IDSA News - July/August 2010
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 (CDC), which funds the EIN. The reader assumes all risks in using this information.
A recent discussion on the EIN listserv highlighted a wide range of practices for placing limits on the duration of treatment when ordering inpatient antibiotics, underscoring the great need for more research in this area.
An EIN member from California asked: “What is your policy regarding length of treatment when ordering antibiotics for inpatients? Is it required that the length of the prescription be specified, or is it open-ended? Is it possible to specify the length, with pharmacy providing a hard stop?
The unofficial poll generated a variety of responses, from 20 members in 13 states, illustrating a need for additional data. “Sadly, there are very few studies in the literature that measure the necessary duration of antibiotic therapy,” a respondent from Texas wrote. “We use a 10-day automatic stop order unless the physician reorders the antibiotic or a stop date is specified with the original antibiotic order.”
An Ohio EIN member reported the availability of both options through an electronic health record (EHR) system: “The ordering physician may specify a hard stop that is enforced by the pharmacy or choose to leave the duration open ended.”
A member from New Hampshire responded that “some, but not all, of our hospitals had a hard stop policy, but there were occasional problems when patients receiving longer-term treatment for osteomyelitis, endocarditis, etc., had their therapy mistakenly stopped too soon. Another option that we’ll likely implement is an automatic review with ID input when a prescription hits the two week mark. This is probably more clinically appropriate than a hard stop order.”
Two other respondents shared similar cautions about hard stops. An alternative may be “to have the pharmacists keeping an eye on the antibiotics and if it appears the patient is nearing the end of their course, discuss the physician’s thoughts with them,” a member from Missouri suggested. If done in a collegial manner, this could be effective at preventing excessive antibiotic use.
An EIN member from Texas shared an experience gained from implementing hard stops: Unless the approach “is paired with an auto-alerting mechanism with a good communication loop built into it, we learned that it’s not going to be very successful,” the member noted. “Prospective audits by the pharmacist may still be our best approach to stop excessively long treatment.”
Another Texas respondent described a multi-tiered approach. For some antibiotics, such as vancomycin and imipenem, “we have a five-day stop unless the order is written for a specific period, so that if you just write the antibiotic (and indication, of course) you get a reminder at four days, and then it’s stopped if you don’t renew.” If a physician specifies 10 days, “you get 10 days without a reminder. Other, cheaper antibiotics do not get the reminders.” Any patient on three or more antibiotics or for more than 14 days is supposed to be reviewed by the pharmacy or an infection control analyst.
A member in Illinois reported the use of a “specified duration of therapy, with hard stops unless there is a follow up either in the form of a phone call or an ID consultation.” A respondent in Wisconsin described a similar strategy: “In circumstances where we have a fixed duration (for example, antibiotic lock for a central line infection) for patients who will remain beyond the period of antibiotic use, [a specified duration] makes sense.”
An open-ended approached described by a Minnesota respondent also included Antibiotic Management Teams that evaluate duration, as well as selection and appropriateness.
More study is needed to answer these questions, and IDSA has been a strong advocate for funding research on antibacterial resistance.
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) with funding from the Centers for Disease Control and Prevention (CDC), EIN tracks emerging infectious diseases and keeps the public health community up to date with new disease trends, difficult cases, and other issues affecting 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. Click here for more information or to join EIN.
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.
Future Payment Cuts Remain a Concern
Congress narrowly avoided a 21.3 percent cut in Medicare payments to physicians earlier this summer, but the temporary fix will end Nov. 30. Unless lawmakers act before then, the cut will return in December 2010 and jump to 30 percent next year, according to the 2011 Medicare Physician Fee Schedule Proposed Rule, released in June. The bad news is one of several items in the proposed rule that could impact ID physicians, their practices, and how they are paid.
Although the proposed rule does not change Medicare’s decision to eliminate payments for consultation codes, it does acknowledge the challenges the decision has caused and asks providers to submit comments about their experience with the new coding policy (see June 2010 IDSA News article). IDSA strongly urges members to submit comments by visiting this website by Aug. 24.
Several changes are slated for the current Physician Quality Reporting Initiative (PQRI), among them the addition of 20 new reporting measures, including those that would allow reporting through claims registries and electronic health record (EHR) systems. Other changes would reduce the claims-based reporting requirement from the current 80 percent of applicable Medicare cases to 50 percent in 2011 and would reduce the minimum practice size eligible to qualify for the group practice reporting option from the current 200 providers to just 2 providers.
As required by the health care reform law, Medicare will also gradually decrease incentive payments for PQRI participation from the current 2 percent level, dropping the figure to 1 percent in 2011 and to 0.5 percent from 2012 to 2014. Starting in 2015, those who do not report through PQRI will see a 1.5 percent penalty.
The health care reform law also requires the Centers for Medicare and Medicaid Services (CMS) to establish a separate PQRI reporting option allowing physicians to submit quality measures data to a Maintenance of Certification Program operated by a specialty body of the American Board of Medical Specialties. Physicians would still need to submit quality data through Medicare claims or qualified-registries. But this new option offers the potential to earn 0.5 percent in extra PQRI incentive payments.
Separately, physicians can still earn additional incentive payments for e-prescribing. The requirements to earn these payments will not change significantly for 2011: Physicians must generate at least 10 percent of their total Medicare charges from outpatient evaluation and management (E&M) service codes, and they must successfully e-prescribe at least 25 times during these situations. Similar to the PQRI option described above, the group practice reporting option for e-prescribing is being modified to account for smaller practices. Incentive payments would drop to 1 percent in 2011-2012, and starting in 2012, those who don’t e-prescribe will face payment penalties. Physicians who earn an incentive under the Medicare EHR Incentive Program for use of technology with these capabilities will not be eligible to earn a separate e-prescribing incentive payment.
For more information about Medicare’s incentive payment programs, see this CMS tipsheet. A tipsheet focused on incentives for EHR use is available here. In another step mandated by health reform, the rule will establish a new “Physician Compare” website by Jan. 1, 2011. Initially, the publicly available website will only report the names of physicians and group practices that successfully earn PQRI and e-prescribing incentive payments. In future years, the website will combine data about individual physicians’ or groups’ quality and cost of care into a composite score benchmarked against their peers.
