his successes in the study of microbial pathogenesis. Those who have trained with him say he instills a genuine love for science and the spirit of scientific inquiry into every one of his trainees—as well as all of those around him. He also embodies humility and generosity, happily giving away pieces of his research focus every time a trainee leaves his lab to set off on his or her own. Dr. Falkow has received numerous awards and honors (including others from IDSA) in recognition of his lifetime of accomplishments, but today the society is pleased to honor this inspiring and selfless advisor with a 2007 Mentor Award.

Neal H. Steigbigel, MD, FIDSA

Neal H. Steigbigel, MD, FIDSA, is professor of medicine in the Division of Infectious Diseases and Immunology at the New York School of Medicine. Before accepting his current position in 2002, he spent more than 30 years as director of the infectious diseases fellowship training program at the Albert Einstein College of Medicine and Montefiore Medical Center, as well as founder and head of the Division of Infectious Diseases at Montefiore Medical Center. Colleagues describe Dr. Steigbigel as a tireless, enthusiastic teacher who has guided and profoundly influenced a “who’s who” list of infectious diseases specialists over the past four decades.

A 1960 cum laude graduate of Harvard Medical School, Dr. Steigbigel completed his residency and infectious diseases fellowship at the Harvard Medical Unit of Boston City Hospital. He also served for two years in the U. S. Public Health Service, working as a clinical associate in the Medicine Branch and Laboratory of Chemical Pharmacology at the National Cancer Institute. After briefly serving on the faculty at Harvard, he was recruited to develop the first formal infectious diseases division and ID fellowship training program at Albert Einstein College of Medicine. According to his colleagues, Dr. Steigbigel developed a training framework that was uniquely successful and largely derived from his intellectual rigor, organizational skills, and ability to interact and gain the cooperation of a highly talented but frequently disparate group of faculty members.

A flair for navigating institutional politics and fostering faculty cooperation wasn’t his only skill. Those who worked and trained with Dr. Steigbigel describe him as a peerless teacher and scholar in clinical infectious disease. His understanding of the fundamental science that relates to clinical infectious disease and his up-to-the-minute knowledge of new discoveries made him a superb role model for his fellows—nearly 180 of whom benefited from his tutelage during his time at Albert Einstein. Past trainees note that his unique teaching style, which often assumed a story-telling format, made even the most mundane and dry subjects memorable and exciting. Moreover, he took an active interest in each and every fellow’s career, provided each with wise counsel, and wrote letters of recommendation on their behalf years and sometimes decades after they moved on. For having inspired generations of infectious diseases specialists with his devotion, intellect, and integrity, IDSA is proud to honor Dr. Steigbigel with a 2007 Mentor Award.

Society Citation

The Society Citation is a discretionary award given in recognition of exemplary contribution to IDSA, an outstanding discovery in the field of infectious diseases, or a lifetime of outstanding achievement in a given area -- either in research, clinical investigation, or clinical practice.  This year IDSA is pleased to present Society Citations to two worthy recipients.

Gary Wormser, MD, FIDSA

Gary P. Wormser, MD, FIDSA, a bold champion for rational, evidence-based medicine, is the recipient of IDSA’s 2007 Society Citation. First awarded in 1977, the Society Citation is a discretionary award given in recognition of exemplary contribution to IDSA, an outstanding discovery in the field of infectious diseases, or a lifetime of outstanding achievement in research, clinical investigation, or clinical practice. Dr. Wormser is receiving the 2007 Society Citation for his dedication and exemplary service to IDSA—often in the face of harsh criticism—as chair of the society’s expert panel that recently updated IDSA’s clinical practice guidelines on Lyme disease.

Dr. Wormser received his medical degree from the Johns Hopkins Medical School in 1972. He completed his internal medicine residency at the Mount Sinai Hospital in New York and remained at the institution for an infectious diseases fellowship. He currently is professor of medicine and pharmacology at New York Medical College, where he also serves as vice chair of the Department of Medicine, chief of the Division of Infectious Diseases, and director and founder of the infectious diseases fellowship program.

A pioneering AIDS researcher during the early years of the epidemic, Dr. Wormser turned his attention to tick-borne pathogens in the 1990s, including Lyme disease, human granulocytic anaplasmosis, and babesiosis. He founded the Lyme Disease Diagnostic Center at the Westchester County Medical Center, allowing patients with tick bite-related rashes to receive rapid diagnosis and treatment. Under Dr. Wormser’s leadership, the New York Medical College ID Division became widely known for groundbreaking and well-designed studies of the treatment and prevention of Lyme disease. IDSA tapped him to head the original Lyme disease guidelines development panel in 2000, and called upon his unparalleled experience and leadership skills for the 2006 update.

That’s when things got interesting. IDSA and the panel members were faced with numerous and repeated criticisms from advocacy groups who took issue with the treatment recommendations, particularly the guidelines’ lack of support for the unfounded and potentially dangerous practice of long-term antibiotic treatment. Dr. Wormser took the lead in responding to these criticisms, including addressing dozens of media inquiries and working with IDSA staff to respond to a legal inquiry about the guideline development process from the Connecticut attorney general. Even more troubling, his institution was the site of a protest rally that included mean-spirited verbal attacks on Dr. Wormser personally. But through it all, he and his panel colleagues stood firm and continued to champion a science-based approach. For his perseverance, steadfast advocacy, and service far above and beyond the call, IDSA is proud to honor Dr. Wormser with a 2007 Society Citation.

Eduardo H. Gotuzzo, MD, FIDSA

Eduardo Gotuzzo, MD, FIDSA, a tireless and enthusiastic infectious diseases scholar, clinician, and teacher, is a recipient of IDSA’s 2007 Society Citation. First awarded in 1977, the Society Citation is a discretionary award given in recognition of exemplary contribution to IDSA, an outstanding discovery in the field of infectious diseases, or a lifetime of outstanding achievement in research, clinical investigation, or clinical practice. Dr. Gotuzzo is receiving the 2007 Society Citation in recognition of his extraordinary career and his numerous contributions to the field of infectious diseases.

