IDSA News - October 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 EIN. The reader assumes all risks in using this information.
A recent EIN discussion highlighted the difficulty of treating multidrug-resistant (MDR) gram-negative bacterial infections and the lack of effective antibiotic options.
“I am seeing an 18-year-old male with right-sided obstructed uropathy due to stones,” an EIN member in California wrote. Over two months, “he has developed a highly resistant Pseudomonas aeruginosa in urine culture. The urologist will not want to do anything with him until [the] urine can be sterilized, and his urine culture isolate is impossible to treat, resistant to amikacin, tobramycin and gentamicin, quinolones, cefepime, imipenem, piperacillin and tazobactam, aztreonam, ceftazidime, etc.”
After being hospitalized with a high fever, low blood pressure, shaking chills, and rigors, the patient was given ciprofloxacin intravenously “even though the MIC was 4 (resistant). The MIC for cipro was the lowest; all other antibiotics were > 16, 32, and 64. I am worried,” the member wrote. “What would you do?”
A respondent in California suggested a “continuous infusion of meropenem, perhaps 6 grams/day,” while a Texas respondent offered methenamine and colistin as treatment options. Colistin “ought to cover most Pseudomonas, though the last one I tested was resistant to colistin as well as everything else.”
An EIN member in Pennsylvania advised checking “what the MIC is for colistin. If it’s less than 4 mcg/mL, then use that drug as your primary agent. If the MICs for all carbapenems and aminoglycosides are too high to consider using a high dose of one to help treat a urine infection, then consider using high-dose fosfomycin (e.g., 2 - 6 grams q 6 hours) in combination with colistin, or some other agent.” The member cited a related article in the February 2010 issue of Clinical Microbiology and Infection.
Other members’ suggestions included polymyxin B/colistin testing and checking susceptibilities to colistin and doripenem. “You probably have one last chance at a definitive procedure before there are no other options,” a respondent in Connecticut warned.
“While colistin might be useful in the treatment of what now appears to be urosepsis, it is unlikely to help sterilize the urine,” an EIN member from Maryland wrote. “Colistin and polymyxin B are excreted by non-renal routes,” the member added, citing a November 2008 article in Clinical Infectious Diseases.
Another Pennsylvania respondent advised “a short course of rifampin (600 mg q 12 hours)” with one of three drugs: meropenem, cipro, or colistin. “This multi-drug combination should prevent P. aeruginosa bacteremia.” The member highlighted two articles related to rifampin: A March 1992 article and an October 1984 article, both from Antimicrobial Agents and Chemotherapy.
A Georgia member described a similar difficult case: A female patient “who has common variable immunodeficiency syndrome and Pseudomonas pneumonia that has gotten progressively more resistant on antibiotics. It currently is resistant to everything tested, including doripenem, [and the] MIC for colistin is 3.”
An Ohio EIN member, meanwhile, described the case of a 19-year-old female patient with cystic fibrosis, who was diagnosed as an infant and has been on a multitude of antimicrobial agents. The woman was infected with a multidrug-resistant Acinetobacter ursingii isolated from sputum.
“The organism is resistant to all aminoglycosides, all carbapenems, quinolones, and beta-lactam agents (except piperacillin—she has had anaphylaxis to this antibiotic and has multiple other antibiotic allergies),” the member wrote. “The MIC for colistin is 8 ug/mL (resistant). [It is also] resistant to tigecycline. Any thoughts on treatment?”
A Georgia member suggested obtaining synergy panels, while a California respondent advised considering “inpatient penicillin desensitization.”
Another EIN member in California asked if the patient was infected or perhaps just colonized. “If so, aerosolized colistin should probably be the backbone agent,” the member wrote. “The local PK/PD of aerosolized colistin in airways may be sufficient to cover an 8 mcg/ml organism. Consider addition of rifampin for synergy based on impressive animal data and published retrospective clinical studies.”
Other resources related to MDR gram‐negative organisms and treatment include a recent paper reviewing the current epidemiology of these infections in the United States, published in a November 2010 supplement of Infection Control and Hospital Epidemiology, and an article in the August 2010 issue of Current Opinion in Infectious Diseases. EIN is also planning a member survey to examine clinicians’ experiences with MDR Enterobacteriaceae infections and other gram-negative bacteria.
E-mail the Emerging Infections Network.
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.
The National Institute of Allergy and Infectious Diseases (NIAID) is funding four new large-scale clinical trials to help address the growing threat of antimicrobial resistance. The trials, which join four others already in progress, will evaluate treatment alternatives for diseases for which antibiotics are prescribed most often, including acute otitis media, community-acquired pneumonia (CAP), and diseases caused by Gram-negative bacteria. Each trial will enroll at least 1,000 patients.
The investigators will conduct trials of new regimens involving the use of already licensed, off-patent antimicrobial therapies to reduce the risk of antimicrobial resistance developing in the diseases of interest. The trials will determine the efficacy and impact on antimicrobial resistance of short-course antimicrobial therapy in young children with acute otitis media; compare narrow-spectrum antimicrobial therapy to standard of care in patients with CAP; compare combination antimicrobial therapy with monotherapy for the treatment of Acinetobacter baumannii; and compare pharmacodynamic guidance of therapy, based on the drug's effect on the body, versus standard of care for Gram-negative bacteremia.