Finally, the maximum period for submitting claims to Medicare has been reduced to 12 months from the date of services. Previously, providers could wait up to three years to submit Medicare claims. IDSA continues to analyze the proposed changes and will be submitting comments to the Centers for Medicare and Medicaid Services (CMS). A final rule is expected Nov. 1. See IDSA’s website for more information about quality improvement resources and tools, including more details about the PQRI and e-prescribing incentive payment programs.
Several important themes emerged from the 18th International AIDS Conference in Vienna in July, including exciting research results for new methods to prevent HIV infection and concerns over future funding. Here is a brief summary of the Center for Global Health Policy’s top five lessons learned from the week-long conference:
Read more about the IAS conference and other global health news at sciencespeaks.wordpress.com. Recent posts include:
The International AIDS Society (IAS) announced in July that the HIV Medicine Association (HIVMA), with its Center for Global Health Policy, will be one of two local scientific partners for the 2012 International AIDS Conference, to be held in Washington, D.C. in July 2012. The National Institutes of Health (NIH) has been selected as the other local scientific partner.
“This is a real opportunity for the members of HIVMA to contribute to the scientific content and political voice of this influential biennial conference,” said HIVMA Chair Michael Saag, MD, FIDSA. “We look forward to working with the IAS, NIH and the other partners to create a program that showcases the latest HIV/AIDS prevention and treatment discoveries and highlights the application of research findings to improving prevention and health outcomes in under-resourced countries and here at home.” For more information, see this press release
The Obama administration in July unveiled the first-ever coordinated national strategy to combat the HIV/AIDS epidemic by reducing HIV infections and HIV-related health disparities, increasing care quality, and expanding access to services. The plan includes several notable goals and proposes that by 2015:
The HIV Medicine Association (HIVMA) and the Ryan White Medical Providers Coalition (RWMPC) applauded the release of the strategy, calling it an important first step. Both emphasized the need for adequate resources and a robust implementation plan to ensure the strategy’s goals can be met. “We are excited about the launching of this long-awaited initiative, and look forward to partnering on its implementation to make the strategy's vision a reality,” HIVMA Chair Michael Saag, MD, FIDSA, said in a joint HIVMA/RWMPC statement. Implementing agencies are charged with developing detailed plans within 150 days. HIVMA is preparing an analysis of the initiative and will keep members informed as it is implemented.
Video and slide presentations available online
Researchers, physicians, regulators, government officials, and industry representatives came together at a joint workshop last month to discuss the science around antibacterial resistance and new drug and related diagnostics development.
Co-sponsored by IDSA, the Food and Drug Administration (FDA), and the National Institute of Allergy and Infectious Diseases (NIAID), the two-day, public workshop included keynote presentations by NIAID Director Anthony Fauci, MD, FIDSA, and FDA Principal Deputy Commissioner Joshua Sharfstein, MD.
The workshop, held July 26-27 in Silver Spring, Md., was well attended, and 160 users viewed a live webcast available through IDSA’s website. Videos of presentations and accompanying slides are available for free on IDSA’s website.
A follow-up report from IDSA will summarize highlights and make recommendations for additional research. The workshop featured presentations and question-and-answer sessions focused on four key areas:
IDSA called on Congress in April to substantially increase NIAID’s funding for antibacterial resistance and drug discovery and development research, and also asked lawmakers to significantly increase FDA’s budget for antimicrobial resistance and antibiotic drug review programs (see IDSA’s congressional testimony).
Eliminating the non-judicious use of antibiotics in cattle, pigs, poultry, and aquaculture will help protect patients and the general public against antibiotic-resistant infections. During a Congressional hearing last month, IDSA member James R. Johnson, MD, FIDSA, and several other witnesses urged lawmakers to take this important step to improve the nation’s public health and extend the utility of existing antibiotics.
At the July 14 hearing, Dr. Johnson told lawmakers an extensive body of scientific evidence demonstrates that antibiotic use in food animals contributes to the spread of resistant bacteria to humans and leads to drug-resistant infections. IDSA’s written testimony cited science-based studies and reports from the past 40 years supporting this position, including studies supported by the World Health Organization (WHO) and the National Academies of Science.
Dr. Johnson also noted IDSA’s support of the Preservation of Antibiotics for Medical Treatment Act (PAMTA)—which would essentially phase out the use of important antibiotics for growth promotion, feed efficiency, and routine disease prevention in animal agriculture—and the Strategies to Address Antimicrobial Resistance (STAAR) Act. Held by the Health Subcommittee of the House Energy and Commerce Committee, the hearing was the final in a series of three focusing on drug resistance and antibiotic use and development.
Other witnesses included Joshua Sharfstein, MD, principal deputy commissioner of the Food and Drug Administration (FDA), and Ali S. Khan, MD, MPH, assistant surgeon general and acting deputy director of the National Center for Emerging and Zoonotic Infectious Disease at CDC. Both spoke of the need for a change in U.S. policy concerning the use of antibiotics on the farm.
In June, FDA issued draft guidance recommending that medically important antimicrobial drugs be limited in food-producing animals to uses that are necessary for animal health and that veterinary oversight of antibiotic uses be required. (For more information, see FDA’s press release.) In IDSA’s testimony, Dr. Johnson called the guidance an important first step but also highlighted ways Congress and FDA and could make the policy more effective. IDSA will submit formal comments in response to the draft guidance as well.
Testimonies from the hearing witnesses are available online, in addition to video of the hearing.
New draft guidance on influenza prevention from the Centers for Disease Control and Prevention (CDC) is a step in the right direction, according to IDSA, but the guidance falls short in one key area: It does not include a definitive recommendation for mandatory influenza vaccination of heath care workers (HCWs).
That was the message IDSA sent to CDC in a July 15 letter, in response to CDC’s request for public comment on its draft “Updated Guidance: Prevention Strategies for Seasonal Influenza in Healthcare Settings.” Overall, IDSA supports the new draft guidance, which would expand and replace the previous seasonal influenza guidance as well as the Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings.
In many respects, the draft updated guidance keeps pace with evolving science and is more in line with principles IDSA expressed last fall concerning infection prevention and control measures that should be implemented in response to H1N1, particularly the new provisions on personal protective equipment. (See this related article in the Oct. 2009 issue of IDSA News.)
But IDSA continues to highlight the fact that immunization is one of the most effective strategies to prevent influenza. “Because HCWs are essential to caring for those with influenza and its complications, and because they care for highly vulnerable patients who if infected are at risk for prolonged hospitalization, other complications, and death, it is critical that HCWs be immunized against influenza,” IDSA President Richard Whitley, MD, FIDSA, said in the letter to CDC. “Mandating such a policy emphasizes that this is a patient safety issue.”