Dr. Gotuzzo received his medical degree from the Universidad Peruana Cayetano Heredia in Lima, Peru, in 1973. He remained at the institution to complete his internal medicine residency and infectious diseases fellowship. Currently he is Director  of Tropical Medicine Institute “Alexander von Humboldt”-Universidad Peruana Cayetano Heredia and Head of Department of Infectious Diseases and Tropical Medicine - Hospital Cayetano Heredia, Lima, and the Director of the Gorgas Course in Clinical Tropical Medicine.   He now serves as principal professor in the university’s Department of Medicine and holds associate faculty positions at Johns Hopkins, University of Miami and the University of Alabama, Birmingham.

Well known to infectious diseases clinicians and investigators around the globe, Dr. Gotuzzo is regarded as Latin America’s premier infectious diseases and tropical medicine expert. His early work with typhoid fever established him as a world authority on typhoid diagnosis, treatment, and prevention. In the early 1990s, when a cholera pandemic hit Peru after a century of absence in Latin America, Dr. Gotuzzo was deeply involved in the response and quickly became known as an international expert in clinical aspects and treatment of cholera. During the last years, Dr. Gotuzzo is also involved, as part of his great interest in investigations, on Emerging and Re-emerging diseases in Latin America: HTLV-I, free-living amebas and MDR-TB.  His reputation as a teacher also is legendary: He has served for many years as the director of the renowned Gorgas Course in Clinical Tropical Medicine, which annually trains dozens of infectious diseases specialists from around the world.

With nearly 300 articles and more than 40 book chapters to his credit, Dr. Gotuzzo has contributed prodigiously to the infectious diseases literature on a broad range of topics. His dedication to the specialty is also obvious from his track record of service. Most notably, he serves as a member of the prestigious Forum on Microbial Threat of the Institute of Medicine. Within IDSA, he has devoted his time and talents to the Society’s International Affairs Committee and the Annual Meeting Program Committee. For his many years of devotion to infectious diseases and the numerous contributions he has made to the field, IDSA is honored to present Dr. Gotuzzo with a 2007 Society Citation.

Clinical Teacher Award

The Clinical Teacher Award honors a career involved in teaching clinical infectious diseases to fellows, residents, or medical students and recognizes excellence as a clinician and motivation to teach the next generation.

Daniel Musher, MD, FIDSA

Daniel M. Musher, MD, FIDSA, described as the “ultimate educator” with a unique combination of intellect, infectious curiosity, healthy skepticism, honesty, and humility, is the recipient of IDSA’s 2007 Clinical Teacher Award. This award honors a career involved in teaching clinical infectious diseases to fellows, residents, or medical students and recognizes excellence as a clinician and motivation to teach the next generation. Recipients must exhibit exemplary teaching skills, implementation of innovative educational programs, outstanding bedside and patient communication skills and the ability to convey these skills to others, and evidence of teaching awards at the local or regional level.

Dr. Musher received his medical degree in 1963 from the Columbia College of Physicians and Surgeons. He interned and completed his first year of residency at Bellevue Hospital in New York. He finished residency at Tufts-New England Medical Center Hospitals in Boston and remained there for a fellowship in infectious diseases. He joined the faculty of Baylor College of Medicine in Houston in 1971, beginning a remarkable teaching career that has continued at Baylor to the present day. Dr. Musher is currently a professor of medicine and of microbiology and molecular virology at Baylor College of Medicine. He also serves as chief of the infectious diseases section at Houston’s VA Medical Center—a position he has held for 36 years as well.

Lauded for his energy, enthusiasm, and dedication to teaching, Dr. Musher’s accomplishments encompass all levels of learners at Baylor College of Medicine. As the director of the infectious diseases curriculum for second-year medical students, he has received the class’s Outstanding Teacher Basic Sciences Award eight times. Similarly, he has earned the admiration of medical students on clinical rotations, receiving the Graduating Class Outstanding Faculty Member Award five times. Residents appreciate his leadership, humility, and high standards of excellence—and awarded him their Excellence in Teaching Award six years in a row. With all those trophies competing for space on his mantle, Dr. Musher’s name was “retired” into Baylor’s Hall of Fame for Excellence in Teaching in 2003, finally allowing grateful colleagues a shot at the prizes he had unintentionally monopolized for so many years.

Although his teaching acumen is legendary at Baylor, Dr. Musher’s natural ability to impart knowledge benefits the broader infectious community as well. Each week, he participates in the City-Wide Infectious Disease Conference, offering insightful and useful thoughts about clinical cases. The popular conference attracts 50 to 100 health care professionals, due in part to Dr. Musher’s gifted approach and style, which colleagues describe as captivating to all who fall under his influence. For his substantial impact on the education of generations of infectious disease physicians, IDSA is honored to present Dr. Musher with the 2007 Clinical Teacher Award.

Watanakunakorn Award

Named to honor the memory of Dr. Chatrchai Watanakunakorn, this award is given annually by the IDSA Education and Research Foundation to an IDSA member or fellow in recognition of outstanding achievement in the clinical practice of infectious diseases.

Timothy Kuberski, MD, FIDSA

Timothy T. Kuberski, MD, FIDSA, a strong and compassionate advocate for patient care, community education, and clinical research, is the recipient of IDSA’s 2007 Watanakunakorn Clinician Award. Named to honor the memory of Dr. Chatrchai Watanakunakorn, this award is given annually by the IDSA Education and Research Foundation to an IDSA member or fellow in recognition of outstanding achievement in the clinical practice of infectious diseases. The recipient must be in clinical practice, spend at least 75 percent of his or her time in direct patient care, and exhibit excellence in clinical care, clinical research, patient or community education, compassion, patient advocacy, and service to a national or state infectious diseases society.

