IDSA News - June 2010
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ACIP Adjusts Seasonal Influenza Vaccination Recommendation for Children
The federal Advisory Committee on Immunization Practices (ACIP) last week recommended that children 6 months to 9 years of age who did not receive at least one dose of the 2009 H1N1 influenza vaccine last season should receive two doses of the upcoming seasonal vaccine. The committee also advised that children in this age group receive two doses if they received only the H1N1 vaccine previously.
The recommendation came in response to data presented at the ACIP meeting, June 23-24, regarding the immunogenicity of the H1N1 vaccine among different age groups. Reports presented to the committee continue to support the safety of the vaccine, according to IDSA’s ACIP liaison, Samuel Katz, MD, FIDSA. Several large studies of the H1N1 vaccine and of the meningococcal conjugate vaccine have revealed no Guillain-Barré Syndrome (GBS) in the 42 days following vaccination. Other updates suggested that supply of the 2010-2011 seasonal influenza vaccine, expected to be available in early autumn, would be more than adequate, Dr. Katz said.
Committee members also received an update on pertussis, which remains the most frequent vaccine-preventable infection, highlighted by a current outbreak in California involving five infant deaths. Vaccination of adolescents and adults—including postpartum mothers to prevent transmission to their newly born infants—must be enhanced, and more research is needed on administering the vaccine to pregnant women.
Influenza and Intra-Abdominal Infections Guidelines Available as Pocketcards
Two new pocket-sized quick reference guides, featuring IDSA’s clinical practice guidelines for influenza and intra-abdominal infections, are now available. These 4-by-7-inch reference tools feature essential diagnostic and treatment recommendations in a brief, easy-to-use format. Pocketcards for aspergillosis, candidiasis, community-acquired pneumonia (CAP), immunization, and HIV primary care guidelines are also available.
IDSA and HIVMA members are eligible for a 35 percent discount when purchasing the Pocketcards. Click here to select and order individual cards. When placing your order, be sure to enter DCIDSA09 in the “Discount” field on the Shopping Cart page. Electronic versions of the Pocketcards are also available for viewing on the website.
In addition, several IDSA and HIVMA practice guidelines are available in a format designed for iPhones and other mobile devices. Visit IDSA’s website for instructions for downloading and using these guidelines on an iPhone or other mobile device.
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). Content includes a range of topics, including new drug approvals and warnings. Recent alerts have included:
IDSA members can sign up for these services online. (You must be logged in to have access to this link.)
Is Your Facility Experiencing Antibiotic Shortages?
Report these to FDA and IDSA.
Physicians Narrowly Dodge 21 Percent Cuts in Medicare Payments
Congressional Fix is Only Temporary
Congress narrowly forestalled a 21.3 percent cut in Medicare payments to physicians this month. The cut was due to the Sustainable Growth Rate (SGR) physician payment formula, which IDSA and other medical societies have protested for years. The Senate passed legislation on June 18 that will retroactively replace the payment cut with a 2.2 percent increase for six months, from June 1 through November 30, 2010, and the House followed suit on June 24.
Medicare began processing claims at the reduced rate on June 18 after holding them for nearly three weeks to give Congress more time to enact a fix. Claims will automatically be reprocessed at the higher rate now that Congress has acted.
Cuts of this magnitude are the result of past congressional fixes that have provided temporary payment relief to physicians but have not changed the flawed SGR. Even before this latest action, Congress had intervened nine times since 2002 and three times during the first half of this year to avert payment cuts, but because lawmakers still haven’t addressed the SGR, those votes have merely prolonged the underlying problem. Even bigger cuts will be in store next year, unless the SGR is reformed.
For additional information regarding future payment cuts or to contact your member of Congress, please visit IDSA’s Physician Payment Toolkit.
Medicare Internet Enrollment Deadline is July 6
Physicians must sign up with Medicare’s Internet-based enrollment system by July 6, 2010, or risk having their claims rejected. Claims submitted not only by referring physicians but also those of consulting physicians may be denied if the referring physician is not enrolled.
ID physicians should check their Medicare enrollment status to make sure it is up to date. Physicians should also discuss the issue with other physicians who often refer patients to them. To learn more, visit the Centers for Medicare and Medicaid Services (CMS)’s website. The American Medical Association (AMA) also provides information about the Medicare enrollment process for providers on its website.