In addition to sending its own comment letter, IDSA also encouraged IDSA members to submit comments. Eighteen members wrote comments to CDC in support of IDSA’s position.
CDC’s draft Updated Guidance is available here.
IDSA is joining the American Academy of Pediatrics (AAP) and other immunization advocates in urging the U.S. Supreme Court to uphold a lower court ruling that affirms the nation’s current vaccine injury compensation system.
A new lawsuit, scheduled to be heard by the court in the fall, would undermine the system that currently safeguards the nation’s vaccine supply and provides compensation to the small number of children who are injured by vaccines. IDSA is one of 21 groups that is signing on to an amicus curiae (“friend of the court”) brief filed by the lawfirm Hogan Lovells on behalf of AAP in the case, Bruesewitz v. Wyeth.
The lawsuit was brought by the parents of Hannah Bruesewitz, whose family believes she was disabled by seizures after receiving the DPT vaccine series in the early 1990s. The Bruesewitzes claimed that Wyeth (now part of Pfizer) failed to adequately warn them of the risks associated with the vaccine. After the federal Vaccine Court rejected their initial claim, the family filed a lawsuit claiming that the federal no-fault system does not ban all lawsuits, particularly if a vaccine’s side effects could have been avoided if the vaccine had been designed better.
In March 2009, a lower federal appellate court held that federal law expressly preempts such claims, including those based in negligence. Lawyers representing the Bruesewitzes argue that judges and juries should be allowed to decide on a case-by-case basis whether a particular vaccine could have been made safer.
At stake is the National Childhood Vaccine Injury Compensation Act, which Congress passed in 1986, when mounting lawsuits and skyrocketing insurance premiums were driving many manufacturers out of the vaccine market. In the early 1980s, roughly 300 lawsuits were filed against manufacturers, and between 1983 and 1984 alone, litigation costs nearly doubled—jumping from $4.7 million to $9.8 million.
Ironically, while some lawsuits resulted in multi-million dollar awards, other injured children received no compensation because their cases did not have the potential to yield a large enough settlement to appeal to attorneys, according to the AAP brief.
To protect children and preserve the vaccine marketplace, Congress set up a no-fault compensation system administered by the U.S. Court of Claims. Families can be compensated if their child suffers an injury listed in a special table of vaccine injuries, or if they can prove that the injury was caused by a vaccine. The Vaccine Court relies upon “special masters” who have developed expertise in the complex medical and scientific issues involved in such cases.
Immunization advocates believe that a ruling against Wyeth could lead to vaccine shortages, an increase in the number of unimmunized children, and the resurgence of vaccine-preventable diseases. The AAP brief argues that unpredictable litigation costs could once again force vaccine manufacturers to abandon the vaccine market, and the progress that has been made in vaccine development since the mid-1980s could come to a halt.
Last year, IDSA joined AAP and others in a similar brief involving a Georgia Supreme Court case, American Home Products Corp./ Wyeth v. Ferrari. (See IDSA News, April 2009.) The family has since voluntarily dismissed their case, but the liability on vaccine manufacturers resulting from that decision remains in force in Georgia.
For more information, see the AAP’s press release.
Election Ballots Due Sept. 15
IDSA and HIV Medicine Association (HIVMA) members will elect new officers and Board members this summer. You will soon receive a ballot including biographical statements and personal sketches from each of the candidates. The IDSA slate is as follows:
Director Slot 1:
Director Slot 2:
The HIVMA slate is as follows:
Infectious Diseases Slot
Internal Medicine Slot 1
Internal Medicine Slot 2
HIVMA Representative to IDSA Board:
The deadline for casting your ballot is Sept 15.
Voting is easy and important for setting the priorities and future direction of your Society. You will soon receive an electronic ballot by e-mail if you are eligible to vote and have e-mail addresses on file. Check your e-mail inbox for a message from IDSA President Richard Whitley, MD, FIDSA, and HIVMA Chair Michael Saag, MD, FIDSA, with a subject line, “2010 IDSA and HIVMA Elections.” Paper ballots will be mailed to all members who are eligible to vote but do not have e-mail addresses on file. Members who do not receive their ballots by e-mail or mail, or who lose their ballots, may call the help desk at Election Services at 1-800-720-4357.
In response to growing interest from members in the Society’s election process, the IDSA Board of Directors also recently approved campaign guidelines, which will be included in the background materials sent with the ballots.