See NIAID’s press release for more information.
IDSA has been a strong advocate for funding this type of research. For more information, see the September 2009 issue of IDSA News.
Committee Also Recommends Booster Meningitis Vaccine Dose For Teens
In light of the recent pertussis outbreak in California and other parts of the country, the federal Advisory Committee on Immunization Practices (ACIP) at its October meeting recommended steps to fill in some vaccination gaps. The committee recommended a single dose of the tetanus, diphtheria, and pertussis (Tdap) vaccine for adults 65 years of age and older who have close contact with infants less than one year old. In addition, those 65 and older who have not received the tetanus-diphtheria (Td) vaccine should receive a single dose of the Tdap vaccine in its place.
The committee also recommended that teenagers receive a booster dose of the meningococcal conjugate vaccine. The recommendation follows studies suggesting that antibodies generated by the vaccine decline rapidly and may no longer be protective five years after vaccination, according to IDSA’s ACIP liaison, Samuel Katz, MD, FIDSA.
Children who have received the vaccine according to the existing recommendation, at 11 to 12 years old, should now receive a booster dose at age 16. Those who may have been vaccinated at ages 13 to 15 should receive a booster dose five years after that (i.e., at 18 to 21 years old).
ACIP recommendations become official once approved by the Centers for Disease Control and Prevention (CDC) and published in MMWR.
When it comes to the common cold, the flu, and other viral infections, antibiotics are often the wrong prescription. During “Get Smart About Antibiotics Week,” Nov. 15-21, the Centers for Disease Control and Prevention (CDC), state officials, and other partners, including IDSA, will work to educate the public, health care providers, and pharmacists about when antibiotics can help—and how misuse of these important drugs can do more harm than good.
CDC’s website offers question-answer sheets, brochures, and posters—in both English and Spanish—to download and use with patients to help explain why antibiotics are not effective in treating viruses, the difference between viruses and bacteria, appropriate antibiotic use in children, and how bacteria develop resistance. Additional CDC materials available online include podcasts and short videos featuring medical experts answering questions from the public about antibiotics, explaining how to use antibiotics the right way, and describing how many common conditions can be overcome by simply treating the symptoms and letting the illness run its course. Other CDC resources for health care providers, including links to related treatment guidelines and continuing education opportunities, are also available online.
This year’s “Get Smart” week will coincide with two similar international events highlighting the importance of appropriate use of antibiotics, European Antibiotic Awareness Day and an observance day in Canada, both on Nov. 18.
IDSA’s mobile resources, including select practice guidelines and coding resources, are now available on your iPad.
Access the App Store using your mobile device or the iTunes Store and download the free Redi-Reader application to get started. For additional instructions, IDSA’s iPhone/iPad/iPod Touch tutorial guides you step-by-step through downloading and viewing the Society’s mobile resources using these devices.
Practice guidelines are available to everyone, but the popular Correct Coding resources are for IDSA members only, so you will need to log in to gain mobile access to the following tools:
Hard copies of the coding resources can also be purchased for a small fee by downloading and completing the order form available here (PDF). Please contact Genet Demisashi at email@example.com with any questions or concerns.
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:
Physicians will see a 21.3 percent across-the-board cut in their Medicare payments starting Dec. 1 unless Congress passes another fix before the current short-term fix expires Nov. 30.
Congress passed legislation in June that provided physicians with a 2.2 percent Medicare pay increase for six months. While the pay increase was retroactive to June 1, Medicare’s decision to hold claims caused significant delays in payments and disrupted practice revenues for several weeks thereafter. Without additional legislation, however, the 21.3 percent cut will take effect Dec. 1, with bigger cuts in store in 2011, unless Congress enacts another fix or permanently reforms the Sustainable Growth Rate (SGR) physician payment formula. IDSA and other medical societies have called for changes to the formula for years.
The cuts are the result of past congressional fixes that have provided temporary payment relief to physicians but have not changed the flawed SGR. Even before the June reprieve, Congress had intervened nine times since 2002 and three times during the first half of 2010 to avert payment cuts. Because lawmakers still haven’t addressed the SGR, however, those votes have merely magnified the underlying problem.
For additional information regarding future payment cuts or to contact your member of Congress, please visit IDSA’s Physician Payment Toolkit.
Physicians must sign up with Medicare’s Internet-based enrollment system by Jan. 3, 2011, 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.
In addition, physicians must have an enrollment record in the Internet-based system in order to receive a Medicare Electronic Health Record (EHR) incentive payment beginning next year. More information about the EHR incentive program is available online.
Medicare and its contractors are currently working through a backlog of enrollment applications because of the new Internet-based enrollment requirement, so ID physicians should check their Medicare enrollment status now, before the deadline, to make sure their status is up to date. Physicians should also discuss the issue with other physicians who often refer patients to them to avoid potential problems.
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.