A 1969 graduate of the University of Missouri School of Medicine, Dr. Kuberski completed his internship at Los Angeles County Hospital and his residency in internal medicine at the University of Washington School of Medicine. He served as a research associate in the U.S. Public Health Service’s Pacific Research Section for two years before completing an infectious diseases fellowship at the UCLA School of Medicine. Since 1981, he has been in private practice in Phoenix, where he also serves as attending staff physician at four local hospitals and has a teaching appointment in infectious diseases at the only medical school in Phoenix, Midwestern Osteopathic University.

Dr. Kuberski’s outstanding abilities as a clinician were recognized early in his career: He received the Upjohn Award as the best clinician of his medical school class. The accolades continue to the present day, with Phoenix Magazine including him on its list of the best clinicians in Phoenix for the past five years. Moreover, Dr. Kuberski is credited with pioneering the specialty of infectious diseases in the Phoenix area—a city where no ID specialist had been on staff at any hospital prior to his arrival. He is an originating member of the Arizona Infectious Diseases Society, has served as the organization’s president for the past six years, and has worked in conjunction with IDSA on a variety of local and national issues. He also has organized numerous well-attended conferences for physicians in his community, thus influencing patient care well beyond his own practice.

Despite his considerable clinical responsibilities, Dr. Kuberski has strong research interests and has added meaningful information to the literature. He has published clinically oriented papers in coccidioidomycosis, mucormycosis, plague, dengue, and eosinophilic meningitis, among others. His numerous achievements and longtime devotion to the clinical practice of infectious diseases make Dr. Kuberski an ideal recipient of IDSA’s 2007 Watanakunakorn Clinician Award.

Winners of the 2007 IDSA/SHEA Advancements in MRSA Awards

sponsored by Pfizer

Young Investigator Award in MRSA 

The purpose of the award is to provide funding for outstanding clinical or epidemiological research on MRSA.  The total award amount is $200,000 given over a two-year period. The recipient will receive unrestricted funds to support his or her salary, technicians, laboratory supplies, and equipment. 

Clarence “Buddy” Creech III, MD

Project:  Methicillin-Resistant Colonization in Women and Newborns

Special Innovation Awards in MRSA 

The purpose of these awards is to help fund new, innovative projects designed to prevent, diagnose, or treat MRSA.  These awards are given to help clinicians, hospital epidemiologists, or public health officials directly involved in combating MRSA at the institutional or community level.  Two awards of $24,000 each were granted.  These one-time, unrestricted awards to be used to help “seed” new efforts, generate hypotheses, and continuous quality improvement initiatives, health services research, educational efforts, surveillance projects, and other demonstration projects. 

Michelle Barton-Forbes, MD

Project: Predicting the Threshold for Change in Empiric Medical Management of Shin and Soft Tissue Infections in the Era of Community-acquired Methicillin-Resistant Staphylococcus aureus 

Cassandra Salgado, MD

Project:  Providing Evidence of Clonal MRSA Spread to Healthcare Workers to Control Nosocomial Spread of the Organism

Special Recognition Award in MRSA

The purpose of the award is to recognize recent outstanding clinical or epidemiological research that can be expected to make an important contribution toward preventing, diagnosing, or treating MRSA.

Vance Fowler, MD

Congratulations to This Year’s 50 Outstanding Scholars!

An important part of IDSA’s mission is to promote the subspecialty of infectious diseases by attracting the best and brightest medical students to the field. To further this goal, the IDSA Education and Research Foundation offers scholarships to medical students in U.S. medical schools with mentorship by an IDSA member or fellow. This year’s winners are:

Tessa Andermann
Stanford University Medical School, Palo Alto, CA
Mentor: David Katzenstein, MD
Project: Trauma, Psychological Distress, and HIV Risk Behavior in Zimbabwe

Vivian Asare
Howard University Medical School, Washington, DC
Mentor: Awewura Kwara, MD
Project: Risk Factors for Mortality in Hospitalized Adult with TB at Komfo Anokye Teaching Hospital, Ghana

Crystal Brown
Case Western Reserve University, Cleveland, OH
Mentor: Adam P. Geballe, MD, FIDSA
Project: Characterization of the dsRNA Binding Properties of the HCMV Protein pTRS1

Emily Chan
New York University School of Medicine, New York, NY
Mentor: Joel D. Ernst, MD, FIDSA
Project: Antigen Presentation to M. tuberculosis-specific CD4+ T Cells

Rushina Cholera
University of North Carolina at Chapel Hill, Chapel Hill, NC
Mentor: William C. Miller, MD
Project: Antimicrobial Susceptibility Surveillance and Development of Algorithms for Clinical Management at Kamuzu Central Hospital in Lilongwe, Malawi

Sarah E. Clifton
Emory University School of Medicine, Decatur, GA
Mentor: Mark Mulligan, MD
Project: Seroprevalance and Duration of Mumps, IgG Antibody Among University Students

Jennifer M. Dan
Boston University School of Medicine, Boston, MA
Mentor: Stuart M. Levitz, MD, FIDSA
Project: Exploiting Pathogen Recognition Receptors in the Creation of a Cryptococcus neoformans Vaccine

Daniel C. DeSimone
University at Buffalo School of Medicine, Buffalo, NY
Mentor: Timothy F. Murphy, MD, FIDSA
Project: Pathogenesis of Haemophilus influenzae in Infection in COPD

Daniel Drozd
University of Washington School of Medicine, Seattle, WA
Mentor: Heidi M. Crane, MD, MPH
Project: The Changing Nature of Mortality and Cause of Death in HIV Disease in the Pre, Early, and Late HAART Eras

Deborah Fromstein
Tulane Medical School, New Orleans, LA
Mentor: Rodrigo Hasbun, MD
Project: Community-acquired Bacterial Meningitis in Children: Factors Contributing to Adverse Clinical Outcomes, Changing Epidemiology and Role of Steroids