Fellowship in IDSA honors individuals who have achieved professional excellence and provided significant service to the profession. The following members were elected to fellowship this year:
Nahed Abdel-Haq, MD, FIDSA
Children's Hospital of Michigan, Wayne State University, Detroit, MI
Javier A. Adachi, MD, FIDSA
The University of Texas M.D. Anderson Cancer Center, Houston, TX
Nikolaos G. Almyroudis, MD, FIDSA
Roswell Park Cancer Institute, State University of New York, Buffalo, NY
Lisa Y. Armitige, MD, PhD, FIDSA
University of Texas Medical School, Houston, TX
Wendy Armstrong, MD, FIDSA
Emory University, Atlanta, GA
Robert L. Atmar, MD, FIDSA
Baylor College of Medicine, Houston, TX
Leslie A. Baken, MD, FIDSA
Park Nicollet Clinic - Infectious Disease, St. Louis Park, MN
Montaser Bilbisi, MD, FIDSA
Jordan Hospital, Amman, Jordan
Philip Brachman Jr., MD, FIDSA
Atlanta Infectious Disease Group, Atlanta, GA
Steven D. Burdette, MD, FIDSA
Wright State University, Dayton, OH
Jay C. Butler, MD, FIDSA
Alaska Native Tribal Health Consortium, Anchorage, AK
Adeel A. Butt, MD, MS, FIDSA
University of Pittsburgh, Pittsburgh, PA
Lyssette L. Cardona, MD, MPH, MS, FIDSA
Cleveland Clinic Florida, Weston, FL
J. Kevin Carmichael, MD, FIDSA
El Rio Special Immunology Associates, Tucson, AZ
Jose G. Castro, MD, FIDSA
University of Miami School of Medicine, Miami, FL
Carol E. Chenoweth, MD, MS, FIDSA
University of Michigan Health System, Ann Arbor, MI
Sandro Cinti, MD, FIDSA
University of Michigan, Ann Arbor, MI
Robert J. Citronberg, MD, FIDSA
Lutheran General Hospital, Park Ridge, IL
George E. Crawford, MD, FIDSA
University of Texas Health Science Center, San Antonio, TX
James F. Cummings, MD, FIDSA
Walter Reed Army Institute of Research, Silver Spring, MD
H. Dele Davies, MD, FIDSA
Michigan State University, East Lansing, MI
Roberta L. DeBiasi, MD, FIDSA
Children's National Medical Center, George Washington University School of Medicine, Washington, DC
Michael W. Ellis, MD, FIDSA
Uniformed Services University of the Health Sciences, Bethesda, MD
James M. Fleckenstein, MD, FIDSA
University of Tennessee Health Sciences Center, Memphis, TN
Jill A. Foster, MD, FIDSA
St. Christopher's Hospital for Children, Philadelphia, PA
Joseph J. Gadbaw Jr., MD, FIDSA
Lawrence and Memorial Hospital, New London, CT
Harumi Gomi, MD, MPH, FIDSA
Jichi Medical University, Shimotsuke, Tochigi, Japan
William C. Gruber, MD, FIDSA
Pfizer Vaccine Clinical Research, Pearl River, NY
David A. Haake, MD, FIDSA
VA Greater Los Angeles Healthcare System, Los Angeles, CA
Susan Hadley, MD, FIDSA
Bassett Healthcare, Cooperstown, NY
Braden Hale, MD, MPH, FIDSA
Naval Medical Center, San Diego, CA
Betsy Herold, MD, FIDSA
Albert Einstein College of Medicine, Bronx, NY
Kevin P. High, MD, MS, FIDSA
Wake Forest University Health Sciences, Winston-Salem, NC
Mark Holodniy, MD, FIDSA
Department of Veterans Affairs/Stanford University, Palo Alto, CA
Robert J. Hopkins, MD, MPH, FIDSA
Emergent BioSolutions Inc., Frederick, MD
Lynn L. Horvath, MD, FIDSA
Texas Center for Infectious Diseases, San Antonio, TX
Eric R. Houpt, MD, FIDSA
University of Virginia, Charlottesville, VA
David Huang, MD, PhD, FIDSA
Pfizer, New York, NY
Janet A. Jokela, MD, MPH, FIDSA
University of Illinois, Urbana, IL
Petros C. Karakousis, MD, FIDSA
Johns Hopkins University School of Medicine, Baltimore, MD
Kenneth Kaye, MD, FIDSA
Brigham and Women’s Hospital, Boston, MA
Muhammad A. Khan, MD, FIDSA
Crozer Chester Medical Center, Upland, PA
Daniel B. Klein, MD, FIDSA
Kaiser Permanente, Hayward, CA
Brian S. Koll, MD, FIDSA
Beth Israel Medical Center, New York, NY
Athena P. Kourtis, MD, MPH, PhD, FIDSA
Centers for Disease Control and Prevention, Atlanta, GA
Regina C. LaRocque, MD, FIDSA
Massachusetts General Hospital, Boston, MA
Nathan Litman, MD, FIDSA
Children’s Hospital at Montefiore, Bronx, NY
Edward Liu, MD, MPH, FIDSA
Jersey Shore University Medical Center, Neptune, NJ
Arthur G. Lyons, MD, PhD, FIDSA
Walter Reed Army Institute of Research, Silver Spring, MD
Preeti N. Malani, MD, FIDSA
University of Michigan Health System, Ann Arbor, MI
Yvonne Maldonado, MD, FIDSA
Stanford University, Stanford, CA
William F. Marshall, MD, FIDSA
Mayo Clinic, Rochester, MN
Thomas A. Moore, MD, FIDSA
Infectious Disease Consultants of Kansas, Wichita, KS
Joseph T. Morris III, MD, FIDSA
Infectious Disease Service, Madigan Army Medical Center, Tacoma, WA
Varsha Moudgal, MD, FIDSA
St. Joseph Mercy Hospital, Ann Arbor, MI
J.W. Mouton, MD, PhD, FIDSA
Radboud University, Nijmegen, The Netherlands
A. Rekha K. Murthy, MD, FIDSA
Cedars-Sinai Medical Center, Los Angeles, CA
Michael Myint, MD, FIDSA
Virginia Mason Medical Center, Seattle, WA
Kathleen M. Neuzil, MD, MPH, FIDSA
PATH, Seattle, WA
Eric G. Pamer, MD, FIDSA
Memorial Sloan-Kettering Cancer Center, New York, NY
Robin Patel, MD, FIDSA
Mayo Clinic, Rochester, MN
Alice K. Pau, PharmD, FIDSA
National Institutes of Health/National Institute of Allergy and Infectious Diseases, Bethesda, MD
Robert G. Penn, MD, FIDSA
Infectious Diseases Associates P.C./Nebraska Methodist Hospital, Omaha, NE
Carlos M. Perez, MD, FIDSA
Pontificia Universidad Catolica de Chile, Santiago, Chile
Russell M. Petrak, MD, FIDSA
Metro Infectious Disease Consultants LLC, Hinsdale, IL
Debra D. Poutsiaka, MD, PhD, FIDSA
Tufts Medical Center, Boston, MA
E. Byrd Quinlivan, MD, FIDSA
University of North Carolina, Chapel Hill, NC
Renee Ridzon, MD, FIDSA