ID practices should make sure their documentation for Evaluation and Management (E&M) service codes is in order or risk having some of their Medicare claims delayed.
A Medicare contractor handling claims for Delaware, Maryland, New Jersey, Pennsylvania, Washington, D.C., and Northern Virginia recently began targeting services billed under codes 99204 and 99205 for additional review, according to a recent article in Part B News. The contractor cited increasing error rates as specialists are now using these codes instead of the consultation codes the Centers for Medicare and Medicaid (CMS) stopped reimbursing for starting Jan. 1, 2010. IDSA and many other internal medicine subspecialties opposed and continue to work to reverse this CMS decision. The article noted the additional scrutiny for high-level E&M service codes could spread to other Medicare jurisdictions around the country.
For more information about E&M coding, codes used by ID physicians, and how an auditor looks at your codes, check out the presentations from the Billing and Coding Workshop held at the 48th Annual Meeting of IDSA earlier this month. Audio and synchronized speaker slides from the workshop are available for purchase online.
Billing and coding resources for IDSA members are also available on the Society’s website. Visit the Billing and Coding Resources page of the IDSA website. (You must be logged in to access this page.)
Following the worst flooding in Pakistan’s history, IDSA encourages members to contribute to the ongoing relief efforts. Please see the Society’s website for links to global relief and response resources suggested by members.
IDSA members often play an important role in responding to disasters such as the cholera outbreak in Haiti, the tsunami in Indonesia, and the flooding in Pakistan. Our thoughts and prayers continue to go to the victims of these and other disasters. If you have other resources specific to medical providers that you would like us to consider listing online, please e-mail us.
International HIV/AIDS advocates made a strong appeal for greater financial support for the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) during a congressional hearing last month. They also sought to dispel myths about PEPFAR’s performance, highlighting the plan’s important contributions to countries’ health systems.
Paula Akugizibwe of the AIDS & Rights Alliance of Southern Africa and Wafaa El-Sadr, MD, of Columbia University’s International Centers for AIDS Treatment and Prevention Programs (ICAP), spoke before the U.S. House Committee on Foreign Affairs. A member of the Center’s Scientific Advisory Committee, Dr. El-Sadr heads one of the largest and longest-standing PEPFAR implementing programs. She challenged the view that PEPFAR has done little to help health systems, a view expressed in a recent Center for Global Development report.
Instead, Dr. El-Sadr told lawmakers, “[A] major contribution has been in the realm of health workforce innovations. ICAP programs have also supported new health worker cadres, from adherence counselors and outreach workers to advanced physician-assistant equivalents, such as the technicos in Mozambique—efforts aimed at addressing the severe shortage of health care workers. These models, systems, and investments position the health system to respond to other threats.”
Government witnesses, who presented updates on PEPFAR and U.S. backing for the Global Fund, included U.S. Global AIDS Coordinator Eric Goosby, MD; Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases (NIAID); and Thomas Frieden, MD, director of the Centers for Disease Control and Prevention.
For a full wrap up on the hearing, including links to the witnesses’ testimonies and video clips from the hearing, please visit the Science Speaks blog.
In November, be sure to check out the blog for details about the Center’s Senior Policy Officer, David Bryden, and his discussion of a successful model of engaging scientists in policy and advocacy Nov. 13 at the International Union Against Tuberculosis (TB) and Lung Disease in Berlin. He will highlight the Center’s activities bringing the perspectives of physician-scientists to U.S. policymakers as part of a symposium entitled, "Perspectives on Global and National Advocacy to Reach Stop TB targets."Stay tuned to ScienceSpeaksBlog.org for more information and a link to his presentation.
The Center for Global Health Policy’s blog, Science Speaks, has a new home and a new look. Check it out at www.ScienceSpeaksBlog.org. Be sure to update your bookmarks!
The blog features thoughts, news, and analysis from the staff of the IDSA/HIVMA Center for Global Health Policy on the latest developments in tuberculosis and HIV/AIDS. The new blog home gives us more freedom to post a variety of content and take advantage of new features. The new design has the latest post on the left side of the page, with featured posts below. Other recent posts are listed to the right.We welcome your thoughts and comments on the new look. And please keep us posted on any story ideas you might have. All of your e-mail subscriptions and RSS feeds should transition to the new blog automatically, but please let us know if you experience any problems, and we will fix them right away.
A new bill in the U.S. House of Representatives focuses on stimulating antibiotic and related diagnostic development. The Generating Antibiotics Incentives Now (GAIN) Act (H.R. 6331) would, among other steps:
U.S. Rep. Phil Gingrey (R-Ga.), a former obstetrician, is the bipartisan bill’s lead sponsor. Co-sponsors include Reps. Gene Green (D-Texas), Mike Rogers (R-Mich.), Diana DeGette (D-Colo.), and Ed Whitfield (R-Ky.). The bill was introduced Sept. 29. IDSA provided input to the bill’s drafters prior to its introduction and continues to work with House members to strengthen the bill. For more information about the Society’s continuing support for a broad strategy to address antibiotic resistance and the lack of new antibiotic drugs, visit the Society’s website.