Benjamin T. Galen
Mount Sinai School of Medicine, New York, NY
Mentor: Betsy. C. Herald, MD
Project: Novel HSV Vaginal Microbicides: The Use of SiRNA to Prevent HSV in a Murine Model

Kristin Gillenwater
Kansas City University of Medicine and Biosciences, Kansas City, MO
Mentor: Patrick G. Clay, MD
Project: Factors that Influence HIV Positive and Minority Participation in Clinical Research

Alison Han
Morehouse School of Medicine, Atlanta, GA
Mentor: Lilly H. Immergluck, MD
Project: Understanding the Epidemiology of Children with Community-associated MRSA and Soft Tissue Infections

Benjamin Ho
University of Minnesota, Twin Cities, Minneapolis, MN
Mentor: Chandy C. John, MD, MS
Project: Using Multiplex Analysis to Compare Antibody Responses to Blood-stage Plasmodium falciparum Antigens in Individuals Living in Two Highland Areas of Western Kenya

Isaac Howley
Dartmouth Medical School, Hanover, NH
Mentor: Elizabeth A. Talbot, MD
Project: Highly Active Antiretroviral Therapy and Employment in Accra, Ghana

Matthew Israel
Vanderbilt University, Nashville, TN
Mentors: David Kimberlin, MD and Richard Whitley, MD, FIDSA
Project: Antiviral Management of Influenza During Infancy

Meghan E. Jennings
Vanderbilt University School of Medicine, Nashville, TN
Mentor: Peter Wright, MD, FIDSA
Project: Investigation of Dengue Virus Prevalence in Infants: GHESKIO Centers, Haiti

Naana Afua Jumah
Harvard Medical School, Boston, MA
Mentor: Edward T. Ryan, MD, FIDSA
Project: Assessing the Memory B Cell Response to Cholera Infection

Jonathan Katz
VCU Medical Center, Richmond, VA
Mentor: Daniel Nixon, DO, PhD
Project: HIV Management Success Quantified with Viral Load and CD4 Counts in Telemedicine Patients Compared in Clinical ID Preceptorship and Research

Ravi Kavasery
Yale School of Medicine, New Haven, CT
Mentor: Frederick L. Altice, MD
Project: Early vs. Delayed Routine HIV Testing of Substance Abusers, the Mentally Ill, and Other Vulnerable Populations in Connecticut Jails

Lara Knudsen
George Washington University, Washington, DC
Mentor: Peter Hotez, MD, PhD
Project: Antiretroviral Treatment in Uganda and Integration of Reproductive Health Services

Paul J. Krezanoski
Boston University School of Medicine, Boston, MA
Mentor: Davidson H. Hamer, MD, FIDSA
Project: Catalyzing Uptake of Insecticide-treated Bed Nets (ITNs) in Madagascar

Scott E. Landis
University of Tennessee Health Science Center, Memphis, TN
Mentor: Mark A. Land, MD
Project: Seeing the Trees: A Comparative Study of Healthcare Delivery for HIV/AIDS Patients in South Africa, Zimbabwe, and Tanzania

Brandon Libby
Dartmouth Medical School, Hanover, NH
Mentor: Timothy Lahey, MD, MMSc
Project: Study the Cellular Sources of HIV Transmission Via Breastfeeding in Mwanza, Tanzania

Michael Liu
Cleveland Clinic Lerner College of Medicine at CWRU, Cleveland, OH
Mentor: Lara Danziger-Isakov, MD, FIDSA
Project: Host Response to Fungal Infections Following Lung Transplantation in Pediatric Patients

Kelly McGlaughlin
Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA
Mentor: Kathleen Squires, MD, FIDSA

Project: Establishing and Implementing a Database for Integration of HIV Clinical Services and Clinical Trials

Katherine Moran
Georgetown University School of Medicine, Washington, DC
Mentor: Princy N. Kumar, MD, FIDSA
Project: HIV and the Aging Population: Clinical Characteristics and Comorbidities Associated with Highly Active Antiretroviral Therapy

Shilpa S. Murthy
Pennsylvania State University of Medicine, Hershey, PA
Mentor: Cynthia Whitener, MD
Project: Assessment of How Current Water and Sanitation Facilities in Schools in Malawi, Africa, Affect Basic Health Indicators in School Children 

    Dharushana Muthulingam
University of California at Berkeley, Berkeley, CA
Mentor:
Project: C. trachomatis Strain Types in Two Ecuadorian Populations

Shantanu Nundy
Johns Hopkins School of Medicine, Baltimore, MD
Mentor: Trish M. Perl, MD, MSc, FIDSA
Project: Evaluation of WHO Campaign to Reduce Nosocomial Infection Worldwide 

Olutoyin Okanlawon
Vanderbilt University School of Medicine, Nashville, TN
Mentor: Wonder Drake, MD
Project: Characterization of Immune Recognition of Mycobacterial Antigens in Systemic Sarcoidosis 

Sara Oliver
University of Alabama at Birmingham, Birmingham, AL
Mentor: David Kimberlin, MD and Richard Whitley, MD, FIDSA
Project: Neurodevelopmental Impact of Antiviral Suppression Following Neonatal Herpes

Marika Orlov
University of California, San Diego, CA
Mentor: Robert T. Schooley, MD, FIDSA

Project: Impact of Typhoon Favio on Tropical Diseases in Central Mozambique 

Payal Patel
University of Texas Health Science Center – San Antonio
Mentor: Thomas F. Patterson, MD

Project: Detection and Significance of Resistant Yeast 

Aimee Peck
Dartmouth Medical School, Hanover, NH
Mentor: C. Fordham Von Reyn, MD
Project: 37 Million and Counting… 

Lindsay Petty
Penn State College of Medicine, Hershey, PA
Mentor: Tonya J. Crook, MD
Project: HIV Prevention Elective

Steve Pham
University of Pittsburgh School of Medicine, Pittsburgh, PA
Mentor: Jared Spotkov, MD
Project: Project Vietnam - Antimicrobial Use and Impact on MDR Pathogens at Cho Ray

Michelle Phuong-Mai Vu
Boston University School of Medicine, Boston, MA
Mentor: John A. Zaia, MD, FIDSA
Project: A Preceptorship in Phase 1 Infectious Disease Research 

Kimberly Pringle
Jefferson Medical College, Philadelphia, PA
Mentor: Erica Dueger, DVM, PhD
Project: 1. A Public Health Early Warning System for Bacterial, Parasitic, and Viral Causes of Diarrhea, Respiratory Disease and Unspecified Illness in Guatemala
2. Socioeconomic Impact of Febrile Illness on Rural and Urban Guatelmalans 

Jennifer Ross
Oregon Health and Science University, Portland, OR
Mentor: Kevin Winthrop, MD, MPH
Project: Risk Factors for Clinically Significant Giardia intestinalis infection in Peruvian children 

Carrie Sailer
University of Utah School of Medicine, Salt Lake City, UT
Mentor: Adi, Gundlapalli, MD, PhD
Project: Assessment of Influenza-related Capabilities in Utah’s Clinical Laboratories

Dan Schwarz
Brown Medical School, Providence, RI
Mentor: Timothy P. Flanigan, MD, FIDSA
Project: Highly Active Antiretroviral Therapy in Pregnant and Breastfeeding Women in Rural Zimbabwe 

Christopher J. Sellers
UNC-Chapel Hill School of Medicine, Carrboro, NC
Mentor: Irving Hoffman, MD
Project: HIV/AIDS Clinical Research and Clinical Preceptorship in Infectious Diseases in Lilongwe, Malawi 

Sonia Singh
University of South Alabama College of Medicine, Birmingham, AL
Mentor: Suresh B. Boppana, MD
Project: Development of Loop Mediated Amplification Method to Detect CMV in Newborns

Sara K. Tedeschi
Vanderbilt University School of Medicine, Nashville, TN
Mentor: Clarence “Buddy” Creech, MD, MPH
Project: The SWAN Study: Staphylococcus aureus in Women and Neonates 

Ashwin Vasan
University of Michigan Medical School, Ann Arbor, MI
Mentor: Carol A. Kauffman, MD, FIDSA
Project: Assessment and Recommendation of Antiretroviral Therapy by Health Workers in Uganda Using the WHO integrated Management of Adolescent and Adult Illness (IMAI) Algorithm 

Ryan J. Vealey
University of Vermont College of Medicine, Burlington, VT
Mentor: Nalini Singh, MD, MPH, FIDSA
Project: Investigation of New Community-acquired MRSA Clones Causing Invasive Infections in the Pediatric Population of the Washington, DC Area

Kartik K. Venkatesh
Warren Alpert Medical School at Brown University, Providence, RI
Mentor: Kenneth H. Mayer, MD, FIDSA
Project: Secondary HIV Prevention in a Clinical Care Setting in South India

Tina S. Wu
UCLA, David Geffin School of Medicine, Hollywood, CA
Mentor: Ellie J.C. Goldstein, MD, FIDSA
Project: Clinical Infectious Diseases Preceptorship plus Lab/Clinical Investigation on C. difficile Trasmission

Louis Yu
State University of New York Downstate Medical Center, Brooklyn, NY
Mentor: Jack A. DeHovitz, MD, MPH, FIDSA
Project: Tackling the Youth AIDS Epidemic in the Drug Abuse Prevalent Favelas of Rio De Janiero, Brazil Through Healthy Sports Participation

IDSA Announces New Board Members

The results are in! IDSA is pleased to announce the winners of this year’s election to the Board of Directors. They took positions on Saturday, Oct. 6, during the 45th Annual Meeting of IDSA in San Diego.

Vice President

Richard J. Whitley, MD, FIDSA, is the director of the division of pediatric infectious diseases and vice chair of the department of pediatrics at the University of Alabama at Birmingham. Dr. Whitley was previously chair of IDSA’s Annual Meeting Program Committee. He served on the editorial board for the Journal of Infectious Diseases(JID) and was chair of the JID Editor Selection Committee.

Secretary

William Schaffner, MD, FIDSA, is professor and chairman of the Department of Preventive Medicine and professor of medicine in the Division of Infectious Diseases at Vanderbilt University School of Medicine. He has served as hospital epidemiologist at Vanderbilt University Hospital for nearly 30 years and is an active member of 20 professional societies. He has served on various IDSA committees including the Awards Committee, the Public Policy Committee, and the JID Editor Selection Committee. He chaired the IDSA Public Health/Preventive Medicine Committee and is a founding member of the Tennessee Infectious Diseases Society.

Directors

Stephen B. Calderwood, MD, FIDSA, is professor and chief of the division of infectious diseases at Massachusetts General Hospital. He has served on IDSA’s ID Training Program Directors Committee, the Board of State and Regional Societies, and the Education Committee, and was chair of the ID Training Program Directors Committee.

Sandra A. Kemmerly, MD, FIDSA, is associate chair of infectious diseases at Ochsner Medical Center, medical director of Ochsner Health System, and clinical assistant professor of medicine at Louisiana State University School of Medicine. She has served on the IDSA Clinical Affairs Committee and the Annual Meeting Program Committee. Dr. Kemmerly is a member of the Louisiana/Mississippi Infectious Diseases Society Board and currently serves as an abstract reviewer for the IDSA Annual Meeting.

HIVMA Representative

Daniel R. Kuritzkes, MD, FIDSA, is associate professor of medicine at Harvard Medical School and director of AIDS research at Brigham and Women's Hospital. He is also head of the Section of Retroviral Therapeutics for the Harvard Division of AIDS and principal investigator of the Harvard Adult AIDS Clinical Trials Unit. He has served on the HIVMA Board of Directors, the National Institutes of Health AIDS Research Review Committee, and has been an associate editor of JID since 2002.

Welcome, New IDSA Members!

Members

Boyanton, Bobby Loyd, MD
Cono, Joanne, MD
Grant, Jennifer, MD
Ionnidis, John P., MD
Jacobsen, Thomas, PharmD, MS
Kim, Myo-Kyoung, MD 

Associate Members

Bernard, Janet 
Chun, Byung, MD, MPH
Lam, Jerika, PharmD

Members-In-Training 

Adalja, Amesh, MD
Becker, Sara, MD
Benjamin, Alex, MD
Chang, Amy, MD
Chary, Aarth, MD
Chavez, Temujin, MD
Christaki, Eirini, MD
Elemam, Azza, MD
Gholami, Amir, MD
Gilkeson, Julie, MD
Hermos, Christina, MD
Hersh, Adam, MD
Hogan, Brian, MD
Islam, Aticu, MD
Kalaskar, Anupama, MD
Kassis, Simon, MD
Kaur, Preeti, MD
Lake, Jordan, MD
Lee, Dong, MD
Marmolejos, Indira, MD
Minniear, Timothy, MD
Mitsani, Dimitra, MD
Mizrachi, Michelle, MD
Mudakha, Shikata, MD
Nayak, Jennifer, MD
Oo, Theingi, MD
Park, Daniel, MD
Patel, Sameer, MD
Peters, Laurenna, MD
Rao, Sriharsha, MD
Raoof, Nazar, MD
Schirmer, Patricia, MD
Serafino-Wani, Robert, MBBS, MRCP
Shoumou, Jean, MD
Thompson, Kathy, MD
Tippor, Shamant, MD
Torok, Mili Estee, MD
Vais, Dana, MD
Versari, Veronica, MD
Wada, Takaaki, MD
Wyatt, Casi, MD
Yeramian, Christine, MD, MS
Zerbe, Christa, MD

Electronic Tools for Infectious Diseases Practitioners

As the development and implementation of health information technology (HIT) continues, incorporating its use in daily practice has become quite an endeavor.  Steven D. Burdette, MD, FIDSA, and Steven K. Schmitt, MD, FIDSA, tackled this vast arena at IDSA 2007 in the Meet-the-Professor session, “Electronic Tools for Infectious Diseases Practitioners.” The informative overview covered electronic medical record (EMR) software selection, unintended consequences of EMR, Internet resources for practitioners, and a live demonstration of the use of health information technology in daily practice. 

EMR software varies widely and each package will look different, use different data structures in databases, and have different means of input, Dr. Burdette said. Choosing the right EMR software requires time and commitment. He identified a useful set of key tasks and considerations for navigating the decision-making process. Some of those considerations included: 

  • Identifying key stakeholders and forming a decision-making team
  • Scheduling demos with vendors and ranking them according to cost, function, and service
  • Visiting working sites and compiling references
  • Presenting the findings to your group 

Dr. Schmitt added that ID doctors must get involved at the decision-making stage. ”What we need is not what the generalists need; it’s not what the family physicians need. We need ways to quickly review cultures and the only one who knows that is you. “ 

HIT tools also include online resources, clinical electronic prescribing, electronic scheduling software, and personal health records. As with any technology, there are some unexpected consequences of implementing the new processes that accompany these tools. Distraction from the doctor-patient relationship, plagiarism and ethical concerns, and additional functions being performed by physicians rather than ancillary personnel are just a few of these consequences. 

Both Dr. Burdett and Dr. Schmitt provided ID-specific web resources and a live demonstration of just how personal technology can aide practitioners on a daily basis.Managing technology rather than letting it manage you is key to successful integration with daily practice.


Slides from this session and many more can be found on the IDSA website.

Audio files of individual sessions or a full-conference CD-ROM are available for purchase from Sound Images.

From the President

The Practicing ID Doctor

As I take the helm as one of the first private practitioners elected president of IDSA I remember my first Annual Meeting, back in 1971. I went with my chief, John Utz, MD, a well-respected and renowned mycologist who was an early leader of the Society. I stood behind him, awestruck, as he mingled with the biggest names in the field.

The meeting at that time was a purely academic affair, and few private practitioners attended. The main session was a two-hour talk on the third component of complement—important, but academic. When in the early 1980s I gave a talk to the Society about the private practice of infectious diseases—the first time the subject had been presented at IDSA—there were only a handful of us in the audience of about 1,000. Private practitioners were not represented on IDSA committees, and we had few opportunities to provide our input.

But the Society has evolved dramatically since then. Today’s IDSA includes academicians, basic and clinical researchers, public servants, military physicians, and members of the pharmaceutical and biotech industries, as well as private clinicians—in fact, more than half of IDSA members list patient care as their primary work activity.

The benefits of our diversity were on full display at this month’s 45th Annual Meeting, in San Diego. One needs to look no further than the named lectures to see the range and depth of IDSA. Louis B. Rice, MD, gave an exhilarating talk on antibiotic resistance, an issue of practical importance to infectious disease practitioner taking care of patients. Kathryn M. Edwards, MD, FIDSA, spoke eloquently on the global impact of influenza, one of our most common viral adversaries. The presentation by Thomas C. Quinn, MD, FIDSA, on lessons from Africa in HIV prevention was stimulating from a scientific, practical, and human-nature point of view. And the stimulating lecture by David Relman, MD, FIDSA, showed how we may change the way we think about microbiota and microenvironments.

The rest of the meeting continued in the same vein. With practical talks for the practicing adult and pediatric clinician, topics of international relevance, a track dedicated to HIV, and cutting-edge research, IDSA 2007 reflected our diversity while furthering our knowledge.