Bill and Melinda Gates Foundation, Seattle, WA
Benigno Rodriguez, MD, FIDSA
Case Western Reserve University, Cleveland, OH
Emmanuel Roilides, MD, PhD, FIDSA
Aristotle University School of Medicine, Thessaloniki, Greece
Alan L. Rothman, MD, FIDSA
University of Massachusetts Medical School, Worcester, MA
Rafik Samuel, MD, FIDSA
Temple University School of Medicine, Philadelphia, PA
Paul E. Sax, MD, FIDSA
Brigham and Women’s Hospital, Boston, MA
Paul S. Sehdev, MD, MS, FIDSA
Providence Medical Group/ID Consultants, Portland, OR
Mamta Sharma, MD, FIDSA
St. John Hospital and Medical Center, Grosse Pointe Woods, MI
Avinash K. Shetty, MD, FIDSA
Wake Forest University Health Sciences, Winston-Salem, NC
Jason C. Sniffen, DO, FIDSA
Infectious Disease Consultants MD PA, Altamonte Springs, FL
Anne Spaulding, MD, MPH, FIDSA
Emory University, Atlanta, GA
Carlos Subauste, MD, FIDSA
Case Western Reserve University, Cleveland, OH
Michael J. Tan, MD, FIDSA
Summa Health System, Akron, OH
Ming Tan, MD, FIDSA
University of California, Irvine, CA
Zelalem Temesgen, MD, FIDSA
Mayo Clinic, Rochester, MN
Jennifer C. Thompson, MD, FIDSA
Brooke Army Medical Center, San Antonio, TX
Glenn S. Tillotson, PhD, FIDSA
ViroPharma Inc., Exton, PA
Marc A. Tribble, MD, FIDSA
Baylor University Medical Center, Dallas, TX
Reina M. Turcios-Ruiz, MD, FIDSA
Centers for Disease Control and Prevention, Atlanta, GA
Russell B. Van Dyke, MD, FIDSA
Tulane University Health Sciences Center, New Orleans, LA
Nicholas J. Vietri, MD, FIDSA
U.S. Army Medical Research Institute of Infectious Diseases, Frederick, MD
Peter J. Weina, MD, PhD, FIDSA
Walter Reed Army Institute of Research, Silver Spring, MD
Amy C. Weintrob, MD, FIDSA
Uniformed Services University of the Health Science, Bethesda, MD
Karen Williams, MD, FIDSA
LSU Health Sciences Center at EKL Medical Center, Baton Rouge, LA
Annie Wong-Beringer, PharmD, FIDSA
University of Southern California, Los Angeles, CA
Joseph D.C. Yao, MD, FIDSA
Mayo Clinic, Rochester, MN
Michael J. Zapor, MD, PhD, FIDSA
Infectious Disease Service, Walter Reed Army Medical Center, Washington, DC
Jane R. Zucker, MD, FIDSA
New York City Department of Health, New York, NY
Adedayo, Olayinka, MD
Bumroongkit, Chaiwat, MD
Camacho-Ortiz, Adrian, MD
Chandran, Uma, MD
Daniels, Anne, PharmD
Francis, Damon, MD
Guo, Yi, PharmD
Hajkowicz, Krispin, MBBS
Hanvanich, Mattana, MD
Intalapaporn, Poj, MD
Jaruratanasirikul, Sutep, MD
Kandiah, Sheetal, MD
Koenig, Helen, MD, MPH
Leelarasamee, Amorn, MD
Lipka, Ozana, PHARMD
Lye, David, MBBS
Mishra, Baijayantimala, MD
Munsakul, Warangkana, MD
Onumah, Chavon, MD
Park, An Na, MD
Rodrigues, Denise, MD, PhD
Tansuphaswasdikul, Somboon, MD
Wagenvoort, Johan, PhD
Ahmed-Bentley, Jasmine, DMD
Anderson, Mark, PhD
Baxter, George, MD
Cargill, Victoria, MD, MSc
Carpenter, Shelley, PharmD
Daher, Sonia, NP
Fung, Ron, RPh
Goss, Carmen, MD
Hladik, John, DPM
Ibrahim, Sarah, PhD
Ijo, Immanuel, PharmD
Kemal, Kimdar, PhD
Khorana, Melissa, NP
Khosrovi, Behzad, PhD
Korczak, Bozena, PhD
Krantz, Ken, MD
Liesenfeld, Oliver, MD
Loe, Heather, BSN
Matravadia, Chirag, MD
Matsko, Shannon, PharmD
McClain, Micah, MD, PhD
McLeay, Allison, NP
Mody, Rajal, MD, MPH
Moeck, Greg, PhD
Parker, Joseph, MS
Pinto, Casey, MSN
Saulibio, Dana, PharmD
Sengupta, Sharmila, MD
Sengupta, Sumit, MD, MBBS, MRCP
Shinha, Takashi, MD
Sicilia, Jasmine, PA-C
Stach, Leslie, PharmD
Thomas, Ben, MD
Utaile, Manaye, DVM
Von Rosenvinge, Erik, MD
Walker, Eric, MD
Watson, Chemeka, MS, PA-C
Abreu-Lanfrranco, Odaliz, MD
Ackerman, Peter, MD
Adegbulugbe, Ademiposi, MD
Al-Juaid, Alaa, MD
Al-Zubeidi, Duha, MD
Aljayeh, Mohsen, MD
Althoff, Amy, MD
Awdaniciewicz, Anna, MD
Azhar, Sobia, MD
Bailey, Justin, MD, PhD
Bains, Karanpreet, MD
Bakhtary, Mariam, MD
Bakman, Irene, MD
Barbee, Lindley, MD, MPH
Bares, Sara, MD
Batog, Cristina, MD
Beauchamp, Elizabeth, MD
Berthold, Gina, MD
Bhaskaran, Archana, MBBS
Bhattacharyya, Rishi, MD
Bilgrami, Mohammed, MD
Bogoch, Isaac, MD
Butler, Isolde, MD
Calvano, Tatjana, DO
Capunitan, Jay Servando, MD
Chatterjee, Soumya, MD
Chotikanatis, Kobkul, MD
Ciuffreda, Donatella, MD
Collins, Julie, MD
Couturier, Marc, PhD
Dang, Bich, MD
Delille, Cecile, MD
Dillon, Erica, MD
Dinh, Quynh-dao, MD
Doshi, Bijal, MD
Doshi, Saumil, MD
Eilertson, Brandon, MD
Eke, Uzoamaka, MD
El Feghaly, Rana, MD
El-Imad, Badiaa, MD
Ellman, Tanya, MD
Espinoza, Fabiola, MD, MS
Falcone, Emilia, MD
Felsen, Uriel, MD, MPH
Ferguson, April, MD
Fernandes, Carolyn, MD, MBBS
Gadzhiev, Marat, MD
Gamn, Kanishka, MD
Gatskevich, Elena, MD
Guiang, Karen Michelle, DO
Hage, Jean, MD
Helbig, Sina, MD
Henao Martinez, Andres, MD
Hess, Bryan, MD
Higbee, Dana, MD
Hodowanec, Aimee, MD
Hoenigl, Martin, MD
Hussen, Sophia, MD
Islam, Shamim, DTM&H, MD
Iyer, Sugantha, MD
Jackson, Jerry, MD
Kabbani, Dima, MD
Kapur, Asha, MD
Katsolis, Jennifer, DO
Keel, Rebecca, PharmD
Kim, Jihye, PharmD
Kim, Suk Chul, MD
Klatte, James, MD
Kobayashi, Miwako, MD
Kono, Yuriko, MD
Laguio, Maryrose, MD
Laurence, Brett, MD
Lee, Grace, MD
Lee, Sulggi, MD, PhD
Lee, Yeon Joo, MD
Leuck, Anne-marie, MD
Lewinski, Mary, MD, PhD
Lin, Jennifer, MD
Marathe, Jai, MD
Masse, Vincent, MD
Maznavi, Khalid, MD
McFaul, Katie, BCh, MB, MRCP
McLemore, Aaron, MD
Mead, Peter, MD
Meissner, Eric, MD, PhD
Merlin, Jessica, MD, MBA
Mitra, Subhashis, MD
Modjarrad, Kayvon, MD, PhD
Moehring, Rebekah, MD
Moon, Song Mi, MD
Mooney, Sarah, MD
Morano, Jamie, MD, MPH
Movva, Kalyani, MD
Murphy, Kerry, MD
Myint, Thein, MD, MBBS