Medicare has postponed the deadline before, and could do so again, but as of June 30, the July 6 deadline still stands.
Editor’s Note: Just as IDSA News was being posted, CMS announced that the agency is reviewing this policy and will NOT automatically reject claims for the time being. Physicians are advised to enroll soon or risk having their claims rejected in the future.
GAO Report Calls for Study of Medicare Coverage of Home Infusion Therapy
A recent report released by the Government Accountability Office (GAO) recommends that the federal government study the possibility of extending coverage for home infusion services to Medicare beneficiaries, a move IDSA has long supported.
The report compares current coverage policies of traditional Medicare plans and private health plans, such as Medicare Advantage Plans, for this therapy and concludes the Department of Health and Human Services should examine the issue further. “Given the long and positive experience health insurers reported having with home infusion therapy coverage, further study of potential costs, savings, and vulnerabilities for the Medicare program is warranted,” the report notes. To download the report, visit GAO’s website.
IDSA remains engaged in this issue and has endorsed legislation that would extend coverage to Medicare recipients, which the Society and other advocates believe would reduce hospital stays, decrease costs, be more convenient for patients, and make patients less likely to be exposed to hospital-acquired infections. For more information, please see IDSA’s website.
Another Delay on FTC’s ‘Red Flag’ Rule on Identity Theft
The deadline has been extended—once again—for physician practices to have in place policies to protect against patients’ identity theft under a new Federal Trade Commission (FTC) “Red Flags Rule.” The new deadline is Dec. 31, 2010.
FTC’s “Red Flags Rule” requires creditors to protect clients’ personal identifying information, such as insurance information, from being used fraudulently. FTC considers physician practices to be creditors, but the American Medical Association (AMA) and others disagree with this interpretation and have filed suit to prevent FTC from extending the rule to physicians.
Click here for an explanation of the rule and a sample compliance policy developed by the AMA. Also see the May 2010 issue of IDSA News.
Preparing for the Future of Global HIV/AIDS Funding
The world spent about $13 billion last year to fight HIV/AIDS. Will this level of funding continue? If not, how will African countries hardest hit by the pandemic cope? Several speakers discussed these issues during a recent session at the Global Health Council’s annual conference in Washington, D.C.
Two African leaders in the field—David Apuuli, MD, director general of the Uganda AIDS Commission, and Benson Chirwa, MD, director general of the National AIDS Council in Zambia—expressed concern about whether international funding would last, potentially leaving their countries with a growing number of people receiving treatment but little resources to pay for them.
“I think we are heading for a crisis,’’ Dr. Apuuli said. “Not only my country, but neighboring countries, Kenya and Tanzania, as the amount of money flattens and the numbers of those who need treatment rise. The money required for those who need it is way beyond the budgets in these countries.’’
Economist Robert Hecht, managing director at Results for Development Institute, a Washington, D.C.-based group of development experts, predicted that the need for AIDS funding in 20 years would rise well above current levels, ranging from $19 billion to $35 billion a year. The number of new infections could be cut substantially, but none of the scenarios developed by the group shows the world getting new infections below 1.2 million a year. Donors and recipients need to engage in serious discussions now about the response to HIV/AIDS and what portion of the burden each will assume. These discussions are well under way, Paul Bouey, U.S. deputy global AIDS coordinator, told the audience.
Tough choices lay ahead, as worries grow among countries receiving international funding about future funding levels, several speakers noted. But Hecht said his research showed that a better-targeted prevention effort could substantially reduce the resource need. Read more about the session and other global health news at the Center for Global Health Policy’s blog, www.sciencespeaks.wordpress.com.
Recent blog highlights include:
- A summary of a recent panel discussion on the linkages between gender, AIDS, and development—and implications for U.S. policy—organized by the Center for Strategic and International Studies. Panelists discussed the disproportionate impact HIV/AIDS has on women and girls around the world and the need to place female health at the forefront of the nation’s global health efforts.
IDSA Urges Action on Antibiotic Development at Congressional Hearing
At a congressional hearing earlier this month, several IDSA members outlined the scope of the threat posed by antibiotic resistance and underscored the need to stimulate new antibiotic development. Brad Spellberg, MD, FIDSA, a member of IDSA’s Antimicrobial Availability Task Force (AATF), highlighted the Society’s 10 x ’20 initiative and the Strategies to Address Antimicrobial Resistance (STAAR) Act, as important components of a broad strategy to combat resistance and spur antibiotic development.