Our diversity fosters a symbiotic relationship among our members. Our private practitioner members rely on our academic members to stay on top of the latest research and developments in our field. Conversely, academicians increasingly are relying on lessons from private practitioners on how to stay afloat as the economics of health care and federal funding change and as funding from the National Institutes of Health becomes harder to come by. Our academic colleagues are more commonly encountering the problems with low reimbursement for cognitive services—which comprise much of what we do—that private practitioners have been struggling with for years. Office-based infusion therapy also is under attack, and low reimbursement may make it difficult for either private or academic clinics to offer this valuable service.

As one who has spent his career facing the economic difficulties of infectious diseases practice, I am honored to be president of IDSA at this challenging time. I also am honored to be elected to lead such a diverse and eminent Society.   As I was at my first IDSA Annual Meeting way back in 1971, I remain in awe of our distinguished membership. I look forward to serving you, and I welcome your feedback.

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Public Reporting of HAIs May Have Unintended Consequences

Everyone agrees that hospitals must be made safer for patients, but not everyone agrees on the best way to make this happen. Public reporting of HAIs has been offered as a possible solution, but it could in fact have unintended consequences. That was the consensus of panel members at a symposium on public reporting at IDSA’s 45th Annual Meeting this month in San Diego. Public reporting, they said, could encourage hospitals and physicians to avoid sicker patients, use intervention targets that may not be appropriate for all patients, and diminish the role of patient preferences and clinical judgment.

There has been significant legislative and regulatory activity around HAIs, according to Denise M. Cardo, MD, FIDSA, of the Centers for Disease Control and Prevention’s Division of Healthcare Quality Promotion. At least 40 states have introduced or passed HAI legislation and eight states have considered additional legislation specific to methicillin-resistant Staphylococcus aureus.

 Click on map to enlarge.

There’s wide variation in the complexity of bills in various states, Dr. Cardo said, with little focus on the validation of reported data. In most states, the reporting systems are an unfunded mandate.

At the federal level, the “Healthy Hospitals Act” has been proposed that would mandate reporting of HAIs. In addition, the federal Deficit Reduction Act of 2005 requires Medicare to stop paying for certain health care-associated conditions (see IDSA News, September 2007). One important bill has been introduced to address antimicrobial resistance (see http://www.idsociety.org/STAARact.htm).

Neil Fishman, MD, of the University of Pennsylvania, described his home state’s new public reporting mandate, which was signed into law in July 2007. Among other things, the new law requires all hospitals to become members of the National Healthcare Safety Network, compile monthly reports on multiple measures, report HAIs to the state, and disclose a new HAI to the patient in writing within 24 hours of detection. The law will provide financial rewards for hospitals that see a 10 percent or more reduction in HAIs. Hospitals that fail to comply with the law will be fined $1,000 a day.

The speakers questioned some of the basic assumptions of advocates of public reporting—for example, although hospitals that report their infection rates generally will work to lower them, it is not yet proven that hospitals that report lower rates are safer or that informed patients will obtain safer care. Some assumptions inherent in public reporting need to be tested, said Robert A. Weinstein, MD, FIDSA, of Stroger (Cook County) Hospital and Rush Medical College.

Public reporting is not a new idea, Dr. Weinstein noted. In the 1980s and 1990s, New York and Pennsylvania reported on cardiac surgery outcomes. However, according to one study, most patients did not actually use the data—either because they were not aware of the data, did not trust it, or did not understand it. Physicians did not use it, either—62 percent reported that the data had no influence on them, and 82 percent cited inadequate risk adjustment. The same study found that cardiac surgeons were turning away the most severely ill patients, with a 31 percent increase in transfers. The study also found an increase in racial disparities. (Werner RM, Asche DA. JAMA 2005;293:1239-44).

According to Dr. Weinstein, certain lessons emerged from the cardiac surgery experience. Outcomes data needs to be risk-adjusted so that providers who see sicker patients aren’t unfairly penalized. The choice of denominators in quality measures is important, so it’s clear what’s being compared. Sophisticated information technology is needed. Benchmarks need to be established (for example, it’s challenging to come up with a fair rate to report in a small hospital that sees few patients). And trends in a given hospital’s rates over time may be more useful than hospital-to-hospital comparisons, he said.

For public reporting to succeed, Dr. Weinstein said, research is needed to identify meaningful metrics, determine the best ways to report them, and assess whether the reports actually improve patient care and safety.

Several speakers noted a cautionary tale of unintended consequences: In 2003, IDSA’s community-acquired pneumonia (CAP) guidelines recommended antibiotics within four hours of emergency department registration. The Centers for Medicare and Medicaid Services adopted this recommendation as a quality measure. Antibiotic use went up—because more patients were being misdiagnosed with CAP. There was no change in mortality. The guidelines have since been revised, but the lesson remains: Rigid adherence to a “quality measure” actually lowered the quality of care. 

Until now, public reporting has not been demonstrated to decrease infection rates or improve quality of care, said Dr. Fishman. Thus far, it’s a case of legislation outpacing science.

Slides from this session and many others from IDSA 2007 are available online.

Audio files of individual sessions or a full-conference CD-ROM are available for purchase from Sound Images.

Treatment Options for C. difficile

With the emergence of a binary toxin positive strain (BI/NAP1/027), the face of Clostridium difficile infection (CDI) has changed since the late 1980s. CDI is now more prevalent and virulent. Meanwhile, the effectiveness of metronidazole has decreased, leaving fewer antimicrobial options for treatment. At the 45th Annual Meeting of IDSA, in San Diego, a large audience of ID specialists gathered to hear experts discuss current and emerging treatment options, which include antibiotics as well as some rather unconventional methods to repair broken ecosystems in the colon.  

According to L. Clifford McDonald, MD, of the Centers for Disease Control and Prevention, BI/NAP1/027 is now present in at least 28 states and most European countries. “Although we’ve identified C. difficile in 28 states, it’s probably in every state,” he added. A study of a Quebec outbreak in 2004 showed that the 30-day attributable mortality rate was 6.9 percent, with a 12-month direct and indirect attributable mortality of 16.7 percent—compared with an attributable mortality of less than 1 percent in a 1988 Boston hospital in 1998. Mortality and prevalence are highest in the elderly.

Problems with CDI Management

With recurrence rates of 20 to 30 percent, CDI is difficult to manage. Dale N. Gerding, MD, FIDSA, of the Hines VA Hospital in Hines, Ill. presented data that suggest a changing response to metronidazole. “Vancomycin appears to be superior for severely ill patients,” he said. A recent study by F.A. Zar et al. suggests a statistically significant superiority in the response rate of vancomycin over metronidazole for severe disease but not for mild disease, although relapse rates associated with the two drugs appear to be similar.

With vancomycin as the only FDA-approved drug for CDI and the off-label use of metronidazole less effective than it once was, presenters at the session discussed potential strategies to improve CDI treatment. One is to use antimicrobial treatment that spares normal flora. Rifaximin, one such drug, is being studied in a Phase III trial for CDI, as is OPT-80, an investigational agent from Optimer.

Nonpharmacologic Approaches

A presentation from Tom Moore, MD, with Infectious Disease Consultants in Wichita, Kansas, included a number of alternative treatment methods for recurrent CDI. These treatments restore the normal colonic bacterial flora. Such methods include prebiotics and probiotics as well as the somewhat controversial method of fecal bacteriotherapy, which restores colon homeostasis by reintroducing normal bacterial flora from stool obtained from a healthy donor. Benefits of fecal bacteriotherapy include reducing the risk of antibiotic-associated resistance, cost savings when compared to repeated courses of antibiotic therapy, and high success rate. Of 80 published reports, the success rate was 94 to 100 percent. Although the benefits are apparently great, there are potential obstacles and risks, which include limitations that might be imposed by the local institutional review board and lack of Medicare coverage for donor stool screening and instillation procedure. Physicians with experience using fecal bacteriotherapy were encouraged to publish their findings.


Slides from this session and many others from IDSA 2007 are available online. 

Audio files, including a full-conference CD-ROM, are available for purchase from Sound Images.

XDR TB: Where it Came From, Where We’re Going

Where have extensively drug-resistant strains of tuberculosis (XDR TB) come from?  How can they be treated? Are there new drugs in the pipeline to fight them? These were the key questions on the agenda at a symposium on XDR TB during IDSA 2007 in San Diego.

Last November, a study in The Lancet (2006; 368:1575-1580) brought to light an outbreak of highly virulent XDR TB in KwaZulu Natal, South Africa. At the symposium, lead author Neel Gandhi, MD, of the Albert Einstein College of Medicine, said TB treatment facilities had been overwhelmed by rising TB rates driven by the growing HIV epidemic. Treatment completion rates suffered, Dr. Gandhi said, and, “One could postulate that low TB treatment completion rates gave rise to a large number of cases of MDR TB.”

But that was just the first step, he added. XDR TB may have arisen, in part, because all MDR TB patients must travel to a single hospital in the nearest major city—a difficult and expensive journey for those living in far-flung rural areas. Many patients likely ended up discontinuing their treatment. “As a result,” Dr. Gandhi said, “patients with incompletely treated MDR TB may have amplified resistance to second-line drugs, resulting in XDR TB.” 

However, incomplete treatment alone does not explain how XDR TB spread to so many patients, he said. Dr. Gandhi presented genetic evidence suggesting that patients being treated for susceptible TB were likely re-infected with new, resistant strains while in the hospital. “Since we believe that primary transmission is the principal driver,” he said, “creating effective infection control programs is the first critical step” to controlling the epidemic. 

The other key step is to diagnose patients earlier so that infection control can be applied quickly and the right treatment can begin promptly. According to Dr. Gandhi’s modeling estimates, combining these two steps can cut future XDR TB cases in half.

Treatment prospects for patients with XDR TB are by definition slim, commented Neil W. Schluger, MD, of Columbia University. Quinolones, especially moxifloxacin, are believed to be very active against many cases of drug-resistant TB (although XDR TB is, by definition, resistant to at least one fluoroquinolone); however, he noted, “One of the very worrisome things about quinolones and the treatment of TB is how available quinolones are in the world generally. This raises the question of whether TB has already become resistant to fluoroquinolones because of their widespread use.”

Linezolid has been used with some success in a very small number of MDR and XDR TB cases. But the drug is very expensive and serious adverse events were common.

Surgery has a fairly high success rate, from 75 to 98 percent in published studies. However, Dr. Schluger said, any surgical procedure to remove part of the lung “is a big operation and has considerable mortality associated with it.”

Furthermore, surgery may not help patients with the most resistant strains, Dr. Schluger added. “If you operate on a patient but you don’t have any drugs to give that patient after surgery, that patient is probably not going to do well,” he said.

There is a glimmer of hope for new drugs to treat MDR and XDR TB, according to the Global Alliance for TB Drug Development’s Ann M. Ginsberg, MD, PhD. Two new fluoroquinolones—moxifloxacin and gatifloxacin—are in phase III clinical trials. Three other drugs with novel modes of action are in phase II: Tibotec’s diarylquinoline compound TMC207, and two nitroimidazole compounds: OPC-67683, by Otsuka Pharmaceutical Co., Ltd., and the Global Alliance for TB Drug Development’s PA-824. Trials for the first two drugs are enrolling MDR TB patients specifically.

Two other compounds are in phase I clinical trials. “We’re a lot further along than we were in 2000. Having seven compounds in the clinic is reason for hope,” Dr. Ginsberg said.


Slides from this session and many others from IDSA 2007 are available online.  

Audio files of individual sessions or a full-conference CD-ROM are available for purchase from Sound Images.