Nagaraja, Aarathi, MD
Narasimhan, Aarthi, MD
Nguyen, Margaret, MD
Nguyen, Ngan, MD
Noto, Michael, MD, PhD
Ogbuagu, Onyema, MD
Okapuu, Julie, MD
Oyedele, Temitope, MD
Parameswaran, Lalitha, MD, MPH
Park, Seong Yeon, MD
Patel, Janki, DO
Paulin, Heather, MD
Petelin, Andrew, MD
Plummer, Donald, MD
Primeggia, Jennifer, MD
Ramarathnam, Vivek, MD
Rhee, Susan, MD
Robinson, Jessica, PharmD
Rose, Dusten, PharmD
Roxby, Alison, MD, MSc
Saffert, Ryan, PhD
Saleheen, Qamar, MD
Salinas, Jorge, MD
Sarwar, Uzma, MD
Shah, Janaki, DO
Shaughnessy, Megan, MD
Sheikh, Abdul, MD
Sigel, Keith, MD
Simoncini, Gina, MD
Singh, Manisha, MD
Slenker, Amy, MD
Stoltey, Juliet, MD
Storm, Jeremy, DO
Sudhakar, Shiv, MD
Suwantarat, Nuntra, MD
Swartz, Talia, MD, PhD
Szumowski, John, MD, MPH
Theodoropoulos, Nicole, MD
Tran, Tuan, MD, PhD
Tremblay, Julie, MD
Tsiakalos, Aristotelis, MD
Tully, Charla, DO
Tysiak, Marissa, PharmD, RPh
Upadhyay, Nitesh, MD
Urday-Cornejo, Varinia, MD
Varughese, Julie, MD
Vasoo-Sushilan, Shawn, MD
Vematter, Joshua, MD
Volk, Jonathan, MD
Wainaina, Njeri, MD
Wang, Sharon, DO
Wang, Xiaodan, MD
Warren, Sanchia, MBBS
Wetzel, Dawn, MD, PhD
Win, Thida, MD
Won, Regina, MD
Wong, Bonnie C.K., MRCP
Wright, Alissa, MD
Yanes, James, MD
Yehia, Baligh, MD
The ID/HIV Career Center, the official online career center of IDSA and the HIV Medicine Association (HIVMA), was recently redesigned to give you access to more jobs in less time. Visit the site to:
If you are hiring, take advantage of the 30 percent member discount when posting a physician position. Our partnership with HEALTHeCAREERS makes it easier to connect with the right candidates.
See what’s new—visit the ID/HIV Career Center today!
The Immunization Action Coalition (IAC) provides access to hundreds of free vaccination-related handouts and fact sheets for health care professionals, such as simple screening tools to help determine which vaccinations an adult patient needs.
IAC has just released its June 2010 issue of Needle Tips, targeting all health care professionals who give vaccines. Also available is Vaccinate Adults, a version of Needle Tips modified for those who work only with adult patients.
Included in Needle Tips and Vaccinate Adults are:
Click here to subscribe to receive an e-mail notification when new issues are published.
While 2009 H1N1 influenza has disappeared from the front pages and nightly newscasts, the issues the novel strain raised remain critically important, especially as another influenza season nears. Now is not the time to let our guard down or become complacent about preparing for either seasonal or pandemic influenza.
While 2009 H1N1 influenza has disappeared from the front pages and nightly newscasts, the issues the novel strain raised remain critically important, especially as another influenza season nears. Just because our experience with H1N1 was not as dire as some feared—although it did cause unexpected complications and mortality in unique populations—now is neither the time to let our guard down nor to become complacent about preparing for either seasonal or pandemic influenza.
As we learned once again with 2009 H1N1, vaccination is the most effective protection against influenza for both patients and those who care for them. Reflecting this experience, the long safety record of annual immunization, and the importance of preventing influenza across the nation’s population, the federal Advisory Committee on Immunization Practices (ACIP) recommended in February that nearly everyone—namely, all people aged 6 months or older—be vaccinated annually against influenza. The Centers for Disease Control and Prevention (CDC) endorsed the recommendation last month in an early online edition of the Morbidity and Mortality Weekly Report (MMWR).
Historically—and sadly—less than half of the people recommended for seasonal influenza vaccination typically get immunized, according to CDC. As experts in infectious diseases, we can play an important role in improving these rates by providing accurate information to our patients and our colleagues about the benefits and risks of influenza vaccination. Our actions will speak louder than words.
Each year, fewer than two in five health care workers (HCWs), on average, are immunized against influenza, a dismal rate that puts both providers and their patients at greater risk. In a July letter to CDC, IDSA reiterated our support for mandatory influenza vaccination of HCWs in response to the agency’s updated draft guidance for preventing seasonal influenza in health care settings. (For more information, see related IDSA News article.) Simply put, it’s a patient safety issue. As health care providers, we and our colleagues owe it to our patients to roll up our sleeves and get immunized against influenza—this year and every year.
The 2009 H1N1 experience again highlighted concerns about the development of resistance to the few effective antiviral medications remaining in our arsenal of antiviral drugs. It remains critical to use these antivirals appropriately and judiciously to preserve their effectiveness for those who need them the most, including infants, pregnant women, and other patients most at risk for serious complications from influenza. We remain one mutation away from a strain of influenza that would put our nation’s health at serious risk, underscoring the need for appropriate use of antivirals and the development of new treatment options.
Given the continuing and real threat posed by the development of new pandemic influenza strains, it is more important than ever to ensure we are prepared. This requires, among other steps, adequate federal funding. That’s why it was disappointing to see lawmakers in the House of Representatives last month initially propose taking $2 billion in unspent funding originally allocated for pandemic influenza preparedness to offset other federal spending. Pandemic funding helps build the nation’s vaccine production capacity, influenza surveillance and laboratory testing, and planning efforts at the federal, state, and local levels.
Previous investments in these areas were critical in mitigating the effects of the H1N1 outbreak. IDSA joined several other groups in a July letter urging the Senate to protect these funds, and fortunately, both houses agreed to retain the funding for its original purpose: preparing America for a biological disaster. IDSA will continue to be vigilant to ensure that this money is retained for its intended purpose
With the dog days of summer now here and fall approaching, another influenza season will soon be upon us. All of us, from providers to patients to lawmakers, can do our part to help prepare for and protect against influenza, not only this year, but well into the future.
New Website Aims To Help Physicians Put the New Rules into Practice
Eligible physicians and hospitals can qualify for Medicare and Medicaid incentive payments when they adopt certified electronic health records (EHR) technology and use it to achieve specified health and safety goals, officially known as “meaningful use,” under final rules announced last month.
The Department of Health and Human Services (HHS) on July 13 announced a final rule under which eligible physicians and hospitals can qualify for Medicare and Medicaid incentive payments when they adopt certified electronic health records (EHR) technology and use it to achieve specified health and safety goals, officially known as “meaningful use.”
Eligible physicians can receive as much as $44,000 under Medicare or $63,750 under Medicaid under the new rules. (Even if you meet the eligibility requirements for both the Medicare and Medicaid incentive programs, you may participate in only one program—no “double dipping” is allowed.)
IDSA and the HIV Medicine Association (HIVMA) had been concerned about the eligibility requirements that were originally proposed (see IDSA News, March 2010), but HHS expanded eligibility in response to provider concerns. The final rule clarifies that hospital-based physicians who provide less than 90 percent of their services in an inpatient hospital setting or emergency room are eligible.
Physicians must report on six total quality measures and 20 meaningful use objectives. The quality measures include three core measures (hypertension, tobacco screening and cessation, and adult weight screening—alternates can be substituted if these don’t apply) and three additional quality measures. The meaningful use objectives include 15 core objectives (such as implementing drug-drug and drug-allergy checks or maintaining an up-to-date list of diagnoses) and five additional objectives (such as implementing drug-formulary checks or incorporating clinical lab-test results into the EHR).
IDSA and HIVMA had also been concerned that ID and HIV physicians would not be included in the quality measure specialty groups. For now, the Centers for Medicare and Medicaid Services (CMS) put off finalizing those groups. In addition, the reporting requirements for many of the objectives, including one dealing with computerized physician order entry (CPOE), have been relaxed from what was described in the proposed rule.
During the first year in which a physician receives an incentive payment, he or she must report on the measures and objectives for 90 continuous days. For every year after the first payment year, the EHR reporting period is the entire year.
Although the new incentive program starts in 2011, physicians do not have to gear up for participation next year. In fact, experts say it is far better to take the time necessary to research, select, and integrate an EHR into your practice to ensure that implementation is successful. With this in mind, 60 regional extension centers will be set-up around the country to provide guidance and feedback to practices, particularly those in rural or underserved areas, on how to achieve meaningful use of EHRs.
To help IDSA members compare EHRs and learn about meaningful use, IDSA is partnering with the American College of Physicians and other medical specialty societies on a new, free interactive website, AmericanEHR Partners (www.AmericanEHR.com). The goal is to provide credible information, tools, and expertise to support the optimal use of health information technology, and to improve the delivery of health care.
For more information on the website, visit www.AmericanEHR.com.
Comprehensive resources on the new EHR incentive programs are available at www.cms.gov/EHRIncentivePrograms and a CMS tipsheet on the program is available at www.cms.gov/MLNProducts/downloads/CMS_eHR_Tip_Sheet.pdf. For more information about all of Medicare’s incentive payment programs, see this CMS tipsheet or go to the related IDSA News article on the 2011 Physician Fee Schedule Proposed Rule.
CMS will also hold a series of calls this week to address the specifics of the EHR incentive programs: A call on Tuesday, Aug. 10, for individual providers; one on Wednesday, Aug. 11, for hospitals; and a question-and-answer call for both groups on Thursday, Aug. 12. Registration instructions are available on the CMS website.IDSA will provide additional information as it becomes available in the Health Information Technology section of the IDSA website (log in required).
This month: Studies investigating low CD4 counts and risk for cardiovascular events in HIV patients, early removal of central venous catheters in patients with candidemia, infection control lapses at ambulatory surgical centers, and hyperkalemia with TMP-SMX in older patients receiving inhibitors of the renin-angiotensin system.
In this feature, a panel of IDSA members identifies and critiques important new studies in the current literature that have a significant impact on the practice of infectious diseases medicine.
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.
Low CD4 Counts and Increased Risk for Cardiovascular Events in HIV Patients
Reviewed by Shireesha Dhanireddy, MD
Low CD4 counts (< 500 cells/ mm3) conferred an equivalent or greater risk for a cardiovascular event (CV) than traditional risk factors, such as tobacco use, in patients with HIV, according to a study in the August 15 issue of Clinical Infectious Diseases.
The observational cohort study included patients from 10 HIV-specialty clinics in the U.S. who were followed until a CV event, death, loss to follow-up, or the end of the study. The primary outcome of an event was defined as myocardial infarction, stroke, coronary artery disease, angina, or peripheral arterial disease. Patients were categorized at baseline using the Framingham 10-year cardiovascular risk (CVR) scale as either low risk, moderate risk, moderately high risk, or high risk.
Of the over 5,000 patients seen during the time period, more than 3,000 were excluded because data were unavailable to determine their baseline CV risk. Of the 2,005 patients analyzed, 148 experienced a CV event. Factors associated with higher rates included presence of traditional risk factors (smoking, diabetes, family history of premature CV disease, hypertension, low high-density lipoprotein [HDL] levels), having public or no health insurance, or a baseline CD4 count < 500 cells/mm3. The attributable risk of CV events for patients with low baseline CD4 counts was 25.6 percent, which is similar to the risk posed by smoking and dyslipidemia in this cohort. Antiretroviral therapy was overall associated with decreased incidence of CV events.
This study shows that low CD4 counts should be considered a risk factor when evaluating a patient’s cardiovascular risk. Another important finding was the absence of increased CV risk with antiretrovirals.
While the findings are striking, one major limitation is that many patients were excluded from the analysis for insufficient data to determine their baseline CV risk, which may have led to selection bias. Additional studies are needed to assess the effect of early HIV treatment on CV events.
Early Removal of Central Venous Catheters in Patients with Candidemia
Reviewed by Ed Dominguez, MD
When to remove a central venous catheter (CVC) in a patient with candidemia remains a debated question. Attempting to remove this ambiguity, a multi-center group of investigators retrospectively analyzed two prospective randomized clinical trials of antifungal therapy in such patients. Their findings are published in the August 1 issue of Clinical Infectious Diseases.
The authors evaluated the effects of early CVC removal at two time points (<24 hours and <48 hours) on six predefined outcomes: treatment success, 28-day and 42-day survival, rates of persistent and recurrent candidemia, and time to mycological eradication. Univariate and multivariate analyses were performed.
In the univariate analysis of these two studies (one comparing an echinocandin to liposomal amphotericin, the other comparing two echinocandins) the investigators found that early removal was indeed associated with higher treatment success and with increased survival at 28 and at 42 days. There was no significant improvement in the rates of persistent candidemia or recurrent candidemia. However, in the multivariate analysis, the benefit of early removal disappeared altogether.
Consequently, the authors conclude that early CVC removal was not associated with clinical benefit. It is important to note that this observation applies only to patients treated with an echinocandin (specifically micafungin and caspofungin) or with liposomal amphotericin B. Furthermore, since only 10 percent of the patients in the combined analysis were neutropenic, the findings are not applicable to this population.
The findings from this analysis call into question recommendations from two different IDSA practice guidelines (one for the management of candidiasis, and one for the diagnosis and management of catheter‐related infection) that recommend CVC withdrawal, when possible, once candidemia is documented. However, an accompanying editorial places the findings in perspective, noting that the lack of overlap in the authorship of the two guidelines suggests a consensus that strengthens the guideline recommendation. In addition, the authors of the editorial note that given the wide, 95 percent confidence intervals for the odds ratio for 28-day and 42-day survival in the multivariate analyses, one cannot rule out anywhere from a 67 percent to 75 percent improvement in survival with early removal.
While not statistically significant, such improvement would surely be clinically relevant. The debate will continue, barring a large prospective study, which is unlikely to be conducted. When the guidelines are revisited, this study will likely be part of the discussion.
Infection Control Lapses at Ambulatory Surgical Centers
Reviewed by Rachel Simmons, MD
Ambulatory surgical centers (ASCs) have increased significantly over the last 10 years and have been the source of some well publicized outbreaks of health care-associated infections (HAIs). To assess compliance with basic infection control practices, the Centers for Medicare and Medicaid Services (CMS) conducted a voluntary audit of the infection control practices at 68 ASCs in three states (Maryland, Oklahoma, and North Carolina). The results appear in the June 9 issue of the Journal of the American Medical Association.
Specially trained state surveyors conducted unannounced assessments that included a standard infection control audit tool and followed at least one patient from start to finish at the ASC. The audit tool focused on five areas: hand hygiene and use of personal protective equipment such as gloves, injection safety and medication handling, equipment processing, environmental cleaning, and handling of blood glucose monitoring equipment.
Forty-six of the 68 centers (68 percent) had at least one lapse in infection control, and 12 (18 percent) had three or more lapses. More than 19 percent were observed to have lapses in hand hygiene and use of personal protective equipment such as gloves. In 28 percent of the ASCs, single-dose medications were used for more than one patient. Twenty-eight percent of the facilities also failed to properly reprocess their equipment. Forty-six percent did not appropriately handle blood glucose monitoring equipment. Ultimately, 39 (57 percent) of the 68 ASCs were cited for deficiencies in infection control.
This pilot study suggests that routine infection control practices are lacking in ASCs. With the prevalence of these centers, the related commentary notes that potentially millions of patients in the U.S. who undergo procedures at ASCs annually are needlessly placed at risk of HAIs. These centers are now mandated by CMS to have infection control programs and should undergo regular self-audits to ensure and improve compliance with infection control guidelines.
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Is the “K” OK? Hyperkalemia with TMP-SMX in Older Patients Receiving Inhibitors of the Renin-Angiotensin System
Reviewed by Christopher J. Graber, MD, MPH
The risk of hospitalization for hyperkalemia among older adults receiving angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) was nearly seven times higher for patients prescribed trimethoprim-sulfamethoxazole (TMP-SMX) compared to other antibiotics commonly used for urinary tract infections. The estimated difference in risk, from an article in the June 28 issue of Archives of Internal Medicine, provides a helpful reminder to clinicians.
The authors reviewed the Ontario Drug Benefit Program to identify 439,677 local residents 66 years of age or older receiving an ACEI or ARB from April 1994 through March 2008. Of this cohort, 371 were admitted to a hospital with the diagnosis of hyperkalemia within 14 days of receiving TMP-SMX (n=204), norfloxacin (n=20), ciprofloxacin (n=76), nitrofurantoin (n=18), or amoxicillin (n=49). Comparing these patients to controls within the cohort who also received one of these antibiotics but were not admitted for hyperkalemia yielded an adjusted odds ratio of 6.7 for TMP-SMX being associated with hyperkalemia compared to amoxicillin. Odds of hyperkalemia for all other antibiotics were similar to that of amoxicillin.
The overall rate of admission for hyperkalemia associated with TMP-SMX in this cohort was not directly reported but can roughly be calculated at 0.4 percent, since 11.6 percent of the cohort received at least one course of TMP-SMX during the study period (204/(439,677*0.116)).
The study is limited by lack of data regarding renal function, medication adherence, or other medications received, as well as reliance on ICD-9 coding for hyperkalemia on hospital admission rather than actual potassium levels. But the studyt does serve as a reminder to clinicians that hyperkalemia associated with TMP-SMX is much more common than with many other antibiotics, particularly in older patients receiving ACEIs or ARBs, and that close monitoring of such patients should be considered.
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: