IDSA News - April 1, 2008
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“Limited” Progress Against Polio in Afghanistan and Pakistan

The number of polio cases in 2007 declined in Afghanistan and Pakistan, two of the last countries where transmission has never been interrupted.

The number of polio cases in 2007 declined in Afghanistan and Pakistan, two of the last countries where transmission has never been interrupted. But security and operational problems remain significant barriers to stopping transmission, according to a recent report by the international polio eradication partnership.

The March 28 issue of Morbidity and Mortality Weekly Report from the U.S. Centers for Disease Control and Prevention reports that Afghanistan had 17 cases in 2007, down from 31 in 2006. Pakistan had 32 polio cases in 2007, compared to 40 in 2006.

Polio transmission continued in regions where significant numbers of children were not fully vaccinated. These regions include remote border areas of both countries, where security concerns have hampered vaccination efforts. In a breakthrough in August 2007, anti-government forces in Afghanistan agreed to support vaccination campaigns.

Security was not the only factor contributing to the spread of polio in Pakistan, though. Vaccination campaigns in some relatively secure southern districts also missed significant numbers of children and had several polio cases as a result.

Most of the 2007 vaccination campaigns targeted the more virulent type 1 virus with monovalent vaccine, alone or in addition to trivalent vaccine. The proportion of cases caused by type 1 virus declined in Afghanistan between 2006 and 2007, from 94 percent to 35 percent, but increased slightly in Pakistan, from 50 percent to 59 percent.

The report described progress against polio as “limited,” and said improvements in security, as well as the quality of vaccination campaigns in secure areas, will be needed to eradicate the disease.

As NIH Funding Dries Up, Young Scientists Are Leaving Biomedical Research

Five consecutive years of flat funding for the National Institutes of Health (NIH) is deterring promising young researchers and taking a severe toll on American medical research, according to a new report by seven major academic research institutions.

The report, “A Broken Pipeline? Flat Funding of the NIH Puts a Generation of Science at Risk,” documents the toll and profiles junior researchers from institutions across the country who are facing funding difficulties.

“Right now, the nation’s brightest young researchers, upon whom the future of American medicine rests, are getting the message that biomedical research may be a dead end and they should explore other career options—and in too many cases, they’re taking that message to heart,” said Drew Faust, PhD, president of Harvard University.

The report focuses particularly on the effect on young researchers, who are getting a much smaller piece of the NIH pie. However, the report notes that “competition for limited resources is affecting scientists at every point of the academic research pipeline.”

Between 1998 and 2003, the Clinton and Bush administrations and Congress doubled the NIH budget—fueling such innovative projects as the completion of the human genome project and the creation of powerful new tools that create a window into biological systems. Everything changed in 2003, when the budget increases stopped. Since that time, NIH’s budget has experienced a 13 percent drop in real purchasing power—a drop opposed by IDSA and other supporters of biomedical research.

Today, only one in ten grants is funded upon first submission. Rejected grants must be resubmitted, which clogs the system and results in a queue in which young researchers feel they are “at the back of the pack.”

“The feedback I received from one reviewer was that my ideas were ‘very innovative and had the potential to make a big impact, but they were too risky,’” said Tricia Serio, PhD, an assistant professor at Brown University whose research is focused on Creutzfeldt-Jakob and other progressive brain diseases. Her point was echoed by other young researchers who said they have stepped away from riskier research.

Their fears are well founded. The overall success rate for NIH research project grants dropped from 32 percent in 1999 to 24 percent in 2007. Only about one in four original research applications is being funded, and many of those are only partially funded.

The report was co-authored by Brown University, Duke University, Harvard University, the Ohio State University, Partners Healthcare, the University of California Los Angeles, and Vanderbilt University. It and a companion report, “Within Our Grasp—Or Slipping Away? Assuring a New Era of Scientific and Medical Progress,” are available online at www.brokenpipeline.org

IDSA Advocacy Update: IDSA Opposes Bundling Hospital and Physician Payments

The Medicare Payment Advisory Commission (MedPAC) has recommended that for some episodes of care, reimbursement for hospitals, physicians, and other providers should be bundled together into a single payment made to hospitals. 

In a letter to MedPAC, IDSA expressed its concerns that a bundled payment model in which hospitals control the purse strings would provide an unfair advantage to hospitalists working on the hospital’s payroll at the expense of private practitioners, including infectious diseases specialists. IDSA said the policy could split infectious diseases practice into hospitalists providing inpatient care and private practitioners providing outpatient care, disrupting continuity rather than improving patient care.

MedPAC’s recommendations will be included in its June report to Congress.

Other recent advocacy efforts include:

  • IDSA submitted testimony to the House Appropriations Subcommittee on Labor, Health and Human Services, and Education opposing disastrous cuts in the president’s fiscal year 2009 budget.

  • IDSA joined other physician groups in supporting the Save Medicare Act of 2008.  A coalition of physician specialty and state medical societies urged senators to co-sponsor legislation that would reverse planned cuts in physician payments which threaten access to care for Medicare beneficiaries.

New Online Resource Tracks State Bills on Thimerosal and Lyme Disease

A new Legislative Map and Advocacy Resources page on the IDSA website highlights state legislation that would restrict thimerosal in vaccines and mandate insurance coverage for controversial Lyme disease treatments.

The page features a clickable map of all 50 states that links to a list of the current and previous bills in each state. The resource includes information about specific provisions of each bill and the bill’s status. Also included are IDSA position letters that can be adapted by state and regional ID societies and local IDSA members.

Please contact IDSA staff with questions or comments about these resources.

Survey Finds Support for Board Review, MOC Courses

IDSA’s recent survey of members’ educational needs found strong interest in the Society offering American Board of Internal Medicine (ABIM) maintenance of certification (MOC) and board review courses.

The survey found 42.5 percent of respondents are enrolled or are planning to enroll in an MOC program for ID certification and would be interested in either a free-standing course or one connected with the Annual Meeting.

The survey, sent to the entire membership this winter, found overall satisfaction with the educational offerings of IDSA’s Annual Meeting. Based on member responses, the Annual Meeting is the premier source for continuing medical education (CME) credit. Aside from live meetings, there is a preference for enduring materials as a CME format.  Those who find the Internet useful for CME prefer self-paced online and online journals as formats. 

Topics with the greatest relevance include:

  • antimicrobial resistance
  • bacterial infections
  • clinical practice guidelines

The survey results will help IDSA plan future educational activities, including the Annual Meeting.

Updated HPV Fact Sheet Available from Kaiser Family Foundation

An updated fact sheet on human papillomavirus (HPV) vaccination policy is available from the Kaiser Family Foundation.

The fact sheet, HPV Vaccine: Implementation and Financing Policy in the U.S., highlights the states that offer funding for the vaccine and those that have mandatory vaccine requirements. Other topics include public and private financing for the HPV vaccine, and public outreach and education.

HPV is an increasingly prevalent infection in the United States. According to a recent survey by the Centers for Disease Control and Prevention (CDC), one in four women ages 14-59 in the United States carry HPV, thus increasing their risk of cervical cancer. The vaccine, Gardisil, which was introduced in June 2006 by Merck, prevents four strains of HPV, with two of those strains being the root of 70 percent of cervical cancer cases. FDA also is reviewing for approval GlaxoSmithKline’s HPV vaccine, Cervarix.

The fact sheet is available on the Kaiser Family Foundation website under Women’s Health Policy.

Drug Approvals, Recalls, Adverse Events Update

IDSA offers two e-mail services to help members stay informed of updates from the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). Recent alerts have included:

CDC Health Alert Network (HAN):

FDA Alerts:

IDSA members can sign up for this service online.

EIN: Antimicrobial Stewardship: Good Idea, Hard to Carry Out

The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of the EIN, the Infectious Diseases Society of America (EIN's sponsor) or the Centers for Disease Control and Prevention, which funds the EIN. The reader assumes all risks in using information.

While rising rates of antimicrobial resistance are driving many institutions to adopt antimicrobial stewardship programs, many are finding the principle difficult to put into practice. Some physicians from across the medical spectrum ignore recommendations to reduce unnecessary use of antimicrobials. In a recent discussion on the EIN listserve, members shared their suggestions for making this important concept work.

Some respondents discussed the need to develop institutional guidelines and “best practice” standards drawing from the IDSA/Society for Healthcare Epidemiology of America (SHEA) antimicrobial stewardship guidelines. One member is focusing on developing clinical practice guidelines designed specifically to focus on conditions involving high rates of antimicrobial usage such as Clostridium difficile-associated diarrhea, ventilator-associated pneumonia, catheter-associated infections, and surgical site infections.

To encourage buy-in, members recommend that “problem prescribers” should be encouraged to participate in formulating guidelines. “Our drafts will be discussed openly at ID conference, and we’ll give everyone a chance to weigh in and be heard,” the member said. “The end product won’t satisfy everyone, but it should be a step in the right direction.” Encouraging outliers to participate in pharmacy and therapeutics committees may also be helpful, another member suggested.

However, it may take a person-to-person approach to change individual habits. “Guidelines make sense. They are comforting and often right, but people need more,” one member said. “The reason an antimicrobial stewardship program is usually successful is because a physician will usually respond to another physician.”

A member suggested talking to problem prescribers in private about their prescription orders. “Chances are they haven't spent as much time thinking about the orders as you have.” Also, “Find out from them what they need and how you can work together,” the member said. Focus on the most active physicians. Others often follow their lead. Get to know your emergency department and surgical pre-op teams. These often are areas where improvements can be made, the member added.

If offering “carrots” doesn’t work, another member said, “The ‘stick’ approach is to track all of the patient harm, increased cost, longer length of stay, etc., which result from their poor clinical care. After several months you should have some ammunition to use with the administration in case there are a few stinkers who still refuse to play ball.”

IDSA and SHEA are working on materials to help institutions as they implement antimicrobial stewardship programs. Watch for more information in upcoming issues of IDSA News.


ID Literature Review: March 2008

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

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



 Two Studies on Screening Patients for MRSA Reach Conflicting Conclusions

Sara E. Cosgrove, MD, MS

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

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

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

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

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 Airborne Varicella-Zoster Virus from Patients With Shingles?

Jason B. Weinberg, MD

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

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

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

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

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 Circumcision Lowers Rates of HPV in Men

Melinda M. Pettigrew, PhD

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

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 PIs Associated with Elevated Fibrinogen Levels

Sabrina R. Kendrick, MD

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

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

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

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

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

Negligible Public Health Risk from Cardiovascular Complications of HAART

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

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In the IDSA Journals

Outcomes of Pseudomonas aeruginosa Bacteremia 

P. aeruginosa bacteremia is associated with grave clinical outcomes, and piperacillin-tazobactam is commonly used as first-line empirical therapy. However, various national regulatory agencies have identified different susceptibility threshold breakpoints for the drug. In this study, which involved 34 patients with bacteremia who had isolates with reduced piperacillin-tazobactam susceptibility (i.e, minimum inhibitory concentration (MIC) of 32 mg/L or 64 mg/L), seven patients received empirical piperacillin-tazobactam, and 27 patients received other appropriate therapy. Thirty-day mortality was found to be 86 percent in the piperacillin-tazobactam group and 22 percent in the other group. In contrast, patients with highly susceptible organisms (MIC ≤16 mg/L) had a mortality rate similar to that of controls. The authors suggest that further studies should examine the appropriateness of the CSLI resistance breakpoint for piperacillin-tazobactam. (Tam et al., Clin Infect Dis. 2008;46:862-867.)

Pandemic Influenza Planning in the United States

This review summarizes planning efforts for pandemic influenza based on proposals from the U.S. Department of Health and Human Services and assessment of these plans from authoritative nongovernmental sources. Despite a variety of substantial planning efforts that have been undertaken in recent years, the authors conclude that the United States needs to be better prepared, and they identify a number of issues that should be addressed. (Bartlett and Borio, Clin Infect Dis. 2008;46:919-925.)

Steroids for Hepatosplenic Candidiasis

Hepatosplenic candidiasis is observed in almost 5 percent of patients with acute leukemia treated with intensive chemotherapy. It occurs principally during neutrophil recovery. Treatment usually consists of several months of antifungal therapy and usually requires postponement of the antileukemic therapy. In this study, corticosteroids were given to patients whose symptoms continued despite antifungal therapy. The addition of corticosteroid therapy appeared to result in a more rapid resolution of symptoms and a shorter hospitalization than has been historically reported. (Legrand et al., Clin Infect Dis. 2008;46:696-702.)

HIV-1 Subtype Influences Disease Progression

In a group of 350 patients in Rakai, Uganda, those infected with HIV-1 subtype A took longer to progress to AIDS or die than those with subtype D, multiple subtypes, or recombinant subtypes. These findings suggest that HIV-1 subtype may need to be considered when deciding when to start treatment, and may have implications for vaccine research. (Kiwanuka et al., J Infect Dis. 2008;197:707-713; commentary by Kuritzkes, J Infect Dis. 2008;197:638-639.)

More from the literature…

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

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

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

April 1

  • Influenza Takes Its Toll
  • Oseltamivir Resistance Slams Europe
  • Fish and Worms in Vietnam
  • How Did Chikungunya Get That Way?

April 15

  • Antiviral Therapy for Bell's Palsy?
  • HIV and Haiti
  • Candidemia and the Eye
  • Ampicillin Susceptibility Testing Predicts Imipenem Susceptibility in Enterococci—But Not Always

New Guidelines Help Physicians Evaluate Fever in Critically Ill Patients

Newly updated guidelines from IDSA and the American College of Critical Care Medicine are intended to help ICU physicians evaluate a new fever in their patients and determine whether infection is present so that additional testing can be avoided and therapeutic decisions can be made. The guidelines also offer a helpful background check for infectious diseases physicians who do consults in the ICU.

In some ICUs a new fever in a critically ill patient can trigger automatic orders for many time-consuming, costly, disruptive tests. The patient may experience discomfort, be exposed to unneeded radiation, have to be transported out of the controlled environment of the ICU, or experience considerable blood loss.

Because fever can have many infectious and noninfectious etiologies, a new fever instead should trigger a careful clinical assessment. “It’s important to make sure the measurement of temperature is an accurate reflection of the patient’s physiology,” said lead author Naomi P. O'Grady, MD, senior staff physician in the critical care medicine department of the National Institutes of Health. Any unexplained temperature elevation merits a clinical assessment that includes a review of the patient’s history and a focused physical examination before any lab tests or imaging procedures are ordered.

The new guidelines include a discussion of novel technologies to measure temperature, with the most accurate being pulmonary artery thermistor, urinary bladder catheter thermistor, esophageal probe, and rectal probe. Technologies to avoid include temporal artery thermometer, axillary thermometer and chemical dot.

A section on blood cultures reports that new data suggest that the cumulative yield of pathogens is optimized when three to four blood cultures are drawn within the first 24 hours of suspected bacteremia or fungemia.

The guidelines include specific recommendations for evaluation of:

  • pulmonary infections and ICU-acquired pneumonia, including an evaluation of new technologies
  • gastrointestinal tracts of patients who are at risk for Clostridium difficile, including a discussion of common antigen testing and follow up
  • urinary tracts for infections related to urinary catheters including bacteriuria and candiduria
  • sinusitis
  • fever within 72 hours of surgery
  • surgical site infections
  • central nervous system infections

The guidelines also make recommendations about other considerations such as the use of biomarkers to determine the cause of fever and how to recognize noninfectious causes of fever, such as new medications.

Finally, the guidelines conclude with an expanded discussion of empiric therapy for unstable or high-risk patients while the diagnostic evaluation is ongoing.

The “Guidelines for Evaluation of New Fever in Critically Ill Adult Patients: 2008 Update from the American College of Critical Care Medicine and the Infectious Diseases Society of America,” were published in Critical Care Medicine. (O’Grady et al., Crit Care Med. 2008;36:1330-49.)

Penicillin’s Back: FDA Raises Breakpoints for S. pneumoniae Pneumonia

Penicillin, one of the safest and most effective drugs for the treatment of community-acquired pneumonia caused by Streptococcus pneumoniae, is back in the armamentarium following action by the Food and Drug Administration (FDA) and pressure from IDSA and several key members.

FDA has raised the concentration at which S. pneumoniae is considered susceptible to penicillin, according to an amended package insert for Baxter Healthcare Corporation’s penicillin G approved by FDA and obtained by IDSA. The breakpoint changes are:

 

 

 

Minimum Inhibitory Concentration (MIC) (mcg/mL)

 

Susceptible (S)

Intermediate (I)

Resistant (R)

Updated

≤2 

4

≥8

Previous 

≤0.06

0.12-1.0

≥2

The susceptible breakpoint for meningitis caused by S. pneumoniae remains unchanged (0.06 mcg/mL). The package insert is available online from FDA’s website.

Evidence has been mounting for years that penicillin is effective against pneumococcal pneumonia at concentrations that would fail for meningitis or otitis media. Victor L. Yu, MD, FIDSA, co-authored one significant study in Clinical Infectious Diseases in 2003 looking at patients with pneumococcal bacteremia who were initially treated with penicillin before laboratory tests came back resistant. “It turned out they uniformly did fine,” Dr. Yu said. The study won IDSA’s Emmanuel Wolinsky Award in 2003. Since then, several other studies have been published showing penicillin is effective against pneumococcal pneumonia at concentrations that would fail for other diseases.

IDSA strongly supported legislation passed last fall that requires FDA to update antimicrobial breakpoints. The Clinical and Laboratory Standards Institute (CLSI) adopted the revised breakpoints in June 2007 and published them in January 2008.  CLSI also supported a citizens’ petition written by Dr. Yu and others urging FDA to raise the penicillin breakpoints by submitting two “citizens petitions” of its own. Dr. Yu learned this month that FDA had signed an approval letter for Baxter’s amended package insert on March 1. “This was a case where FDA acted expeditiously,” Dr. Yu said.

Although a formal response from the FDA to Dr. Yu’s group and CLSI has not yet been received and the package inserts of other generic penicillins have not yet been changed, “the implication of the FDA’s action is that all of the package inserts for generic penicillins should be changed and that microbiology laboratories and clinicians should feel comfortable using the revised breakpoints to guide therapy for pneumococcal infections,” said Melvin P. Weinstein, MD, FIDSA, IDSA’s liaison to CLSI.

This is good news, Dr. Yu said, because now that quinolones have become the standard therapy for community-acquired pneumonia, reports of quinolone failures are on the rise. “You use it and you lose it,” he said.

“People laughed at me when I said I would bring back penicillin,” Dr. Yu said. But, he added, it will take some time and some effort for penicillin to really make a comeback. As empiric therapy has taken over, he said, clinicians and laboratories have lost the skills and the tools to diagnose the causes of CAP. “If anyone should be delighted, it should be infectious diseases specialists, because the skill of making a diagnosis returns. But because the practice of giving empiric therapy without thinking has become so inculcated in the last seven years, I think it’s going to take publicity to go back to what we were so good at.”

Single-Dose Vials of Yellow Fever Vaccine Again Available

Single-dose vials of yellow fever vaccine are again available in the United States, according to the Centers for Disease Control and Prevention (CDC), but with limitations on the quantity ordered.

Sanofi pasteur, manufacturer of the only yellow fever vaccine available in the United States, has informed CDC that single-dose vials are again available following a shortage announced in January. The limitations on quantity are intended to help the manufacturer rebuild its inventory. Five-dose vials are still available, and CDC recommends that clinics schedule vaccinations to use these efficiently.

Call sanofi pasteur for more information on ordering vaccine: 1-800-VACCINE (1-800-822-2463). Updates on yellow fever vaccine availability, and the countries requiring and recommending vaccination can be found online in CDC’s Travelers’ Health section.

From the President:

Fighting Bad Bugs, and Bad Policy

Very few of us are immune to the changes taking place in the American health care system today. To name a few, the strains in Medicare, the movement to pay-for-performance, and the tightening of federal funding will touch nearly all of us in one way or another. There are dangers and opportunities in all of these changes. What comes out of them depends very much on how involved we—and you—are. 

IDSA is opposing the losses in funding—either through cuts or inflation—contained in President Bush’s 2009 budget proposal for the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC). CDC is looking at a cut of nearly half a billion dollars, while flat funding at NIH has already eroded 13 percent of its budget since 2003.

More junior researchers are rethinking careers in biomedical research or shying away from really innovative research that’s considered too risky to be funded . With federal funding increasingly hard to come by, our academician colleagues are becoming more familiar with billing and coding for third-party payers in order to help keep their departmental budgets in the black.

Meanwhile, bad news about one of the most important third-party payers, Medicare, continues to pile up. For the second year running, the federal government’s Medicare Trustees issued an official warning in March about the program’s shaky finances. As a result, the president is again legally obligated to propose ways to control spending and Congress is required to consider them “expeditiously.” Last year the proposals made no progress, however.

Also in March, the Medicare Payment Advisory Commission (MedPAC) voiced criticism of the series of physician payment cuts Medicare projects for the next several years. MedPAC’s report echoed IDSA’s long-held position that beneficiaries’ access to care ultimately will suffer. The threat of another payment cut looms this summer.

At the same time as funding is drying up, greater responsibility is falling on infectious diseases specialist to help contain costs. Facilities are coming under increasing pressure from both public and private insurers to reduce costly and preventable health care-acquired infections (HAIs), even as resistant organisms make it ever harder to do so. For the good of our patients, we wholeheartedly support the goal of reducing HAIs and many other pay-for-performance initiatives. Medicare in particular must change to value quality of care over quantity. But policies must be driven by science.

Promoting science-based policy is one of IDSA’S core missions. This issue of IDSA News reports on the Society’s success convincing Medicare to change a policy that increased the risk of catheter-associated infections.

IDSA also is gaining support in Congress for the Strategies to Address Antimicrobial Resistance (STAAR) Act, important legislation that aims to improve the federal government’s response to the growing epidemic of antimicrobial-resistant infections that we face every day.

IDSA is dedicated to fighting bad bugs and fighting bad policy—but the Society is only as strong as its members. It’s surprisingly easy for you to make a difference, and the Society is eager to help. I was fortunate enough to meet Sen. John Warner (R-VA) recently, and I took the opportunity to share with him the Society’s support for the STAAR Act. IDSA staff provided important background materials to give him. I am proud to say Sen. Warner is now a co-sponsor of the STAAR Act.

Other members have had an impact, too. Andrew Pavia, MD, FIDSA, was instrumental in winning the support of one of the original STAAR Act sponsors, Rep. Jim Matheson (D-UT). Board member Jan Patterson, MD, FIDSA and other state ID society presidents have also worked with IDSA staff to secure additional support for the bill. Several IDSA members have played key roles in policy-making at the state level on the issues of Lyme disease and the use of thimerosal in vaccines.

This issue of IDSA News reports another successful effort by IDSA and several of its key members: The Food and Drug Administration has raised the breakpoints for penicillin in the treatment of community acquired pneumonia.

These efforts demonstrate what can be done when the Society and its members work together on important issues. You have a role to play. IDSA is looking for members who can serve as key contacts with members of the U.S. Congress as well as your state legislatures. As a key contact, you would work with IDSA policy staff to engage federal policymakers on Capitol Hill. If you already have a relationship with a U.S. senator or representative from your state, your help could be invaluable. The Society will soon launch a survey to identify those members with these key connections who would like to serve an advocacy role. However, you can volunteer immediately by contacting IDSA Government Relations Associate Michael Ochs at mochs@idsociety.org.

Medicare Changes Policy to End Reuse of Intermittent Catheters

Medicare beneficiaries will no longer have to reuse intermittent catheters multiple times in a week, thanks in large part to support provided by IDSA to change the policy. 

Under the new policy, Medicare covers enough intermittent catheters so that all beneficiaries will be able to use a catheter only once.  For certain patient populations, sterile catheter kits also are covered. The change took effect April 1.

For decades, Medicare’s policy regarding intermittent catheters covered only one catheter per week, except for very limited patient populations or for beneficiaries who already had sustained two documented and severe urinary tract infections.  This policy was in place despite the fact that the Food and Drug Administration has approved single-use-only labels for all intermittent catheters on the market.

Last May, IDSA sent a letter to Medicare regarding this policy. In the letter, IDSA stated that catheter-associated bacteriuria had been shown to serve as a reservoir of often highly resistant pathogens that can cause infections in other sites.  As a result, catheter-associated UTIs and their sequelae can cause significant morbidity and increased cost to the U.S. health care system, not to mention possible hospitalization for these beneficiaries.  

The policy has been changed by all four Medicare contractors that cover the entire United States with respect to durable medical equipment and supplies.  The four policies are identical. View the revised policy of the National Heritage Insurance Company. 

Medicare Recruiting for EHR Demo Project

A new national Medicare demonstration program is aiming to show health care professionals the on-the-ground advantages of connecting to the information age.

Medicare is looking for 12 communities across the country that can bring together a broad cross-section of community leadership, leverage resources, and recruit small and medium-sized primary care physician practices willing to provide the evidence that electronic health records (EHRs) can improve the quality of patient care. 

As many as 1,200 physician practices nationwide could be eligible for incentive payments of up to $58,000 per physician—up to $290,000 per practice—over the five-year life of the demonstration.  Incentives would be based on a practice’s level of EHR use, and for reporting and performance on 26 clinical quality measures.  Medicare plans to announce the winning communities in June 2008.

Learn more about the new EHR demonstration project and e-mail EHR_Demo@cms.hhs.gov or EHR_Demo_communityselections@cms.hhs.gov for more information about community selection.

Members on the Move

Martin S. Hirsch, MD, FIDSA, was awarded the Maxwell Finland Award for Scientific Achievement by the National Foundation for Infectious Diseases (NFID).  The award is presented to a scientist who has made outstanding contributions to the understanding of infectious diseases or public health.  Dr. Hirsch is currently professor of medicine at Harvard Medical School and editor of The Journal of Infectious Diseases.

Carol Dukes-Hamilton, MD, MHS, FIDSA, has been named IDSA’s representative to the TB Alliance’s Stakeholders Association.  The TB Alliance’s Stakeholders Association includes representatives from developed and developing nations’ governments, non-governmental organizations, professional organizations, academia, foundations, and industry who share an interest in developing a faster, better cure for tuberculosis.  Dr. Dukes-Hamilton is currently associate professor of medicine at Duke University Medical Center and medical director of the North Carolina TB Program.

Welcome, New IDSA Members!

Members

Arcenas, Rodney, PhD
Connick, Elizabeth, MD
Erdem, Guliz, MD
Jones, Timothy, MD

Associate Members

Ayala-Sims, Veronica, MD
Bergeron, Shannon, NP
Heintz, Brett, PharmD
McClellan, Scott, MD
Olagundoye, Damaris, MD
Ong, Christine, PharmD
Ryan, Vonda, PharmD

Members-In-Training

Culligan, Brent, MD
Denman, Britta, DO
Douvoyiannis, Miltiadis, MD
Haley, Clinton, MD
Hartzler, Anthony, MD
Hemachandra, Sonali, MD
Kang, Seung, MD
Lagnese, Meena, MD
Leekha, Surbhi, MBBS
Marino, Elizabeth, PharmD
Oh, Chi Eun, MD
Vinnard, Christopher, MD