“We encounter multi-drug-resistant bacteria daily, every day on rounds,” Dr. Spellberg told a House of Representatives committee June 9. “Over a one-month period at my institution, we had 23 patients who were infected with extreme drug-resistant Acinetobacter that’s resistant to everything except one last ditch drug, colistin, which was abandoned in the ’60s because it’s so toxic. That’s all we have left. Twenty-three patients in one month for one bacterium—that’s the scope of the problem.”
Janet Woodcock, MD, director of the Center for Drug Evaluation and Research at the Food and Drug Administration (FDA), acknowledged that regulatory uncertainty about the data required for FDA approval presents a challenge for antimicrobial development and the need for new scientific methods to evaluate these drugs. FDA plans to publish additional guidance on these methods within the next six months, Dr. Woodcock told lawmakers.
AATF member John Bradley, MD, FIDSA, spoke at the hearing on behalf of the American Academy of Pediatrics (AAP) about the threat antibiotic resistance poses for pediatric patients; Barry Eisenstein, MD, FIDSA, an advisor to IDSA’s Research on Resistance Work Group, spoke on behalf of Cubist Pharmaceuticals.
Held before the health subcommittee of the House Energy and Commerce Committee, the hearing was the second in a series of three planned on drug resistance and antibiotic use and development, a sign of increasing momentum on these issues (see related IDSA News article). A third hearing on the use of antibiotics in animals has been tentatively scheduled for July 15. Earlier this month, the American Medical Association (AMA) and the American College of Physicians (ACP) joined a growing list (PDF) of more than 20 organizations endorsing IDSA’s 10 x ’20 initiative, which calls for a global commitment to develop 10 new antibiotics by 2020.
Testimonies from the hearing witnesses are available online, in addition to video of the hearing.
AMA Endorses 10 x ’20 Initiative
Group Also Approves IDSA Proposals on HIV Testing and Clinical Practice Guidelines
The American Medical Association (AMA) endorsed IDSA’s 10 x ’20 initiative earlier this month, joining a growing list (PDF) of more than 20 organizations, including the American College of Physicians (ACP). AMA’s House of Delegates voted to endorse the campaign at their annual meeting, June 12-16, in Chicago. AMA delegates also approved resolutions submitted by IDSA that:
- Support coverage of routine HIV testing by all public and private insurers. The Society’s resolution, developed by the HIV Medicine Association (HIVMA), also encouraged a review of the evidence for routine testing by the U.S. Preventive Services Task Force, whose recommendations influence insurance coverage decisions.
- Support an independent development process for clinical practice guidelines and oppose efforts to improperly influence or politicize recommendations in these guidelines. IDSA’s resolution called on AMA to oppose efforts to legislate the practice of medicine by mandating coverage of or sanctioning treatments proven to be ineffective or potentially harmful, such as long-term antibiotic therapies for Lyme disease.
Members on the Move
James E. Crowe Jr., MD, FIDSA, has been named director of the new Vanderbilt Vaccine Center, which will foster development of vaccines from the bench to the bedside. Dr. Crowe is an Ingram Professor of Cancer Research and professor of pediatrics, microbiology, and immunology at Vanderbilt University. Dr. Crowe is a member of the Annual Meeting Program Committee.
Mary E. Klotman, MD, returned to Duke University School of Medicine as chair of the Department of Medicine in March. Previously, she was the chief of the Division of Infectious Diseases and co-director of the Global Health and Emerging Pathogens Institute at Mount Sinai School of Medicine. Dr. Klotman held the position at Mount Sinai for 13 years, and was also a professor of medicine and microbiology and associate professor of gene and cell medicine.
Louis B. Rice, MD, has been appointed chair of medicine at The Warren Alpert Medical School of Brown University and chief of medicine at Rhode Island Hospital and The Miriam Hospital, effective in September. Dr. Rice is currently at Case Western University where he serves as professor of medicine and chief of medical service at the Cleveland Veterans Affairs Medical Center, as well as vice chairman of the department of medicine at the University Hospitals of Cleveland. He is chair of the IDSA Research Committee and the Research on Resistance Work Group.
Are you a member on the move? Do you know someone who is? Contact Stephanie Cox at email@example.com so that we can announce it to our membership.
Welcome, New Members!
Gidengil, Courtney, MD, MPH
Iwabuchi, Sentaro, MD
Khot, Prasanna, PhD
Legendre, Davey, PharmD
Moenster, Ryan, PharmD
Robien, Mark, MD, MPH
Shirley, Rhett, MD
Sukstorf, Angela, MD, MS
Tayeb, Sarah, MD
Welch, Verna, MPH, PhD
Wissinger, Erika, PhD
Alva, Manuel, MD
Arapian, Michael, MD
Arroyo, Awilda, MD
Bositis, Christopher, MD
Bruun, Trond, MD
Bukharie, Huda, MBBS
Edmonson, M. Bruce, MD, MPH
Fox, George, FNP, MSc, RN
Grodi, Jeff, PharmD
Gupta, Rajesh, MD, MPH, MS
Hamm, Darrell, MD
Harada, Sohei, MD, PhD
Harfouch, Chawki, MD
Hazlewood, Katie, PharmD
Jordanov, Emilia, MD
Kamei, Katsuhiko, MD
Karpov, Igor, MD
Leslie, Ryan, PharmD
MaDugonde, Nagaraj, MD, MPH
Merrill, Charley, PhD
Moss, Marie, RN, MPH
Petty, Christopher, PhD
Press, Natasha, MD
Prince, William, MD, PhD, BCh, MB
Schraa, Charles, PharmD
Teston, Lilian, MD
Weeden, Virginia, MT(ASCP)
Yamamoto, Shungo, MD
Ahmed, Yasir, MD
Collins, Jonathan, MD
Deiss, Robert, MD
Dillon, Jasmine, MBBS, MPH
Guedes de Morais, Amanda, MD
Haraoui, Louis-Patrick, MD
Havens, Nicholas, MD
Jose, Sheena, MD
Kaiser, Robyn, MD, MPH
Khan, Abdur, MD
Khumri, Samina, MD
Kiet, Grace, MD
Kreppel, Andrew, MD
Ma, Shuhua, PhD
MacQueen, Douglas, MD
Malouh, Abdel Abu, MD
Mangraj, Sunanda, MD
Marquez-Minondo, Dianne, MD
Matsuo, Hiroo, MD
Neemann, Keri, MD
Okon, Emmanuel, MD
Poursina, Arash, MD
Qi, Xiaohua, PhD
Shalhoub, Sarah, MD
Srinivas, Nivedita, MD
Thacker, Stephen, MD
Touzard Romo, Francine, MD
Trible, Ronald, MD, PhD
Tymchuk, Christopher, MD, PhD
Vento, Rebecca, MD, MPH
Rynkiewicz, Dianna, MD
Revised CPT Coding Resources Available
Updated inpatient and outpatient coding resources were mailed to IDSA members last month. The updated content includes new information about how to maximize reimbursement by coding for prolonged service and critical care service time. These revisions are especially important in light of Medicare’s decision to eliminate payments for consultation codes (see related IDSA News article). These resources include:
- The inpatient correct coding pocket card, which provides evaluation and management (E&M) coding guidance related to consultations, admissions, subsequent hospital visit, prolonged services, and critical care.
- The outpatient correct coding wall poster, which provides E&M coding guidance related to office consultations, new patient, established patient, and prolonged services.
Log in to the IDSA website to access the ID-Specific Correct Coding Resources to download these and other coding tools. Additional hard copies of the coding resources can be purchased for a small fee by downloading and completing the order form available here (PDF). In addition, IDSA is also preparing coding resources for handheld devices; more information will be available soon. Please contact Jason Scull at firstname.lastname@example.org with any questions or concerns.
IDSA Annual Meeting Update
The premier event in the ID field is fast approaching. The 48th Annual Meeting of IDSA, Oct. 21-24, 2010 in Vancouver, will offer cutting-edge, up-to-the-minute clinical and research information that you won’t want to miss.
The deadline for discounted registration is July 23.
The premier event in the ID field is fast approaching. The 48th Annual Meeting of IDSA, Oct. 21-24, 2010 in Vancouver, will offer cutting-edge, up-to-the-minute clinical and research information that you won’t want to miss. Check out the preliminary program, now available online.
Other important Annual Meeting reminders:
- As of June 2009, everyone travelling between the United States and Canada is required to present a valid passport. For additional information about passports, visas, customs, and travel discounts, visit the travel page on IDSA’s Annual Meeting website.
- Register for the Annual Meeting by July 23, 2010 to receive the early registration discount.
- The deadline for submitting late breaker abstracts is 5 p.m. EDT, August 20, 2010. Visit the Annual Meeting site for more information.
Stay tuned for further updates and announcements about the 48th Annual Meeting of IDSA. We look forward to seeing you in Vancouver!
IDSA, FDA, and NIAID to Hold Antibacterial Resistance Research Workshop, July 26-27
Next month, this joint workshop will bring together key researchers, physicians, regulators, and government officials to discuss the science around antibacterial resistance and new antibacterial drug and related rapid diagnostics development. Register now to view a live webcast of the workshop.
Next month, IDSA, the Food and Drug Administration (FDA), and the National Institute of Allergy and Infectious Diseases (NIAID) will hold a joint workshop to bring together key researchers, physicians, regulators, and government officials to discuss the science around antibacterial resistance and new antibacterial drug and related rapid diagnostics development. The free public workshop, to be held July 26-27 in Silver Spring, Md., will focus on four key areas:
- scale of the current antibacterial resistance problem
- science and mechanisms of bacterial resistance
- science of development of rapid diagnostics
- science of antibacterial drug development
A follow-up IDSA report is planned to capture workshop highlights, note research gaps and priorities, and make recommendations for future research in these critical areas. In April, IDSA called on Congress to substantially increase NIAID’s funding for antibacterial resistance and drug discovery and development research to $500 million to help address the public health threat posed by drug resistance. The Society also asked lawmakers to significantly increase FDA’s budget for its antimicrobial resistance and antibacterial drug review programs and to support FDA’s new regulatory science initiative, part of a recommended overall funding increase for the agency (see IDSA’s congressional testimony).
The workshop will be webcast online and may be viewed for free by pre-registering online. Videos of the workshop presentations will also be available for free on IDSA’s site following the workshop. For more information, including how to register and attend in person, please visit the Society’s website.
Physicians Forced to Make Cutbacks as Medicare Eliminates Payment for Consultation Codes
Medicare’s decision to eliminate payment for consultation codes is forcing physicians to reduce services to Medicare patients, eliminate staff, and defer purchase of new equipment, according to a recent survey of several medical societies, including IDSA.
Medicare’s decision to eliminate payment for consultation codes is forcing physicians to reduce services to Medicare patients, eliminate staff, and defer purchase of new equipment, according to a recent survey by the American Medical Association (AMA) and 11 medical societies, including IDSA. Few specialties have been hit as hard as infectious diseases.
When Medicare’s new policy went into effect on Jan. 1 of this year, the Centers for Medicare and Medicaid Services (CMS) predicted that no specialty would see Medicare revenues decline by more than 3 percent and that there would be little impact on the coordination of care.
But the medical societies’ survey casts serious doubts on those assumptions. Nearly three quarters (72 percent) of the approximately 5,550 physicians who completed the survey estimated that the elimination of billing for consultations had decreased their total revenues by more than 5 percent, and 30 percent experienced losses of more than 15 percent. Among ID, an extraordinary 95 percent said their total revenue stream has decreased. Infectious disease accounted for more than 10 percent of the survey responses.
The survey found that many practices cannot sustain cuts of this size and have either reduced their services to Medicare patients or are contemplating cost-saving steps that will impact care. Overall, 20 percent of all survey respondents have eliminated or reduced appointments for new Medicare patients—a concern given how common consultations are for seniors. In addition, 39 percent will defer the purchase of new equipment or information technology, and 34 percent are eliminating staff, including physicians. More troubling for the success of the Patient Centered Medical Home and other delivery system reform ideas that are focused on reducing costs through improved care coordination, 19 percent of respondents stopped providing reports back to primary care physicians.
Among infectious disease respondents, 16 percent said they already have had to modify their practice or services. Of those ID physicians who made modifications, 60 percent said they have reduced the number of new Medicare patients, and 36 percent said they have reduced the amount of time spent with Medicare patients. The percentage of ID physicians who stopped providing reports back to primary care physicians was even higher at 22 percent.
Nearly half (49 percent) of ID respondents said they will defer purchase of equipment or IT, and 37 percent said they will eliminate staff.
Survey results suggest that many private payers have already adopted Medicare’s non-payment policy for the consultation codes. ID practices should contact individual payers to verify.
IDSA, AMA, and more than 30 physician groups are urging CMS to revise its policy in light of the survey findings. Click here for the groups’ June 18 letter to CMS. For a summary of the survey’s ID results, click here. (You must be logged in to have access to this link.)
In response to the survey results and the letter, Medicare’s 2011 Physician Fee Schedule Proposed Rule seemed to acknowledge the challenges created by the consultations decision and requested comments on providers’ experiences with the new coding policy. IDSA members are strongly encouraged to submit comments. To submit comments, visit this website and follow the prompts for electronic submission—comments will be accepted through August 24.
Also see IDSA News, January 2010. Stay tuned to IDSA News for future updates on this issue and the proposed rule.
IDSA Journal Club
This month: Studies investigating safety and efficacy of childhood vaccines, antiretroviral therapy and rates of HIV transmission, the sensitivity of detecting catheter-related bloodstream infections, antibiotic therapy and treatment failure in patients hospitalized for acute exacerbations of COPD, geoclimatic influences on invasive aspergillosis after hematopoietic stem cell transplantation (HSCT), and long-term daptomycin use and the risk of CPK elevation.
In this 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 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.
Recent Studies Support Safety and Efficacy of Childhood Vaccines
Reviewed by Jason Weinberg, MD
Children who received all recommended vaccines during the first year of life are not at risk for long-term detrimental effects on neurodevelopmental outcome, according to a study published in the June 2010 issue of Pediatrics
This study analyzed publicly available data from a cohort of 1,047 children who underwent neuropsychological testing at 7 to 10 years of age. Results for children with timely vaccination (vaccine doses received within 30 days of the recommended age; 47 percent of the study population) were compared to results for children with delayed (23 percent), incomplete (20 percent), or absent (0.83 percent) vaccination. Children with timely vaccination performed no worse on neuropsychological tests than those with untimely vaccination. Timely vaccination was actually associated with better performance on two measures in a multivariable analysis. This difference was no longer significant when secondary analyses were conducted, but children with the most timely vaccination again performed no worse than children with the least timely vaccination.
Childhood vaccination remains a public health mainstay, but parental concerns regarding vaccine safety persist. These concerns can lead to delayed, incomplete, or absent vaccination, increasing the risk of infection for children and their contacts who would otherwise be protected by herd immunity. Although children included in this study were born between 1993 and 1997, and therefore received fewer vaccines than children undergoing primary vaccination now, the results of this study provide reassurance that timely vaccination is unlikely to be associated with neurodevelopmental problems.
One newer vaccine, which was recently incorporated into the recommended childhood immunization schedule, has decreased hospitalizations for acute gastroenteritis, according to a study in the June 1 issue of The Journal of Infectious Diseases.
Investigators analyzed hospitalization data from 18 states after the pentavalent rotavirus vaccine (RV5) was licensed (2007 and 2008) and compared them to pre-RV5 licensure (2000-2006) data. The acute gastroenteritis hospitalization rate was 16 percent lower in 2007 and 45 percent lower in 2008 than the pre-licensure median rate. This effect was greatest in age groups eligible for vaccination but was also present in children either too young or too old to be vaccinated. The investigators estimated that 55,000 acute gastroenteritis hospitalizations were prevented during the 2008 rotavirus season in the United States.
While acute gastroenteritis hospitalization was used as a surrogate for rotavirus-specific hospitalizations, and vaccine coverage data was not available for this study, these encouraging results further support the effectiveness of RV5 in reducing rotavirus-associated disease. Together, both of these studies reinforce the safety and effectiveness of childhood vaccines.
(Smith and Woods. Pediatrics. 2010; 125(6):1134-1141. and Curns et al. J Infect Dis. 2010; 201(11):1617-1624.)
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Antiretroviral Therapy Dramatically Decreases Rates of HIV Transmission
Reviewed by Jonathan Li, MD
Plasma HIV viral load is known to be one of the most important factors in determining the risk of HIV transmission to an un-infected partner. In a study published in the June 12 issue of The Lancet, antiretroviral treatment (ART) of the HIV-infected individual resulted in a 92 percent reduction in the rates of HIV transmission to the HIV un-infected partner.
Investigators performed a secondary analysis of 3,381 HIV-discordant couples enrolled in the Partners in Prevention HSV/HIV Transmission Study, a randomized trial testing the efficacy of acyclovir suppression in preventing HIV transmission. Participants began ART based on national guidelines, which recommended treatment at CD4 cell counts less than 200-250 cells/μl. HIV sequencing was performed to establish that the transmission was genetically linked between the partners.
Among the 349 (10 percent) HIV-infected participants who initiated ART, only one genetically linked transmission event was recorded. In contrast, 102 genetically linked HIV-transmission events occurred from individuals not on ART. This corresponded to a transmission rate of 0.37 per 100 person-years in those on ART versus 2.24 per 100 person-years in participants not on treatment, a 92 percent reduction in rates of transmission. Not surprisingly, CD4 cell counts less than 200 cells/μl and higher plasma HIV viral load (>50,000 copies/mL in those with CD4 cell counts >200 cells/μl) were also associated with higher rates of HIV transmission.
These results are in accordance with another large study of discordant couples and demonstrate the importance of antiretroviral treatment as an HIV prevention strategy. Despite the dramatic effects noted here, the lone case of HIV transmission by an individual on treatment is a warning that ART use may not be 100 percent effective and should continue to be combined with safe sexual practices.
(Donnell et al. Lancet. 375(9731):2092–2098.)
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Enhancing the Sensitivity of Detecting Catheter-Related Bloodstream Infections
Reviewed by Khalil Ghanem, MD, PhD
All lumens should be cultured to enhance the sensitivity of diagnosing a catheter-related bloodstream infection (CRBSI). The finding comes from a retrospective study published in the June 15 issue of Clinical Infectious Diseases.
Patients had blood cultures drawn from all non-clotted catheter lumens in addition to peripheral vein cultures. CRBSI was defined based on differential time to positivity or differential colony count compared to cultures obtained from a peripheral vein. The investigators used basic probability calculations to determine what fraction of CRBSI would have been missed if one or more lumens had not been cultured.
One hundred and fifty four patients contributed 171 episodes of microbiologically proven CRBSI. The majority of patients studied were immunocompromised. Most infections consisted of coagulase-negative staphylococci, gram-negative rods, and yeast. If only a single lumen were cultured from a double or triple lumen catheter, 27.2 percent and 37.3 percent of CRBSI, respectively, would have been missed.
The study has several limitations: It was retrospective with a relatively small sample size; information on types of blood culture bottles used, and volume of blood inoculated into each bottle were not provided. Clinicians should be aware that obtaining samples from all catheter lumens is not recommended unless concomitant peripheral vein cultures are obtained to decrease the likelihood of false-positive culture results. Additionally, culturing blood from more than one lumen is time consuming, expensive, and may contribute to anemia in critically ill patients.
(Thanks to Karen Carroll, MD, FIDSA, for her insights on this study.)
(Guembe et al. Clin Infect Dis. 2010;50:1575–1579.)
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Antibiotic Therapy and Treatment Failure in Patients Hospitalized for Acute Exacerbations of COPD
Reviewed by Sara Cosgrove, MD
Antibiotics received within two days of hospital admission for acute exacerbations of chronic obstructive pulmonary disease improve treatment success, according to a study in the May 26 issue of the Journal of the American Medical Association.
The retrospective cohort study, using administrative data, included patients with acute exacerbations of COPD at 413 acute care hospitals. Antibiotic treatment was defined as receipt of at least two consecutive doses of first-through-third generation cephalosporins, quinolones, macrolides, tetracyclines, TMP/SMX, amoxicillin, or amoxicillin/clavulanate started on the first or second day in the hospital. The primary outcome was treatment failure, defined as starting mechanical ventilation after day two of hospitalization, in-hospital mortality, or readmission for COPD within 30 days.
Of 84,621 patients, 79 percent received antibiotics (60 percent of these were quinolones). These patients had lower rates of treatment failure (9.8 percent vs. 11.7 percent), were less likely to require mechanical ventilation (1.1 percent vs. 1.8 percent), had lower in-hospital mortality rates (1 percent vs. 1.6 percent), and had lower rates of readmission (7.9 percent vs. 8.8 percent). After multivariable analyses, receipt of antibiotics remained protective against treatment failure (OR 0.87, 95 percent CI 0.82-0.92). Patients who received antibiotics were significantly more likely to develop C. difficile diarrhea (0.2 percent vs. 0.09 percent).
While this study supports guidelines recommending treatment with antibiotics, there are some caveats. The retrospective study design leaves open the possibility of confounding factors such as differences in socioeconomic status or management that contribute to the apparent association between antibiotics and improved outcomes. In addition, data were obtained from administrative databases using ICD-9 codes and were not validated with chart review. The increased rates of C. difficile diarrhea among patients who received an antibiotic also reminds us of the potential consequences of antibiotic use. The relatively high rates of quinolone use may have contributed to this finding. Additional studies are needed to better define which patients benefit from antibiotics, the narrowest spectrum antibiotic that is effective, and the appropriate duration of antibiotic therapy.
(Rothberg et al. JAMA. 2010;303(20):2035-2042.)
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Geoclimatic Influences on Invasive Aspergillosis after Hematopoietic Stem Cell Transplantation (HSCT)
Reviewed by George R. Thompson III, MD
The source and mode of acquisition of Aspergillus spp. is not completely understood. Infection late after hematopoietic stem cell transplantation (HSCT) has been documented recently, suggesting factors outside of the hospital environment likely play a key role. Changes in weather conditions are well known to affect spore counts; however, an association with invasive aspergillosis (IA) in allogeneic HSCT patients has not previously been reported.
In the June 15 issue of Clinical Infectious Diseases, investigators describe the results of a comparative analysis of HSCT patients from geographically and diverse regions (Seattle and Houston) to examine potential seasonal variations in IA rates and the possible association of infection with local spore counts and climate.
Data from Seattle demonstrated a high incidence of IA (5.8 percent) after seasonal periods of low precipitation and high temperatures, coinciding with high environmental spore counts. A comparably lower incidence of IA during the non-summer months (3.3 percent) was also observed at this location, coinciding with low environment spore counts and higher precipitation.
The Houston cohort was chosen specifically as a comparator to the Seattle group, given the much warmer weather during the spring and summer than in Seattle, and precipitation increases in warmer months rather than decreases. However, the incidence of IA in Houston HSCT patients was relatively constant throughout the year (1.6-2.4 percent) as were spore counts. No climatic association on person-month IA rates was seen in this group.
These findings support the notion that a substantial portion of IA is acquired outside the hospital and that climatic variables affecting spore counts may correlate to IA rates in HSCT patients. Host and environmental prevention strategies will need to be examined in future studies to decrease the disease burden in this highly susceptible population.
(Panackal et al. Clin Infect Dis. 2010;50(12):1588-1597.)
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Long-term Daptomycin Use and the Risk of CPK Elevation
Reviewed by Kathryn E. Stephenson, MD, MPH
Daptomycin is used as an alternative agent to vancomycin for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infective endocarditis (IE) and bacteremia. One of the concerns with long-term use of daptomycin is the development of adverse musculoskeletal events, which are generally heralded by a rise in creatine phosphokinase (CPK) levels. A study in the June 15 issue of Clinical Infectious Diseases sheds some light on this relationship and the clinical implications.
The investigators studied 108 patients who had received daptomycin 6 mg/kg IV daily for a minimum of 10 days for the treatment of MRSA IE or bacteremia. Only a small percentage (5.6 percent) of patients had CPK elevations as defined in the study, and only two patients had clinically significant symptoms. CPK elevations were significantly associated with a trough daptomycin level >24.3 mg/L, and five of the six CPK elevations occurred during the first two weeks of therapy. In addition, CPK elevations were significantly associated with a total body weight >111 kg.
The authors suggest that CPK levels should be checked more frequently than once weekly during the first two weeks of therapy, but that routine monitoring of daptomycin trough levels is not warranted. Instead, they propose checking a trough level only for patients with CPK elevations for whom continuing daptomycin therapy would be imperative (as a trough <24.3 mg/L suggests that the elevation is not due to daptomycin). Currently, this may be difficult in clinical practice as daptomycin levels are not available routinely. The authors also question whether daptomycin dosing should be based on lean body weight to reduce the risk of CPK elevations in obese patients, but warn that doing so might also reduce the efficacy of therapy.
(Bhavnani et al. Clin Infect Dis. 2010;50:1568–1574.)
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:
- Clinical Therapeutic Implications of Macrolide Resistance in Mycoplasma pneumoniae
- Treatment of Pneumocystis jirovecii Pneumonia (PCP) When Trimethoprim‐Sulfamethoxazole (TMP‐SMZ) Fails or Cannot Be Used
- Treatment of Pulmonary Infection Due to Mycobacterium abscessus
- Cheeky Mycobacteria
- Acute Appendicitis: Management with Antibiotic Therapy Alone?