IDSA News - September 2008
Vol. 18, No. 9
(Print All Articles)

CDC Campaigns Target MRSA, Inappropriate Antibiotic Use

Steve Baragona

The Centers for Disease Control and Prevention (CDC) is launching two national campaigns aimed at educating parents and health care providers about inappropriate antibiotic use and antibiotic-resistant infections. 

The Centers for Disease Control and Prevention (CDC) is launching two national campaigns aimed at educating parents and health care providers about inappropriate antibiotic use and antibiotic-resistant infections. “Get Smart About Antibiotics Week” will target a major source of inappropriate use: upper respiratory infections. Meanwhile, new outreach efforts are directed at teaching parents and physicians about preventing and treating methicillin-resistant Staphylococcus aureus (MRSA).

Get Smart About Antibiotics

During “Get Smart About Antibiotics Week,” Oct. 6-10, CDC, state officials, and non-profit partners including IDSA will be working to educate the public and providers on how to minimize unnecessary use of antibiotics for upper respiratory infections.

For providers, the CDC website contains collections of one-page physician information sheets useful for influencing other physicians’ prescribing habits. Information sheets for both pediatric and adult physicians are available, detailing appropriate use for pharyngitis, bronchitis, otitis media, and other respiratory tract infections. Treatment guidelines for appropriate use also are found on the website.

To help providers educate their patients, the website also includes downloadable brochures and posters in English and Spanish that explain in lay language why antibiotics are not the answer for most upper respiratory infections. There is also a video demonstration of how to talk to a patient about why antibiotics won’t work for a cold.

For those seeking to hold their own Get Smart Week events, CDC has a webpage of resources to help you prepare, including planning guidance, suggested activities, media resources, and more.

MRSA Education

CDC’s National MRSA Education Initiative aims to “help Americans better recognize and prevent MRSA skin infections,” according to the initiative’s homepage. The page on information for health care providers notes that, given the rising incidence of MRSA, “When a patient has a skin infection, it may very likely be MRSA.” Identification and treatment options are explored in downloadable brochures, flyers, and a treatment algorithm developed by IDSA, CDC, and the American Medical Association. For parents, answers to frequently asked questions about MRSA are available, along with downloadable, full-color fact sheets and posters.

2009 Clinical Practice Meeting in San Diego

Jeanna Ray

IDSA will hold its fourth Clinical Practice Meeting March 20-21 in San Diego, featuring valuable resources and practical strategies for clinicians in practice.

IDSA will hold its fourth Clinical Practice Meeting March 20-21 in San Diego, featuring valuable resources and practical strategies for clinicians in practice.

The 2009 meeting will include sessions on how to negotiate with private payers, address the challenges of human resources management, and improve billing and coding processes. Other topics include wound care clinic management and best practices, electronic medical records and other health care technology, and travel medicine. The 2009 meeting will also feature plenty of break-out sessions so that attendees can tailor the meeting to their own interests.

Registration will open October 25. View the preliminary agenda and session descriptions. 

IDSA Journal Club, August 2008

This month: studies on antibiotics for sinusitis, silver-coated endotracheal tubes, rapid HIV testing in the emergency department, West Nile Virus, and single-dose nevirapine.

In this feature, a panel of IDSA members identifies and critiques important new studies 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.


Antibiotics for Sinusitis May Help a Little, Hurt a Lot

Melinda M. Pettigrew, PhD

Although antibiotics may provide some benefit for acute sinusitis, that small benefit comes with the cost of increased adverse events, according to two recent studies.

Antibiotic prescriptions for upper respiratory tract infections are common and often inappropriately prescribed. In the first study, in the September issue of The Lancet Infectious Diseases, Falagas et al. published a meta-analysis of 17 randomized controlled trials to compare the benefit of antibiotics for acute sinusitis compared to placebo. Antibiotics were associated with an 82 percent higher cure rate and faster resolution of symptoms. The number of disease complications and sinusitis recurrences did not differ between the two groups.

Unfortunately, the small benefit of antibiotics corresponded with an 87 percent rise in the risk for adverse events due to treatment. Amoxicllin was the antibiotic most often prescribed and gastrointestinal symptoms were the most common adverse event.

The authors note that the difference in the cure rate in the antibiotics group may have been smaller than might be expected because many of the patients treated with antibiotics likely had viral, not bacterial, sinusitis. Furthermore, even bacterial sinusitis symptoms can resolve quickly with or without antibiotics.  

Caution should be used when interpreting these data. The analysis included studies with a range of inclusion criteria and differing outcome definitions. Most of the studies focused on the resolution of symptoms during a short time period. Several of the studies excluded patents with severe disease, and these are the patients who are the most likely to develop complications. (Falagas et al., Lancet ID. 2008;8:543-55.)

The second study, which adds to the concerns about adverse events, appears in the September 15 issue of Clinical Infectious Diseases. It suggests that antibiotic prescriptions are responsible for more than 142,000 emergency department visits. Shehab et al. analyzed nationally representative surveillance data to estimate the risk of emergency department visits for adverse events associated with systemic antibiotics by drug and type of adverse event. They estimated that out of all emergency department visits for adverse drug events, 20 percent were related to antibiotics. Half of the events were due to penicillin and cephalosporins. The majority of adverse events were due to allergic reactions.

These data may underestimate the number of adverse events, since patients with mild reactions are unlikely to visit the emergency room. The data sources used in this study also may not capture all prescriptions. The authors did not assess whether the antibiotics were prescribed appropriately. (Shehab et al., Clin Infect Dis. 2008;47:735-743.)

Together these two important studies indicate that in addition to the threat to public health of antibiotic resistance, the potential for adverse events should be considered when clinicians are deciding how to treat individual patients. More research is needed so that clinicians can correctly identify patients with disease of bacterial origin and those who could benefit most from antimicrobial treatment, especially with regard to upper respiratory tract infections. Novel interventions to decrease the frequency of inappropriate antimicrobial prescribing are needed.

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Silver-coated Endotracheal Tubes: Not a Silver Bullet for VAP

Jason B. Weinberg, MD

Silver-coated endotracheal tubes decreased the rate of microbiologically confirmed ventilator-associated pneumonia (VAP) but had no effect on other important outcomes in a study in the August 20 issue of the Journal of the American Medical Association.

VAP is a substantial cause of morbidity, but there is not yet a prevention strategy that consistently eliminates this problem.  In this well-designed, multicenter, prospective study, patients expected to require mechanical ventilation for more than 24 hours were randomized to use either a standard, uncoated endotracheal tube or an endotracheal tube coated with silver.  Among all patients and patients intubated 24 hours or longer, use of the silver-coated endotracheal tube was associated with a 36 percent reduction in risk of microbiologically confirmed VAP, the study’s primary outcome.  This effect was not particularly robust, however, and the overall incidence of VAP in the study population was relatively low.

Post-hoc analyses suggested that VAP was associated with increased duration of intubation, ICU stay, and hospital stay.  Despite these results, use of the silver-coated endotracheal tube was not associated with improvements in these relevant secondary outcomes.  Unfortunately, other related measures such as antibiotic use and hospital charges were not assessed in the study.

Simple interventions that decrease the incidence of diseases such as VAP are clearly important goals.  If they prove effective, devices such as the silver-coated endotracheal tube used in this study are particularly appealing because they may provide the additional benefit of limiting antibiotic use and reducing the emergence of antibiotic-resistant organisms.  In this case, however, it seems that additional data is needed before silver-coated endotracheal tubes should be recommended in all cases. (Koleff et al.,  JAMA. 2008;300:805-13.)

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Rapid HIV Testing in the Emergency Room: Interpret Positive Tests Carefully

Khalil G. Ghanem, MD

While rapid HIV tests are a quick, easy, and highly sensitive way to broaden HIV screening, an article in the August 5 issue of Annals of Internal Medicine shows that one commonly used oral test gave more false positives than the manufacturer advertised.

The number of new cases of HIV in the United States has been relatively stable (although underestimated) for over a decade.  Many who are HIV-infected are unaware of their diagnosis. This has led to expanded screening efforts to try and identify these patients and bring them to care. One such effort is rapid HIV testing in the emergency room (ER).

Walensky et al. report the results of rapid screening of 849 adults in an ER in Boston using the OraQuick ADVANCE Rapid HIV-1/2 Antibody Test.  The investigators found 39 positive results. Confirmatory testing using Western Blot, EIA, and HIV-RNA testing revealed that only five of these 31 tests were true positives. (Eight patients declined follow-up testing.) The specificity of the test was found to be 96.9 percent, somewhat lower than the 99 percent specificity suggested by the manufacturer. Confirmatory Western blot was conclusive in only 50 percent of patients on the first attempt. The addition of HIV-1 RNA testing improved the rate of conclusive results to 96 percent.

There are several lessons to be learned. Negative rapid HIV tests may be reassuring, but positive rapid tests need to be confirmed before discussing the results with patients. A confirmatory testing approach must be in place to deal with positive test results; in a significant number of cases, Western blot testing alone may not offer immediate clarification. HIV-RNA testing on positive rapid test results and indeterminate initial Western blot tests may provide a more rapid answer than the current CDC-recommended approach of repeating the Western blot four weeks later.

This study should not dissuade us from performing rapid HIV testing in the ER or other such venues; indeed, patients with a reactive  screening test had an eight- to 32-fold increased odds of HIV infection compared with the pretest odds; it should, however, encourage a reasoned approach to dealing with positive test results.  (Walensky et al., Ann Intern Med. 2008;149;153-160.)

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Long-term Prognosis after West Nile Virus Infection

Khalil G. Ghanem, MD

Physical and mental outcome measures appear to normalize within approximately one year in patients with West Nile virus (WNV), according to a study published in the August 19 issue of Annals of Internal Medicine. Women, those with neuroinvasive disease, and patients with multiple co-morbid conditions took longer to recover.  

The investigators followed 156 patients diagnosed with WNV for a median of 203 days. They included patients with neuroinvasive (both meningitis and encephalitis) and non-neuroinvasive disease. The outcome measures consisted of scores on the Physical Component Summary and Mental Component Summary of the Short Form-36, Depression Anxiety Stress Scale, and Fatigue Severity Scale.

Within about a year, patients recovered to levels of physical and mental functions similar to the general population. Patients who did not have significant co-morbid conditions were more likely to recover physical and mental functions faster; men were more likely to recover mental function faster than women.

ID clinicians are frequently called upon to discuss prognosis of illnesses with patients and their families. This study should help frame the discussion as it relates to WNV. A few limitations are worth highlighting: only 156 of 367 potential participants were enrolled; seven patients died before enrollment; and seven patients who had acute flaccid paralysis were excluded from the prognostic curves. Whether these limitations biased the results towards better outcomes is unclear but should be kept in mind. (Loeb et al., Ann Intern Med. 2008;149:232-241.)

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Does Repeated Use of Single-dose Nevirapine Increase Resistance?

Sabrina Renee Kendrick, MD

In a small study in the August 15 issue of the Journal of Infectious Diseases, Flys et al. report that repeated use of single-dose (SD) nevirapine (NVP) to prevent mother-to-child transmission of HIV does not appear to influence NVP resistance.

Researchers in Uganda compared the emergence and persistence of NVP-resistant HIV strains in 57 women who had not received SD NVP in a prior pregnancy to 34 pregnant women who had. NVP resistance was studied in samples collected from these two groups of women and their 17 HIV-infected infants at fixed times after SD NVP administration.

The authors found no significant difference in the proportion of women in whom NVP resistance was detected, the types of resistance mutations, or the frequency and level of the K103N resistance mutation at six weeks or six months post partum. Infants born to SD NVP-naïve and SD NVP-experienced women also had similar proportions of NVP resistance.

The small sample sizes in this study limited the power to detect significant differences in NVP resistance between the comparison groups. Therefore, caution is advised when interpreting the data. (Flys et al., Journ Infect Dis. 2008;198:465-469.)

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IDSA Ascendant

With our next Annual Meeting drawing near and my term as your president drawing to a close, I am proud to have presided over the Society as its status as the definitive source of ID information has continued to grow. On the major infectious diseases issues of the day, policymakers now come to us regularly for insight.

For example, the Bush administration recently has been considering a policy tacitly encouraging individuals to stockpile antibiotics at home in case of a future anthrax attack. Administration officials came to IDSA for advice, and the Society advised them it was a bad idea: The benefits are unclear and the risks are considerable. Antibiotic misuse—already common—would likely become more widespread as people self-diagnosed and self-treated for a wide range of symptoms whether or not a bio-emergency was occurring, with the accompanying risks of adverse reactions and increasing resistance. Furthermore, the policy would likely create inequities as only individuals with financial resources and access to a health care provider would be able to benefit. Administration officials listened and are now rethinking the issue.

By the same token, IDSA has been one of several leading medical societies advising the federal government against home stockpiling of antiviral drugs as part of pandemic influenza plans. The risks of inappropriate use, adverse reactions, and rapidly emerging resistance outweigh any theoretical benefit. Again, IDSA’s input has led the administration to change course. IDSA has been invited to deliver comments on other proposals in late October at an advisory committee meeting of the Food and Drug Administration (FDA).

IDSA also has become FDA’s go-to source on antimicrobials. For years, the Society has been pressing FDA on a number of antimicrobials issues, including long-overdue guidance for industry on how to conduct clinical trials for antibiotics against several serious infections. This past year has brought a sea change at FDA. The agency has issued four clinical trial design guidances for industry and has invited IDSA’s input on several more. IDSA and FDA co-sponsored a workshop in January on clinical trials for community-acquired pneumonia and are planning another next year for hospital-acquired and ventilator-associated pneumonia.

FDA’s heightened attention to antibacterial drugs is in part due to the IDSA’s growing influence on Capitol Hill. IDSA endorsed the legislation that required FDA to publish many of the guidances the agency released over the past year. That legislation also requires FDA to update breakpoints for antimicrobials regularly. As a result, FDA has not only acted to modify the breakpoints for penicillin to treat pneumococcal pneumonia and vancomycin to treat staph infections, but also issued guidance outlining how the agency plans to keep on track in updating breakpoints for the long term.

In this case and others, IDSA could not have achieved what it did without the dedicated advocacy work of key volunteers. When it comes to policy issues that affect all of us as infectious diseases specialists—from pandemic influenza to physician payments to antimicrobial availability—your experience, your insights, your voice, and your membership in IDSA matter, now more than ever.

You recently received an e-mail asking you to help the Society build its grassroots network by becoming a Key Member-Advocate. If you haven’t done so already, please take a moment and fill out the brief questionnaire.

It has been an honor to serve as your president. I look forward to seeing you this October at the 48th Annual ICAAC/IDSA 46th Annual Meeting in Washington, DC.

EIN: Difficulty Treating Multidrug-resistant Gram Negative Infections

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 EIN, IDSA (EIN's sponsor), or the Centers for Disease Control and Prevention, which funds the EIN. The reader assumes all risks in using this information.

Highly resistant gram-negative infections and the lack of effective drugs to treat them are a growing problem for infectious diseases clinicians. In several recent discussions on the Emerging Infections Network (EIN) listserve, clinicians have discussed how to deal with these difficult-to-treat infections.

One thread noted the rapid evolution of resistance to quinolones in Pseudomonas aeruginosa. A member had treated a patient for urosepsis with intravenous (IV) levofloxacin and discharged him with a two-week oral course of the same drug. Before he could complete the course, the patient relapsed with a resistant strain of the bacterium.

Others reported experiences with resistant strains of Pseudomonas, as well as in E. coli and Klebsiella pneumoniae. “I avoid use of ciprofloxacin first up, as widespread use of fluoroquinolones in the community may have selected for mutations,” one member noted. “Subsequent exposure when there is high bacterial load increases the risk.”

Another member referred to a 2005 study in Clinical Infectious Diseaseson Pseudomonas resistance to quinolones. “The more you use them, the more resistance you'll see, at least on a population level,” the member said.

Another member was concerned about resistance to tigecycline developing in a patient with a Klebsiella urinary tract infection (UTI) that was already resistant to multiple drug classes. The member mentioned case reports of tigecycline treatment failures for gram-negative infections and asked for other suggestions.

Members reported both success and failure with tigecycline. One noted that only 10 percent of the drug gets into the urine, which may account for failures in treating UTIs with tigecycline. For alternatives, some suggested fosfomycin, amikacin, doxycycline, or colistin, although renal toxicity is a well-known problem for the latter.

Colistin is making an unexpected comeback due to the shortage of new antimicrobials, particularly for gram negatives. A member looking for a protocol for prescribing colistin was directed to two references: a 2007 article in Expert Review of Anti-infective Therapycomparing colistin (polymyxin E) and polymyxin B; and a pharmacokinetics case study from 2005 in Antimicrobial Agents and Chemotherapy.

In addition to the shortage of effective new drugs to treat highly resistant gram-negative infections, in some cases there is a shortage of good data on using current drugs. Case in point: a member was treating a child with cystic fibrosis (CF), allergic bronchopulmonary aspergillosis and Stenotrophomonas maltophilia resistant to at least a dozen different drugs. “If her lung function does not improve we want to admit her for IV antibiotic treatment,” the member wrote. “The question is, with what?”

Some suggestions included:

  • high-dose trimethoprim/sulfamethoxazole in combination with ticarcillin/clavulanic acid or ceftazidime
  • aztreonam in combination with amoxicillin/clavulanic acid or ticarcillin/clavulanic acid
  • tigecycline
  • inhaled tobramycin with amiloride (according to one small reportfor treating Burkholderia cepacia in CF patients, which might also work for S. maltophilia)
  • chloramphenicol as a last resort, despite the risk of aplastic anemia

For information on IDSA’s efforts to address the antimicrobial resistance crisis, see the web pages on the “Bad Bugs, No Drugs” campaign and the Strategies To Address Antimicrobial Resistance (STAAR) Act

The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public-health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) and supported by funding from the Centers for Disease Control and Prevention.

EIN tracks emerging infectious diseases and keeps the public-health community up to date with issues that are currently affecting or may soon affect members’ clinical practices.The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. The EIN listserve allows members to discuss new disease trends and difficult cases. Click here for more information or to join EIN.

Drug Approvals, Recalls, Adverse Events Update

Rebecca Dotson

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:

IDSA members can sign up for this service online. (You must be logged in to have access to this link.)

In the IDSA Journals

Another Strategy for Hepatitis B Vaccine Non-responders

In a small study of subjects who did not respond to hepatitis B vaccine, re-vaccination with a double-dose of combined hepatitis A and B vaccine greatly improved response rates. Out of 44 non-responders, 59 percent had protective levels of antibody to hepatitis B virus after the first double-dose of combined vaccine, and 95 percent responded after three doses. The authors speculate that the addition of the hepatitis A vaccine, the increased dose of hepatitis B vaccine, or both could be responsible for the improved response rate. (Cardell et al., J Infect Dis. 2008;198:299-304; editorial commentary by Diepolder, J Infect Dis. 2008;198:297-298.)

HIV Scars GALT, Inhibits ART Recovery

HIV infection appears to scar gut-associated lymphoid tissue (GALT) early in infection and to a greater extent than it does other tissues, which may help explain why CD4+ T cell counts do not recover as well in the gut following antiretroviral therapy (ART). Researchers found greater areas of collagen deposition in GALT biopsies from HIV-positive subjects compared to HIV-negative subjects. In biopsies from early-acute HIV-infected subjects, researchers found greater areas of collagen deposition in GALT than in lymph node tissue. Greater areas of collagen deposition correlated with lower levels of CD4+ cells. Beginning ART earlier may help reduce GALT damage and improve immune recovery. (Estes et al., J Infect Dis. 2008;198:456-464; editorial commentary by Read and Sereti, J Infect Dis. 2008;198:453-455.)

Predicting Need for Intensive Care Unit Management in Community-acquired Pneumonia 

From the Australian Community-acquired Pneumonia Study, the authors devised a tool—SMART-COP—to predict which patients would require intensive respiratory or vasopressor support. By assessing features such as low systolic blood pressure, multilobar chest radiograph involvement, low albumin level, high respiratory rate, tachycardia, confusion, poor oxygenation, and low arterial pH, they were able to identify 92 percent of the patients who required intensive respiratory or vasopressor support. In comparison, the sensitivity of the pneunomia severity index was 74 percent, and that of the CURB-65 score was 39 percent. (Charles et al., Clin Infect Dis. 2008;47:375-384.)

XDR TB in California  

Using case reports submitted to the California tuberculosis (TB) registry during 1993–2006, Banerjee and colleagues investigated the characteristics and magnitude of extensively drug-resistant (XDR) TB. Of 424 multidrug-resistant TB cases, 4 percent were XDR and 18 percent were “pre-XDR,” the latter being defined as TB with resistance to isoniazid and rifampin and either a fluoroquinolone or second-line injectable agent, but not both. The proportion of pre-XDR TB cases increased over time, from 7 percent in 1993 to 32 percent in 2005. Among patients with XDR TB, 83 percent were foreign born and 43 percent received a diagnosis of XDR TB within 6 months of arrival in the United States. (Banerjee et al., Clin Infect Dis. 2008;47:450-457.)

Management of MDR and XDR TB

Recent guidelines have varied considerably in their therapeutic recommendations for multidrug-resistant (MDR) tuberculosis. This Korean study of 155 patients with MDR TB found that the use of at least 4 drugs to which the organisms were susceptible was associated with a favorable outcome. The treatment success rates were similar between the patients with MDR TB and those who had XDR TB, although the patients with XDR TB were more likely than the patients with MDR TB to have had surgical resection (48 percent vs. 17 percent). (Kwon et al., Clin Infect Dis. 2008;47:496-502.)

More from the literature: the IDSA Journal Club

Don’t miss this feature to help you stay up to date on the infectious diseases literature. Each month, the IDSA Journal Club features 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 (CID) highlights several important studies from that journal. (Click for September 1 or September 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 CID.

Sept. 1

  • Active Surveillance for Detection of Colonization with Methicillin-Resistant Staphylococcus aureus (MRSA)

Sept. 15

  • CNS Vasculopathy and Varicella Zoster Virus (VZV)
  • Monogamous Couples and a Promiscuous Virus
  • Possible Protection against Group A Streptococcal (GAS) Infection Associated with Influenza Vaccination

ID Physicians Have Second-highest Coding Error Rate in CMS Report

Steve Baragona

Infectious diseases (ID) specialists had the second-highest rate of improper coding for Medicare fee-for-service payments in the latest semi-annual error rate report from the Centers for Medicare and Medicaid Services (CMS)—a fact that may subject you to increased scrutiny as CMS expands its auditing program.

In the May 2008 Improper Medicare Fee-for-Service Payments (IMPF) Report, 16.4 percent of claims that Medicare paid to infectious diseases physicians contained an error. Nearly 45 percent of these errors were because documentation was lacking or insufficient.

IDSA strongly encourages members and their staffs to submit all requested documentation in a timely manner. If you fail to do so, you may soon be more likely to find an auditor on your doorstep. CMS is setting up a nationwide auditing system to recover funds overpaid to providers and expects to have the system running by 2010. (Information on what to do in the event of an audit is available in the Billing and Coding section of the IDSA website. You must log in to access this page.)

The majority of ID physicians’ errors (55.4 percent) were due to what CMS considered incorrect coding. In most cases, CMS and the physician differed by only one coding level. Coding evaluation and management (E&M) services is an inherently subjective process—especially in the E&M families with 5 code levels—and IDSA has previously asked CMS not to include one-level coding differences in its error rate calculations.

Key Points to Remember in Determining the Appropriate Level E&M Code

  • Understand the documentation requirements: Some E&M code families require all three key elements, and others require only two of three key elements.
  • High-level initial patient visits do not always lead to high-level subsequent-patient visits. Changes in a patient’s condition between visits should be reflected in the code levels chosen.
  • If a patient is non-responsive or uncommunicative, you should document “unable to execute review of systems and history” in the patient’s chart.
  • In order to bill critical care codes, you must document at least 30 minutes of floor/unit time that meets criteria for critical care. Providing care in an ICU setting is not in and of itself justification for billing a critical care code.

Please go to for more information on how to avoid coding errors, including ID-specific correct coding resources.

IDSA, HIVMA Launch Infectious Diseases Center for Global Health Policy and Advocacy

Diana Olson

IDSA and the HIVMA Medicine Association (HIVMA) are establishing a new center to support and promote U.S. efforts to combat HIV/AIDS and tuberculosis throughout the world. The Infectious Diseases Center for Global Health Policy and Advocacy is made possible by a $1.9 million grant from the Bill & Melinda Gates Foundation. It will be housed within the IDSA Education and Research Foundation.

The Center will promote effective use of U.S. funding for addressing the global HIV/AIDS and TB epidemics by providing scientific and policy information to policymakers, federal agencies, non-governmental organizations, and the media. The Center will ensure that key decision-makers have access to input and guidance from IDSA/HIVMA physicians and scientists and their colleagues from developing countries.

To get the Center’s work underway, IDSA and HIVMA will survey members next month to identify and organize individuals who are working in HIV/AIDS or tuberculosis in developing countries. Those individuals will be kept informed about key federal policy issues and the role they can play in bringing their expertise to the table. Specific activities of the Center will include hosting congressional and press briefings, and producing issue briefs and profiles of successful HIV and TB programs that merit scale-up and expansion.

The Center’s work will be overseen by a scientific advisory committee of leading physicians and scientists with expertise on global HIV and TB. Co-chairs of the committee will be Kenneth H. Mayer, MD, director of the Brown University AIDS Program and medical research director of the university’s Fogarty AIDS International Research and Training Program, and Carol Dukes Hamilton, MD, associate professor of medicine at Duke University Medical Center and IDSA’s representative to the Global Alliance for TB Drug Development. Daniel R. Kuritzkes, MD, FIDSA, of Partners AIDS Research Center and Brigham and Women’s Hospital, will serve as the liaison to the IDSA and HIVMA boards of directors. Other members of the Scientific Advisory Committee will include Henry Blumberg, MD, FIDSA, Tom Quinn, MD, FIDSA, Sten Vermund, MD, PhD, FIDSA, Deborah Cotton, MD, MPH, FIDSA, Veronica Miller, PhD, Renee Ridzon, MD, Eric Goosby, MD, Richard Chaisson, MD, FIDSA, Gerald Friedland, MD, FIDSA, and William Burman, MD.

“The United States has been a bold leader in fighting HIV/AIDS worldwide, but it is now time to take that commitment to the next level by ramping up the U.S. response to the twin epidemics of tuberculosis and HIV, and by aggressively supporting research and programmatic measures to combat HIV-TB co-infection,” Dr. Hamilton said. 

“The U.S. must support comprehensive, science-based global HIV prevention strategies, including making HIV screening routine for everyone, and incorporating prevention into the care and treatment of people who test positive for HIV,” added Dr. Mayer.

The Center will be led by Christine Lubinski, who assumes the role of vice president for global health at IDSA. Lubinski previously served as executive director of HIVMA, where she spearheaded the Association’s advocacy efforts including its support for reauthorization of the President’s Emergency Plan for AIDS Relief (PEPFAR). Andrea Weddle becomes executive director of HIVMA, after having served as associate director since HIVMA’s inception in 2001.

“The Center will allow IDSA and HIVMA to bring the voices and insights of physician scientists to policymakers and U.S. government program implementers to ensure that the U.S. government is supporting efficacious, evidence-based programs and policies to address HIV and tuberculosis,” Lubinski said. “At a time when HIV/TB co-infection is threatening to undermine the progress made by antiretroviral therapy, that voice is more crucial now than ever before.”

“The experience of IDSA and HIVMA members, coupled with the breadth of their medical knowledge and technical expertise, will prove invaluable to discussions among policymakers and civil society organizations,” Weddle said.

Chikingunya Fever in Italy, Singapore

Steve Baragona

A patient in Italy has developed chikingunya fever after traveling to Sri Lanka, according to the U.S. Centers for Disease Control and Prevention (CDC). Singapore officials have also recorded 37 recent cases of chikingunya fever.

Chikingunya fever is a mosquito-borne viral infection with similar symptoms to dengue, including fever, headache, nausea, vomiting, muscle pain, rash, fatigue, and joint pain. Joint pain may be debilitating and, unlike dengue, prolonged; however, as with dengue, fatigue in some cases may last for weeks or months. The disease is rarely fatal.

There is no vaccine. Treatment is symptomatic, including rest, fluids, and common pain killers such as acetaminophen, ibuprophen, naproxen, or paracetamol; however, aspirin should be avoided.

More information on the outbreak is available on CDC’s Travelers’ Health webpage.

Q Fever in Holland

Steve Baragona

Dutch health authorities have reported 660 cases of Q fever this year, according to the U.S. Centers for Disease Control and Prevention (CDC). The outbreak is centered in the southern part of the country. A sharp increase in cases occurred in May. Last year also saw an outbreak of Q fever in Holland, with most cases occurring between May and July.

Q fever is caused by Coxiella burnetii, most often carried by goats, sheep, or cattle. Patients contract Q fever by inhaling contaminated dust or soil, or by consuming unpasteurized dairy products. Patients generally become ill two to five weeks after exposure. About half of those infected develop symptoms, including fever, chills, sweats, severe headache, muscle aches, abdominal pain, chest pain, sore throat, non-productive cough, vomiting, diarrhea, and malaise. One-third to one-half of patients will develop pneumonia. Liver function may be affected and hepatitis may develop. The disease is fatal in 1 to 2 percent of cases.

The more serious, chronic form of the disease is uncommon but may lead to endocarditis. Chronic Q fever is fatal in 65 percent of cases. Most of those who develop chronic Q fever have pre-existing valvular heart disease or have received a vascular graft.

Serologic testing or DNA detection are recommended for diagnosing Q fever. Doxycycline is the drug of choice to treat it. More information on the outbreak is available on CDC’s Travelers’ Health website.

Polio Resurges in Nigeria After a Promising Year

Steve Baragona

After making significant gains last year, Nigeria is currently undergoing a major outbreak of polio. In a setback to the global polio eradication campaign, more than 670 cases of the paralyzing disease have been reported as of Sept. 23, compared to 285 cases in all of 2007, according to the latest figures from the Global Polio Eradication Initiative.

Nigeria is one of just four countries that have never interrupted transmission of the polio virus. ( India, Pakistan, and Afghanistan are the other three.) Several northern Nigerian states halted mass vaccination campaigns in April 2003 following an outbreak of rumors that the vaccine was unsafe. Vaccination resumed in July of 2004, but case counts continued to soar, peaking at 1,122 in 2006. Between 2003 and 2006, virus imported from Nigeria re-infected 20 previously polio-free countries and spread as far as Indonesia. Recent cases in Chad, Benin, Niger, and Burkina Faso also have been traced back to Nigeria.

Stepped-up efforts improved vaccination rates in Nigeria in 2006 and 2007. Routine polio immunization rates went up from a nationwide average of 32 percent in 2005 to 62 percent in 2007. But the northern states, where polio is most common, continued to be on the low end of the scale, with routine coverage in some local areas dipping below 30 percent.

Many residents in areas with low vaccination rates complain that the government expends extraordinary effort on polio eradication while malaria and other diseases take a much heavier toll. In an effort to address these complaints, “Immunization Plus Days” began in May 2006, giving away insecticide-treated bed nets, de-worming medications, and other vaccines during mass polio immunization campaigns.

Following these efforts, the estimated number of unvaccinated children fell somewhat in the high-incidence northern states, from 45 percent in early 2006 to 30 percent in early 2007. But it has not been enough to prevent the latest outbreak, or to curb an ongoing outbreak of vaccine-derived poliovirus.

The World Health Assembly took the unusual step in May of singling out Nigeria for the spread of polio beyond its borders. The government has responded with new commitments to improve immunization activities.

Yellow Fever in Côte d'Ivoire

Steve Baragona

Nineteen cases of yellow fever have been reported in and around the city of Abidjan, Côte d’Ivoire, since May of this year, according to the U.S. Centers for Disease Control and Prevention (CDC).

A mosquito-borne viral disease, yellow fever is fatal in 15 percent to more than 50 percent of cases. Early symptoms may include fever and chills, severe headache, back pain, general muscle aches, nausea, fatigue, and weakness. Symptoms may resolve briefly then return, along with hemorrhagic symptoms such as black vomit, nose or gum bleeding, and bruising. Jaundice and proteinuria are common in severe cases. Hypotension, shock, metabolic acidosis, acute tubular necrosis, myocardial dysfunction, and cardiac arrhythmia may develop in late-stage disease, along with confusion, seizures, and coma. In those who recover, weakness and fatigue may persist for several months.

In addition to clinical symptoms and travel history, diagnosis includes blood tests for the virus, DNA, or, in later stages, antibodies. There is no specific treatment for yellow fever. Vaccination, protective clothing, and insect repellant can prevent it.

More information on the outbreak in Côte d’Ivoire is available on CDC’s Travelers’ Health webpage.

IDSA and HIVMA Urge Presidential Candidates to Put Science Before Politics

Diana Olson

With the presidential election heating up, IDSA and the HIV Medicine Association (HIVMA) have reached out to both campaigns urging the next administration to promote a science-based approach to public health policy.

In a joint letter sent to Sens. John McCain and Barack Obama, the societies listed four areas in particular where politics and other agendas have intruded into the realm of science and medicine: immunization safety, sexuality education programs, access to clean syringes and needles for injecting drug users, and diagnosis and treatment of Lyme disease.

“As physicians, our goal is to help all our patients become well,” wrote IDSA President Donald M. Poretz, MD, FIDSA, and HIVMA Chair Arlene Bardequez, MD, MPH. “To do so, we must be able to rely on prevention, diagnosis, and treatment strategies that are supported by the medical and scientific evidence.”

In their letter, IDSA and HIVMA outlined the scientific evidence debunking the alleged link between vaccines and autism. The two groups advocated investing federal prevention dollars into practices that are empirically proven to prevent the transmission of HIV and other sexually transmitted infections. Noting that no data have demonstrated any long-term benefit to abstinence only programs, the letter called for educating young people in an age-appropriate, culturally sensitive, and value-neutral manner. The two groups called for widespread availability of harm-reduction techniques such as needle and syringe exchange and drug treatment programs. And they pointed out the scientific rationale for IDSA’s recommendations on the diagnosis and treatment of Lyme disease.

The letter called on the presidential candidates to “foster public health strategies that are well grounded in science,” and offered IDSA and HIVMA as a source of credible, science-based information about the full range of infectious diseases.

IDSA Advocacy Update

CMS Postpones 2009 Competitive Acquisition Program

The Centers for Medicare and Medicaid Services (CMS) on September 10 announced the postponement of the 2009 Competitive Acquisition Program (CAP) for Part B drugs and biologicals. As a result, participating CAP physicians will not be able to obtain Part B drugs from an approved CAP vendor after December 31. CMS will provide additional guidance for participating CAP physicians to transition out of the program later this fall on the CMS CAP physicians' page.  For more information on CAP please visit the IDSA website.

IDSA, HIVMA Respond to Medicare’s Physician Fee Schedule Proposed Rule

CMS has released the Medicare Part B Physican Fee Schedule proposed rule for 2009.  IDSA and HIVMA urged the administration and Congress to enact long-term reform of the physician payment system—specifically by building a physician payment formula that accounts for annual practice cost increases and does not include the cost of non-physician services such as Part B drugs and biologicals. IDSA and HIVMA also supported Medicare’s efforts to promote gainsharing between physicians and hospitals of monies saved from quality improvement initiatives, expressed concern over efforts to expand nonpayment for hospital-acquired conditions to other settings, and suggested several future enhancements to the Physician Quality Reporting Initiative.

Other advocacy efforts include:

  • Public Health Surveillance: IDSA endorsed the “National Integrated Public Health Surveillance Systems and Reportable Conditions Act,” which would increase and assure funding for epidemiological and laboratory capacity in state and local health departments, establish standards for electronic disease reporting, and strengthen the Centers for Disease Control and Prevention’s capacity to detect antimicrobial resistant infections and other emerging infectious disease threats.
  • Emergency Response: IDSA and other groups endorsed the Public Health Emergency Response Act to provide medical coverage to uninsured persons and reimburse health care providers for services rendered during a public health emergency.
  • Public Confidence in Immunization: IDSA joined the American Academy of Pediatrics and other members of the Immunization Alliance in issuing a national Call to Action to raise the public’s confidence in vaccines. The Alliance calls on policymakers, public health agencies, physicians, and the public to work together to preserve the health of the nation’s children through immunization.

Two New Training Grants Available For Global Research

Stephanie Cox

Two new training grant opportunities are available from the National Institutes of Health (NIH) for ID training programs and fellows who want to work on global research in infectious diseases in low- or middle-income countries. The two new opportunities are available through NIH’s John E. Fogarty International Center for Advanced Study in the Health Sciences.

The Ruth L. Kirschstein National Research Service Award (NRSA) Institutional Research Training Grants aim to provide predoctoral and postdoctoral research training opportunities for individuals interested in pursuing research careers in biomedical, behavioral and clinical research. The grants will be awarded to eligible institutions as the primary means of supporting graduate and postdoctoral research training to help ensure that a diverse and highly trained workforce is available to assume leadership roles related to global health-related research needs.

The deadline for applications is January 9, 2009. To learn more, please visit

The Fogarty International Clinical Research Scholars (FICRS) Program is designed primarily for students having a strong interest in, and potential for, a career in international health activities and/or clinical research. The FICRS Program offers a one-year clinical research training opportunity for graduate-level U.S. students in the health professions to experience mentored research training at top-ranked NIH-funded research centers in developing countries.

The deadline for applications is December 5, 2008. To learn more, please visit

In Memoriam: Thomas Weller

Pioneering Vaccine and Virus Researcher

Thomas H. Weller, MD, MS, FIDSA, Nobel laureate, vaccine pioneer, and first to isolate several viruses, passed away in his Needham, Mass. home on August 23 at age 93.

Dr. Weller shared the 1954 Nobel Prize in Physiology or Medicine with John P. Enders, MD, FIDSA, and Frederick C. Robbins, MD, FIDSA, for their research on tissue-culture methods for isolating viruses. This work led to the Sabin and Salk polio vaccines, as well as vaccines for other viral diseases.

The discovery nearest to his heart, however, was isolating varicella-zoster virus and demonstrating that it causes both chicken pox and shingles. In a July1998 supplement in Pediatrics, he wrote, “Although my work in isolating and growing the poliomyelitis virus in tissue cultures was the most significant contribution I have made to medical science in terms of global impact, I am most proud of my work with the varicella-zoster virus.  It’s something I planned to do and worked for years to do.”

He also discovered the cytomegalovirus and shares credit for discovery of the rubella virus with Albert Sabin, MD, and others.

Dr. Weller graduated from Harvard Medical School in 1940 and was a teaching fellow there until 1942, when he entered the Army to work on malaria control in the Caribbean. He left the Army in 1946 as a major and returned to Harvard’s Children’s Hospital. There he became a founding member of the hospital’s research division of infectious diseases, and later went on to head Harvard’s department of tropical medicine, a position he held until 1981.

In addition to the Nobel Prize, Dr. Weller’s awards include the Bristol Award from IDSA, the George Ledlie Prize from Harvard University, and the Walter Reed Medal from the American Society of Tropical Medicine and Hygiene (ASTMH). He is past president of ASTMH. 

Dr. Weller is survived by his wife, Kathleen Fahey Weller; two sons, Peter and Robert; a daughter, Janet; and six grandchildren.

Members on the Move

Rebecca Dotson

Stanley Falkow, PhD, FIDSA, is the recipient of the prestigious 2008 Lasker-Koshland Special Achievement in Medical Science Award.  The award, given every two years, honors scientists whose contributions to research are of unique magnitude and have immeasurable influence on the course of science, health, or medicine.  Dr. Falkow is being recognized for his 51-year career as one of this country’s most eminent scientists and his discovery of the molecular nature of antibiotic resistance.  Dr. Falkow will be presented with the award at a ceremony in New York City on September 26.  He is currently the Robert W. and Vivian K. Cahill professor of microbiology and immunology and medicine at Stanford University School of Medicine in Palo Alto, Calif.

David W. Hines, MD, has been named president of the medical staff for a two-year term at Our Lady of the Resurrection Medical Center Chicago, where he has been a practicing physician since 1987. During his tenure, Dr. Hines has served as chairman of the Department of Medicine and has been an active member of many staff committees.  He is board-certified in infectious diseases and internal medicine and is a fellow in the American College of Physicians (ACP). 

Welcome, New IDSA Members!


Caruso-Prendergast, Patricia, PharmD
Darlak, Kelly, PharmD
Fairhurst, Rick, MD, PhD
Jebraeili, Fatemeh, MD
Jones, Jeffrey, MD
Lyles, Rosie, MD
Malhotra, Suneil, PhD


Abreu, Mary, PhD
Bell, Todd, MD
Citron, Mark, PharmD
Cox, Donald, DO
Drzala, Annette, MS
Harris, Kelly, PharmD
Martin, Sonya, PharmD, MBA
Sharma, Roopali, PharmD
Staley, Ben, PharmD
Weber, David, MD


Alozie, Ogechika, MD
Aneja, Parul, MD
Aziz, Mariam, MD
Bahabri, Nezar, MD
Bolton, Michael, MD
Bowling, Jason, MD
Bowman, Vi, MD
Bridge, Michelle, MD
Crist, Matthew, MD
Day, James, MD
Deans, Greg, MD
Fadel, Hind, MD
Gaifer Ali, Zied, MD
Gardner, Adrian, MD, MPH
Granger, John, MD
Griffin, Paul, MD
Herrera, Victor, MD
Hunter, Michael, MD, MRCP, DTM&H
Jinadatha, Chetan, MD
John, Susan, MD
Kalokhe, Ameeta, MD
Kang, Julia, MD
Kim, Jocelyn, MD
Knoll, Bettina, MD, PhD
Krakowen, Douglas, MD
Kuppalli, Krutika, MD
Lapphra, Keswadee, MD
Lassmann, Britta, MD
Leto, Daniela, MD
Linares, Leslie, MD
Lisboa, Luiz, MD
Livorsi, Daniel, MD
Mahmud, Aneela, MD
Malvestutto, Carlos, MD
Manickam, Nisha, DO
Manrique, Luis, MD
Martinez-Capolino, Cynthia, MD
Marwaha, Shilpa, MD
McLees, Margaret, MD
Montesino, Ernesto, MD
Nadarajah, Jeya, MD, MSc
Naik, Nimesh, MD
Nangia, Payal, MD
Onyia, Ikemefuna, MD
Ory, Bridget, MD
Pacheco, Susan, MD
Parrish, Deidra, MD
Patel, Vipul, MD
Pernica, Jeffrey, MD
Rios, Liliana, MD
Rogg, Luise, MD, PhD
Sheth, Anandi, MD
Sikazwe, Izukanji, MD
Sims, James, MD
Smitasin, Nares, MD
Steer, Andrew, MD
Tims-Cook, Zandraetta, MD
Travassos, Mark, MD
Trivedi, Julie, MD
Tsaras, Geoffrey, MD
Vadnerkar, Aniket, MD
Warren, Thomas, MD
Wenzler, Danya, MD
Zachary, Dalila, MD