Other recent IDSA advocacy efforts include:
Leading public health and infectious disease experts, including IDSA, recently issued a framework for eliminating health care-associated infections (HAIs). Published in the November 2010 issue of Infection Control and Hospital Epidemiology, the white paper, “Moving Toward Elimination of Healthcare‐Associated Infections: A Call to Action,” outlines a four-part strategy based on successful preventive practices and public health strategies:
Progress in controlling a specific HAI, central line-associated bloodstream infections (CLABSIs), has demonstrated the potential of these efforts. Recent initiatives have shown 60-70 percent overall decreases of CLABSIs in intensive care units (ICUs), with some locations reporting zero CLABSIs for up to four years following implementation. Political will and investment at the federal, state and local levels, and consumer expectations for transparency and accountability are providing additional momentum for addressing HAIs.
The white paper was jointly authored by representatives from IDSA, the Centers for Disease Control and Prevention (CDC), the Society for Healthcare Epidemiology of America (SHEA), the Association for Professionals in Infection Control and Epidemiology (APIC), the Association of State and Territorial Health Officials (ASTHO), the Council of State and Territorial Epidemiologists (CSTE) and the Pediatric Infectious Disease Society (PIDS).
IDSA and HIVMA members have elected the following new members of the two organizations’ boards of directors:
IDSA Vice President:
David A. Relman, MD, FIDSA
Kathryn M. Edwards, MD, FIDSA
Vanderbilt University School of Medicine
HIVMA Vice Chair:
Michael A. Horberg, MD, MAS, FACP
HIVMA Board Members:
IDSA and the IDSA Education and Research Foundation offer awards to individuals to honor outstanding achievements in the field of infectious diseases.
Alexander Fleming Award
The Alexander Fleming Award is granted in recognition of a career that reflects major contributions to the acquisition and dissemination of knowledge about infectious diseases.
Herbert L. DuPont, MD, FIDSA, is one of the world’s foremost experts in infectious diarrheal diseases. Dr. DuPont is chief of internal medicine at St. Luke's Episcopal Hospital in Houston and a professor at the University of Texas-Houston, Baylor College of Medicine, University of Texas MD Anderson Cancer Center, and the University of Houston’s College of Pharmacy. Through his seminal work on the pathogenesis, epidemiology, host immunology, diagnosis, prevention, and therapy of infectious diarrheal illnesses, Dr. DuPont has enriched our understanding and practice of medicine throughout the world, especially in the area of enteric diseases.
Oswald Avery Award
The Oswald Avery Award recognizes outstanding achievement in an area of infectious diseases by an individual member or fellow of IDSA who is 45 or younger.
Eleftherios Mylonakis, MD, PhD, FIDSA, is a physician-scientist recognized for his research on microbial pathogenesis and host-pathogen interactions. Dr. Mylonakis is associate professor of medicine at Harvard Medical School. Dr. Mylonakis’ work is based on the hypothesis that identification of genes involved in bacterial-host interactions, but independent of the specific model system used to characterize this interaction, would preferentially identify genes relevant to pathogenesis.
Walter E. Stamm Mentor Award
The Mentor Award was created to recognize individuals who have served as exemplary mentors and is presented to an IDSA member or fellow who has been exceptional in guiding professional growth of infectious diseases professionals.
The Mentor Award is being renamed this year in honor of former IDSA president Walter E. Stamm, MD, FIDSA, who died in December 2009 and was renowned for mentoring both basic laboratory and epidemiologically trained researchers.
Jack S. Remington, MD, FIDSA, is a well-known researcher on toxoplasmosis and on opportunistic infections in immunologically impaired patients. Dr. Remington is professor emeritus of medicine in the Division of Infectious Diseases and Geographic Medicine at Stanford University, and the Marcus A. Krupp Research Chair emeritus and past chairman of the Department of Immunology and Infectious Diseases at the Research Institute of the Palo Alto Medical Foundation. In his 45 years as a clinician, researcher, and teacher, Dr. Remington has mentored more than 60 fellows in infectious diseases.
The Society Citation is a discretionary award given in recognition of exemplary contribution to IDSA, an outstanding discovery in the field of infectious diseases, or a lifetime of outstanding achievement in a given area—either in research, clinical investigation, or clinical practice.
John G. Bartlett, MD, FIDSA, is an internationally renowned authority on AIDS and many other infections. Dr. Bartlett is a professor of medicine in the division of infectious diseases at Johns Hopkins University School of Medicine. Dr. Bartlett is recognized for being the first to direct clinical trials in Baltimore of new treatments that prevent HIV from replicating, as well as for pioneering the development of dedicated inpatient and outpatient medical care for HIV-infected patients. Dr. Bartlett is a member of the Institute of Medicine, a master of the American College of Physicians, past president of IDSA, and a recipient of the Kass Award from IDSA. In 2005, Dr. Bartlett was awarded the Alexander Fleming Award by IDSA and the Finland Award from the National Foundation for Infectious Diseases.
Theodore C. Eickhoff, MD, FIDSA, is an advocate for adult immunization and professor emeritus of medicine at the University of Colorado in Denver. Dr. Eickhoff’s interests include influenza and viral respiratory diseases, vaccines and adult immunization, and the epidemiology and control of nosocomial infections. He has served as a consultant to the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and the American Hospital Association, and has served on each of the federal committees that deal with vaccines, including CDC’s Advisory Committee on Immunization Practices, FDA’s Vaccines and Related Biological Products Advisory Committee, and the U.S. Department of Health and Human Services National Vaccines Advisory Committee. He is a former secretary and past-president of both IDSA and the American Epidemiological Society.
Clinical Teacher Award
The Clinical Teacher Award honors a career involved in teaching clinical infectious diseases to fellows, residents, or medical students and recognizes excellence as a clinician and motivation to teach the next generation.
Adolf W. Karchmer, MD, FIDSA, is an established expert in the diagnosis and treatment of infective endocarditis and diabetic foot infections. Dr. Karchmer is professor of medicine at Harvard Medical School and attending physician at Beth Israel Deaconess Medical Center, where he supervises internal medicine and infectious disease teaching of medical students, interns, residents, and fellows. Highly admired by his peers, Dr. Karchmer actively consults on hospitalized patients and is called upon to provide second opinions for challenging cases, in particular those involving infective endocarditis, implantable devices, and osteomyelitis. His seminal work on infections in the diabetic foot popularized the concept of “probing the bone” as an inexpensive, readily available, and sensitive method to detect osteomyelitis. During the past 40 years, he has trained numerous physicians, gaining the recognition of his trainees and colleagues.
Watanakunakorn Clinician Award
Named to honor the memory of Dr. Chatrchai Watanakunakorn, this award is given annually by the IDSA Education and Research Foundation to an IDSA member or fellow in recognition of outstanding achievement in the clinical practice of infectious diseases.
Marvin J. Tenenbaum, MD, FIDSA, has practiced as a full-time clinical infectious disease specialist for more than 30 years. Dr. Tenenbaum is a clinical assistant professor at New York University Medical Center. His peers describe him as “the best doctor, an excellent teacher, and a compassionate, caring, warm, and highly respected individual.” Despite being in a very busy private practice, Dr. Tenenbaum has been actively involved at IDSA, having co-authored two important papers on the business aspect of infectious diseases and the value of the infectious disease specialist. He served as a member of the Clinical Affairs Committee from 1999 to 2002 and then as a chairman from 2003 through 2005.
The awards were presented during the Opening Plenary Session at the 48th Annual Meeting of IDSA in Vancouver on Oct. 21. More information about this year's Society Award winners is available online.
Joseph W. St. Geme III, MD, and Thomas E. Wellems, MD, PhD, are among the Institute of Medicine’s (IOM) newly elected members. The IOM announced the names of 65 new members at its 40th annual meeting held in October. Election to the IOM is considered one of the highest honors in health and medicine and recognizes individuals who have demonstrated outstanding professional achievement and commitment to service.
Dr. St. Geme is a James B. Duke Professor and Chair in the Department of Pediatrics and a James B. Duke Professor in the Department of Molecular Genetics and Microbiology at Duke University School of Medicine in Durham, N.C.
Dr. Wellems is chief of the Laboratory of Malaria and Vector Research at the National Institute of Allergy and Infectious Diseases, National Institutes of Health, in Bethesda, Md.
Ganachari, Malathesha, PhD
Moss, Gregory, MD
de Vente, Jerome, MD
Weissman, Scott, MD
Wieczorkiewicz, Sarah, PharmD
Aggarwal, Saurabh, MBBS
Allen, Meigo, PharmD
Aly, Sameh, MD
Bauman, Susanne, PhD
Briscoe, Dan, MBA
Bufton, Marilyn, PharmD
Buppanharun, Wanchai, MD
Cies, Jeffrey, PharmD
Collins, Martha, MBA
Domond, Yolanda, MD, ME
Dunn, Keith, PharmD
Fitchett, Joseph, MSc
Han, Jonathan, PharmD
Harder, Curtis, PharmD
Johnson, Laurie, PA-C
Keckich, David, MD
Mehta, Saurabh, MBBS, MS, ScD
Parpia, Salvi, PharmD
Perkins, Patricia, MPH, MSc, ScD
Rothberger, Edward, MD
Shah, Charudutt, MSc
Surles, Tiffany, PharmD
Vargas, Pilar, MD, PhD
Adeyiga, Oladunni, MD
Cadilla, Adriana, MD
Carrier, Marc, MD
Deol, Dilraj, MD
Dunachie, Susanna, MB, MRCP, PhD
El Zakhem, Aline, MD
Green, Abby, MD
Hewagama, Saliya, MBBS
Hoffman, Jennifer, MD, BCh
Jackson, Arthur, BCh, MB
Kasper, Erica, MD
Kulhanek, Grace, MD
Maco, Vicente, MD
Multani, Ami, MD
Nguyen, Luong, MD
O'Connell, Sarah, MD
Patel, Payal, MD
Paulsen, Grant, MD
Ponce Terashima, Rafael, MD
Rajakumar, Derek, MD
Rasul, Samad, MD, MBBS
Rodwan, Omar, MD
Rogo, Tanya, MD, MPH
Shehab, Kareem, MD
Ton, Quy, MD, MPH
Trepanier, Pascale, MD
Udeh, Darlington, MD
Uto, Kaoru, MT
Wong, Titus, MD
Wuerz, Terence, MD
If you attended the 48th Annual Meeting of IDSA, you can claim continuing medical education (CME) credit and continuing pharmacy education (CPE) credit through the Annual Meeting website by clicking the “Claim CME or Certificate of Attendance from IDSA 2010” link. To log in, use your first and last name and the ZIP code you used to register for the meeting. For non-U.S. residents, enter your country name in place of the ZIP code. Please note that IDSA is not providing CME/CPE credit for sessions with faculty who are employed by commercial interests.
An updated version of the popular online infection control fellows course—developed by IDSA, the Society for Healthcare Epidemiology of America (SHEA), and Johns Hopkins University—is now available at www.iccourse.org.
Designed to give infectious diseases fellows and others basic training in infection control and hospital epidemiology, at their own pace, and without having to travel, the course satisfies the Accreditation Council for Graduate Medical Education (ACGME) requirement for training in hospital epidemiology.
Featuring entirely new content and topics, the course is geared toward first- and second-year fellows in infectious diseases training programs and includes lessons from world-renowned faculty from various specialties in health care epidemiology. The cost is $250 per registrant, and registrants will receive a certificate of completion when they finish the course. Training program directors who enroll their fellows in the course can request final scores for the trainees they registered.
To register for the updated course, visit www.iccourse.org.
For fellows progressing through the earlier version of the course, it remains available at version1.iccourse.org.
An interactive, multimedia, case-based continuing medical education (CME) activity on the diagnosis and management of invasive mycoses is available online. The free activity includes case-based discussions, didactic presentations, and panel discussions related to aspergillosis, mucormycosis, candidiasis, and coccidioidomycosis. At their own pace, participants can evaluate cases, compare answers, and receive feedback about the optimal answers from faculty experts. Up to 1.5 free credit hours are available.
The activity is available online and is jointly sponsored by the University of Nebraska Medical Center, the Mycoses Study Group Educational Committee, and Terranova Medica LLC. It is supported by educational grants from Pfizer and MiraVista Diagnostics.
Annual Meeting Coverage
Anthony Fauci, MD, FIDSA, director of the National Institute of Allergy and Infectious Diseases (NIAID), laid out a comprehensive plan for improving the nation’s response to a range of infectious disease threats at the 48th Annual Meeting of IDSA in Vancouver.
Anthony Fauci, MD, FIDSA, director of the National Institute of Allergy and Infectious Diseases (NIAID), laid out a comprehensive plan for improving the nation's response to a range of infectious disease threats during the opening plenary presentation at the 48th Annual Meeting of IDSA in Vancouver.
The U.S. experience with the 2009 H1N1 pandemic influenza vaccine and morbidity and mortality data on other infectious diseases help illustrate the need to improve the country's ability to rapidly develop medical countermeasures, including therapeutics, diagnostics, vaccines, and other preventive tools, to protect against public health threats. Dr. Fauci outlined a comprehensive, 6-month review conducted by the Department of Health and Human Services, which called for action in five areas:
"You and I, as members of the infectious disease community, have to play an important role in this, regardless of what you do every day," Dr. Fauci told meeting attendees. "This is not just product development in a vacuum. It is a multi-faceted process that involves the basic researcher at the bench who never sees a patient, the clinical investigator, the clinician, the regulatory agencies, and, importantly, the pharmaceutical industry."
Dr. Fauci also outlined a plan to expand the research focus of the NIAID Clinical Trials Networks to go beyond HIV/AIDS and to include AIDS-related morbidities such as tuberculosis and hepatitis B and C, as well as non-AIDS infectious diseases (using non-AIDS resources) including antimicrobial resistance, influenza, and neglected tropical diseases, among others. The NIAID clinical trial networks have worked "marvelously well" for HIV, Dr. Fauci noted. "Why not expand the clinical capacity for infectious diseases that go beyond HIV? There are so many other infectious diseases that could use a boosted up clinical trials capability."
Dr. Fauci also discussed a current NIAID project to identify barriers that serve as obstacles to clinical research, including issues related to Institutional Review Boards (IRBs), that will produce recommendations intended to improve both the effectiveness and efficiency of research.
Check out the next issue of IDSA News for more 2010 IDSA Annual Meeting coverage. Audio and synchronized speaker slides from sessions are available for purchase online.
Annual Meeting Coverage
The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has faced budget pressures in recent years, but nevertheless has made a tremendous impact on the lives of people with HIV/AIDS, according to Eric Goosby, MD, U.S. Global AIDS Coordinator, who spoke at the IDSA Annual Meeting.
The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has faced budget pressures in recent years, but nevertheless has made a tremendous impact on the lives of people with HIV/AIDS, according to Eric Goosby, MD, U.S. Global AIDS Coordinator, who spoke at the IDSA Annual Meeting.
The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has faced budget pressures in recent years, but nevertheless has made a tremendous impact on the lives of people with HIV/AIDS, according to Eric Goosby, MD, U.S. Global AIDS Coordinator, speaking at the opening plenary session of the 48th Annual Meeting of IDSA in Vancouver.
In 2009, 29 million people were tested for HIV through PEPFAR; 3.6 million orphans and vulnerable children were cared for; 340,000 babies of HIV-positive mothers were born free of HIV; and nearly 2.5 million people received antiretroviral therapy (ART).
With 2010 data still to come, Dr. Goosby estimated the updated figures would put the program well on its way to reaching more than 4 million people with lifesaving treatment by 2014, its current goal.
Dr. Goosby acknowledged the difficult fiscal context and noted that finding efficiencies had allowed PEPFAR to expand access to services. Savings from the cost of antiretroviral drugs have been exhausted, with the program now purchasing 92 percent of medications as generics. The focus has shifted to making improvements in supply management and procurement that will free up more resources, he said.
Moving forward, male circumcision as a one-time intervention has the potential to save millions of lives with a scaled implementation, noted Dr. Goosby, who announced that PEPFAR was poised to do country-level scale up of male circumcision in Swaziland, Lesotho, and several key provinces in South Africa. “The pilot projects that have been done are very promising,” Dr. Goosby said, with significant potential cost savings as well.
In the prevention of mother to child transmission, PEPFAR also has targeted six countries for major investment over the next year with the goal of testing at least 80 percent of pregnant women for HIV infection and ensuring that at least 85 percent of those who test positive are offered ART.
Dr. Goosby also described an aggressive effort to ensure the most effective use of PEPFAR’s resources through an analysis of program expenditures that has already been completed in 14 countries and will now be expanded to 30 countries. “It’s not to point a finger at who is able to do it cheaper, it’s really to allow us to transform those more expensive efforts into cheaper efforts, and use that as a technical assistance tool that moves our costs down.”
For more coverage of Dr. Goosby’s presentation and other global health related sessions at the Annual Meeting, visit the Center for Global Health Policy’s blog, Science Speaks. Audio and synchronized speaker slides from sessions are available for purchase online.
This month: Studies investigating the widespread presence of NDM-1 in Enterobacteriaceae in India, Pakistan, and the UK; excessive diagnostic testing and broad antibiotic use for SSTIs; safety and immunogenicity of HPV vaccine in HIV-infected men; and the survival of hepatitis C virus in syringes.
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.
Widespread Presence of NDM-1 in Enterobacteriaceae in India, Pakistan, and the UK
Reviewed by Christopher J. Graber, MD, MPH
A new metallo-β-lactamase has become widespread among Enterobacteriaceae isolates throughout India and Pakistan and is now the most common carbapenemase in Enterobacteriaceae in the United Kingdom, according to a study published in the September issue of Lancet Infectious Diseases.
New Delhi metallo-β-lactamase 1 (NDM-1) was first described in 2009 and has sporadically been reported in Klebsiella pneumoniae and Escherichia coli isolated from patients in the United States, Sweden, Canada, the Netherlands, and Australia who had recently received medical care in India. The study authors found that, among 141 and 47 carbapenem-resistant Enterobacteriaceae isolates collected in 2009 in the Indian cities of Chennai and Haryana, 44 (31 percent ) and 26 (55 percent) were positive for NDM-1 by PCR. NDM-1 was also identified in Enterobacteriaceae from several other communities throughout India and Pakistan, typically occurring in community-acquired infections.
An analysis of 73 carbapenemase-producing Enterobacteriaceae isolates referred to the UK’s national reference laboratory in 2009 revealed the presence of NDM-1 in 32 (44 percent); at least 17 isolates were from patients who had traveled to India or Pakistan within the prior year. While the Chennai and UK NDM-1 isolates were clonally diverse Enterobacteriaceae (mostly E. coli and K. pneumoniae), the Haryana isolates represented a single clone of K. pneumoniae.
All NDM-1-positive isolates were resistant to carbapenems (except two isolates with borderline meropenem susceptibility) and aminoglycosides; less than 10 percent were susceptible to aztreonam or ciprofloxacin. Approximately 60 percent were susceptible to tigecycline, and 90 percent were susceptible to colistin. The NDM-1 gene was mostly found on plasmids that were of highly variable size, though three UK isolates also carried the NDM-1 gene on their chromosome.
NDM-1 has clearly demonstrated ability for rapid spread. Its presence only further emphasizes the worldwide need for heightened efforts in antibiotic stewardship, infection control, and antibiotic drug development. There should be a heightened suspicion for these organisms among patients who have traveled to areas where NDM-1 is endemic.
Excessive Diagnostic Testing and Broad Antibiotic Use for SSTIs
Reviewed by Nina Kim, MD, MSc
The incidence of skin and soft tissue infections (SSTIs) has increased substantially in both hospital and outpatient settings in recent years. Despite this, we have few contemporary studies that systematically catalogue the clinical spectrum and current management of these common infections. Investigators from the University of Colorado in Denver reveal some important and alarming findings in a study published in the Oct. 15 issue of Clinical Infectious Diseases.
They examined a total of 322 consecutive cases of SSTI during 2007, captured through ICD-9 coding from hospital discharge diagnoses and categorized as cellulitis (20 percent), cutaneous abscess (32 percent), and SSTI with complicating factors (48 percent), such as deep tissue infection, bacteremia, and diabetic or chronic ulcer. In the latter two groups, where a pathogen was identified through abscess drainage, tissue specimen, or blood, Staphylococcus aureus and streptococci comprised the overwhelming majority (97 percent).
Despite this well-established predominance, antibiotics with broad activity against gram-negative organisms were used in two-thirds of cases. The median duration of therapy was two weeks for all categories, regardless of severity—despite available evidence that suggests many patients, especially those with uncomplicated forms of SSTI, can be treated safely with shorter courses. Diagnostic tests of questionable utility in SSTI were routinely used. Serum inflammatory markers (erythrocyte sedimentation rate or C-reactive protein) were measured in 70 percent of cases and imaging studies, particularly plain radiography, were done in 94 percent of cellulitis cases.
Although this is a retrospective study at a single academic center, it is a thorough overview of current inpatient SSTI presentation and management that brings into sharp focus excesses in diagnostic testing and antimicrobial therapy unlikely to be isolated to this Denver institution. The study underscores the need to examine our own care settings and to conduct careful prospective studies that clarify the clinical care of SSTIs.
HPV Vaccine Safe and Immunogenic in HIV-Infected Men
Reviewed by Shireesha Dhanireddy, MD
The quadrivalent human papillomavirus (HPV) vaccine is safe and immunogenic in HIV-infected men, according to a study in the Oct. 15 issue of The Journal of Infectious Diseases.
The single-arm, open-label, multicenter trial included male patients from eight clinical trial sites in the U.S. The patients were HIV-infected men > 18 years old with CD4 counts > 200 cells/uL and HIV-1 RNA levels < 200 copies/mL on antiretroviral or with CD4 counts > 350 cells/uL, not on treatment, and without history of anal cancer or high-grade squamous anal intraepithelial neoplasm (HGAIN). Individuals were also excluded if HPV 16 and 18 were detected by PCR of anal swabs. Subjects received vaccine at entry, week 8, and week 24. The primary endpoints included immunogenicity, determined by antibody titer to vaccine serotypes, as well as the development of serious vaccine-related adverse events.
Of the 235 eligible patients, a significant number were excluded based on the presence of HGAIN at baseline. One hundred patients were eligible for the per-protocol analysis. Participants achieved a > 95 percent response rate based on anti-HPV antibodies to vaccine serotypes. No serious adverse events were associated with the vaccine.
Interestingly, a significant proportion (60-78 percent) of men were seronegative for at least one vaccine serotype at baseline, suggesting that despite age and history of sexual intercourse, HIV-positive men may still benefit from HPV vaccine. A significant proportion of men (nearly 30 percent) were excluded based on the presence of high-grade lesions at baseline, however. A limitation of this study is that the median CD4 count of participants was >500 cells/uL, which may explain the high rates of response compared to other vaccines.
This study shows that quadrivalent HPV vaccine may be given safely to HIV-infected men with relatively preserved CD4 counts. However, clinical efficacy data is still lacking.
Survival of Hepatitis C Virus in Syringes
Reviewed by Ed Dominguez, MD
Harm reduction programs have reduced the incidence of HIV infection among intravenous drug users (IDUs) but not for hepatitis C virus infection (HCV). The estimated probability of HCV transmission via this route is five-fold to twenty-fold higher than for HIV. In the Oct. 1 issue of The Journal of Infectious Diseases, researchers determined the viability of HCV in two types of commonly used syringes at different temperatures over time.
The team measured infectivity via a microculture assay. Syringes were loaded with blood spiked with HCV, duplicating the common sequence used by IDUs. The syringes were then assayed for virus immediately or stored at 4°C, 22°C, and 37°C for up to 63 days. Low void volumes (2 microliters) were investigated with U-100 1-ml insulin syringes and high void volumes (32 microliters) with 1-ml tuberculin syringes. The researchers recovered HCV in 5 percent of insulin syringes stored at 4°C for up to seven days. No virus was recovered from those stored at 22°C and 37°C after one day of storage. Infectivity declined almost as rapidly. Syringes stored at 4°C showed 92 percent reduction at day seven, while those stored at 37°C showed 96 percent reduction at day one.
This inverse relationship between temperature and HCV survival was more pronounced in the high void volume syringes. Although HCV infectivity decreased by at least 90 percent after one day of storage at all temperatures, syringes stored at 4°C showed consistently higher infectivity than those stored at other temperatures through the first 21 days.
Harm reduction programs, such as syringe exchange, have reduced the circulation time of used syringes to < 3 days. However, this seminal study suggests that HCV infectivity may persist beyond that time, particularly in high void volume syringes and in syringes stored at 4°C. Public health recommendations for preventing HCV in IDUs will need to be reevaluated in light of this finding.
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: