IDSA News - March 31, 2011
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CDC Reports Drop in CLABSI Rates
Rates of bloodstream infections in ICU patients with central lines decreased by 58 percent in 2009 compared to 2001, according to a new report by the Centers for Disease Control and Prevention (CDC). The drop represented up to 27,000 lives saved and $1.8 billion in excess health care costs, according to CDC. Central line-associated blood stream infections (CLABSI) can kill as many as one in four patients who acquire them.
According to CDC, recent studies have shown that most of these infections can be prevented by following infection control recommendations, which include removing central lines as soon as medically appropriate. In hemodialysis patients, central lines should only be used when other options are unavailable, the agency advises.
The biggest drop was in CLABSIs caused by Staphylococcus aureus (73 percent), followed by Enterococcus (55 percent), Candida (46 percent), and Gram-negative pathogens (Klebsiella, Escherichia coli, Acinetobacter baumannii, Pseudomonas aeuriginosa) (37 percent).
In addition to the ICU findings, the report found that about 60,000 CLABSIs occurred in non-ICU health care settings such as hospital wards and kidney dialysis clinics. About 23,000 of these occurred in non-ICU patients (2009) and about 37,000 occurred in dialysis clinic patients (2008).
“The report findings point to a clear need for action beyond ICUs,” said Denise Cardo, MD, director of CDC’s Division of Healthcare Quality Promotion, in a press release.
For more information, see the following:
Note: CDC’s Healthcare Infection Control Practices Advisory Committee is releasing new guidelines for the prevention of intravascular catheter-related infections, which will be published in an upcoming issue of Clinical Infectious Diseases. See next month’s IDSA News for more information.
UTI Practice Guideline Now Available for Mobile Devices
IDSA’s practice guideline for the diagnosis, prevention, and treatment of catheter-associated urinary tract infections (UTIs) is now available in a format designed for iPhones and other mobile devices. Visit IDSA’s website for instructions for downloading and using this guideline and others on your mobile device.
Also, don’t forget about Pocketcard versions of the guidelines, which are also available on the IDSA website. IDSA members are eligible for a 35 percent discount when ordering these 4x7-inch quick-reference tools that feature essential diagnostic and treatment recommendations in a brief format. Use discount code DCIDSA09.
Drug Approvals, Recalls, Adverse Events Update
IDSA offers two e-mail services to help members stay informed of updates from the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). Content includes a range of topics, including new drug approvals and warnings. Recent alerts have included:
IDSA members can sign up for these services online. (You must be logged in to have access to this link.)
Is Your Facility Experiencing Antibiotic Shortages?
Report these to FDA and IDSA.
IDSA Annual Meeting: New International HIV Travel Grants Available
This year, new travel grants are available for international investigators who submit excellent research abstracts in the category of HIV/AIDS for the 49th Annual Meeting of IDSA, Oct. 20-23, in Boston. IDSA, HIVMA, and the Center for Global Health Policy have received funding from the National Institutes of Health (NIH) Office of AIDS Research to provide these travel grants in the amount of $3,000 for up to six international investigators. All approved abstracts submitted in the category of HIV/AIDS from outside the U.S. and Canada will be considered for the travel awards. Please share this opportunity with your international colleagues.
For more information, visit the Call for Abstracts, now available online. The abstract submission deadline is Wednesday, May 18.
Online registration and housing for the Annual Meeting is also now open for HIVMA and IDSA members only. Visit the meeting website to register.
Visiting Physicians Educate Policymakers on Value of Global Health Programs
The Center for Global Health Policy hosted several visiting physicians in March to educate lawmakers and federal agency staff in Washington, D.C., about the doctors’ work and the value of global health programs to combat HIV and tuberculosis (TB). Dr. Liz Corbett, a clinical researcher specializing in infectious diseases who has been based in Africa for more than a decade, spoke with congressional staffers on Capitol Hill and visited government officials. Now based in Malawi, Dr. Corbett’s main research interest is improving TB control in populations with high HIV prevalence. In a presentation to staffers from the U.S. Agency on International Development and the World Health Organization, Dr. Corbett discussed early diagnosis and prevention of TB and HIV in the community, successes in HIV self-testing in Malawi, and disturbing news about delayed puberty and stunting among perinatally HIV-infected adolescents. You can read more about her presentation on the Center’s blog, Science Speaks.
Three former National Institutes of Health (NIH) Fogarty International fellow—Drs. Juliet Akao, Samar Mehta, and Evelyn Ford—also met with key legislators who have influence over funding for global health programs. A video clip of Dr. Akao, an HIV medicine specialist from Uganda, discussing the importance of U.S. funding to AIDS programs in her country, is available on Science Speaks.
Global Center Marks World TB Day
The Center for Global Health Policy marked the week leading up to World Tuberculosis (TB) Day on March 24 with a series of interviews and commentaries on its blog, Science Speaks. Participants included Mario Raviglione, MD, who joined his co-authors from the World Health Organization’s Stop TB Partnership to summarize a recent report on multidrug-resistant tuberculosis, and Cherise Scott, MPH, PhD, secretariat of the Stop TB Partnership Working Group on New TB Drugs, who discussed the creation of shorter and more effective TB drug regimens. Check out the series on Science Speaks.
Anneke Hesseling, MD, of the Desmond Tutu TB Centre in South Africa also visited Washington, D.C., the week of World TB Day, giving a presentation to an audience at the United Nations Foundation. The discussion, “TB in Children: A Global Crisis and a South African Perspective,” was co-sponsored by the Center. An interview with Dr. Hesseling, recorded after her presentation, is available on Science Speaks.
FDA HABP/VABP Guidance Must Address Key Issues, IDSA Says
New draft guidance for industry from the Food and Drug Administration (FDA) for developing new drugs for hospital-acquired and ventilator-associated bacterial pneumonia (HABP/VABP) is a welcome step, IDSA said in recent comments to the agency. But there are issues IDSA believes must be addressed in the final FDA guidance to ensure that clinical trials for treating these two infections are feasible. Two key issues include allowance for prior antibiotic therapy in patients prior to clinical trial enrollment and the use of biomarkers as an alternative to the collection of respiratory culture specimens. The Society’s comments, submitted in February, are available online (PDF).
In other IDSA policy and advocacy news, IDSA joined with five other medical societies in a March letter to the Medicare Payment Advisory Commission (MedPAC) to reiterate the negative impact of the Centers for Medicare and Medicaid Services (CMS) 2010 decision to eliminate payments for the consultation codes. The letter followed a meeting between the organizations and MedPAC officials to discuss the issue. In the letter, the groups noted that new payment models should recognize the value of cognitive specialty care and that specialty consultations improve quality and reduce costs.
Members on the Move
John G. Bartlett, MD, FIDSA, has joined the Forum for Collaborative HIV Research Leadership Team as co-chair of the Forum’s executive committee. Dr. Bartlett was former chief and is now professor of medicine in the Division of Infectious Diseases at Johns Hopkins University School of Medicine. Dr. Bartlett serves on IDSA’s Antimicrobial Availability Task Force, is past president of IDSA, a recipient of IDSA's Alexander Fleming Award for Lifetime Achievement, and a member of the Institute of Medicine.
Welcome, New Members!
Altfeld, Marcus, MD, PhD, DTM&H
Ebright, Richard, PhD
Gutierrez, Liliana, MD
Jerome, Keith, MD, PhD
Kwon, Douglas, MD, PhD
McClelland, Erin, PhD
Ploss, Alexander, PhD
Rogers, Mary, PhD
Tennant, Sharon, PhD
Zachary, Dalila, MD
Araujo, Joao, PhD
Balila, Maida, MBBS
Chacko, Ron, MD
Chelak, Kristen, MSc
Chikumi, Hiroki, MD
Desai, Himanshu, MD
Greene, Todd, PhD
Kim, Kye-Hyung, MD
Kutzler, Michele, PhD
Nangia, Vivek, MD
Okamoto, Koh, MD
Rao, Satish, MD, MBBS
Schade, Meredith, MD
Seeliger, Jessica, PhD
Soule, Barbara, MPA
Bearden, Allison, MD, MPH
Bowman, Natalie, MD
Gerrior, Melanie, MD
Hui, Siong, MBBS
Justo, Julie Ann, PharmD
Ndow, Gibril, MBBS
Van Wagoner, Nicholas, MD
ID and HIV Maintenance of Certification Modules Now Available
Two new Maintenance of Certification (MOC) modules—one in general ID medicine and one in HIV medicine—are available online from IDSA and the HIV Medicine Association (HIMVA).
Developed by panels of experts from both organizations, each 25-question module is worth 10 points toward MOC by the American Board of Internal Medicine (ABIM). Continuing medical education (CME) credit is also available from IDSA. To pass the module, you must have a score of 75 percent or better. To receive MOC points, you must be enrolled in ABIM’s MOC program. (For more information about the program requirements, visit ABIM’s website or call the ABIM Contact Center at (800) 441-ABIM, extension 3598.)
Even if you’re not enrolled in ABIM’s MOC program, the modules provide an excellent opportunity to earn CME credit. Each activity has been approved for 2 AMA PRA Category 1 Credits™.
For more information about MOC activities, visit IDSA’s website. For additional questions about the MOC modules, contact Kathy Matikonis at firstname.lastname@example.org or (703) 299-0200.
To get started, just follow the simple directions below:
- Go to idsa.knowledgedirectweb.com and click “Registration” to register as a new user/“student.”
- On the “Welcome” page, select one module, and then click “Purchase Course.”
- Review the learning objectives and disclosure information, then click “agree.”
- Check “ABIM Eligibility.”
- Review the documents in the General Information section.
- Start the examination and select the corresponding correct answers.
- Complete the course evaluation.
- Select “Request ABIM Credit” to submit answers to ABIM.
- Select “Certificate of CME” to print your CME certificate. Each module earns two AMA PRA Category 1 Credits™.
- Follow and complete the same steps for the second module (go to “Student Home Page” and log in using your e-mail address and password).
- If you need technical help with the online modules, send an e-mail to email@example.com.
Both modules are valid until Oct. 31, 2013. You may complete the modules now and submit your answers to ABIM any time until then.
ID/HIV Career Center Helps You Meet Your Match
The ID/HIV Career Center, the official online job bank of IDSA and the HIV Medicine Association (HIVMA), gives you access to more jobs in less time. Visit the site to:
- Find the right jobs, quicker: Look for positions in ID and HIV medicine by location, specialty, keyword, and organization name.
- Get job alerts: Register for e-mails about jobs that match your qualifications and interests.
- Connect at events: Use the improved Conference Connection™ feature to see who is attending the IDSA Annual Meeting and plan a time to network with potential employers.
- Sign up for eNewsletters: Receive employment best practices and job tips in your inbox.
- Read career advice: Access the ID/HIV Career Center for articles about résumés, interviews, and landing the right position.
- Tie it all together: Manage your résumés, jobs, and application histories.
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.
Whether you’re job hunting or tracking the ideal candidates, the ID/HIV Career Center offers tools for success. Your search stops here—visit the ID/HIV Career Center today!
From the President: Escalating the Fight against Global HIV/AIDS and TB
Tuberculosis killed an estimated 1.7 million people worldwide in 2009 and remains the number one killer of those living with HIV globally. The Society’s Center for Global Health Policy is a powerful voice supporting and promoting U.S. efforts to combat these diseases, which have formed a deadly synergy around the world.
Tuberculosis (TB) killed an estimated 1.7 million people worldwide in 2009, including 380,000 infected with HIV, and remains the number one killer of those living with HIV globally. Yet only 28 percent of TB patients were tested for HIV and accessed HIV prevention, treatment, and care services in 2009.
Each March, the World Health Organization (WHO) recognizes the threat posed by TB on World TB Day, held this year on March 24. The day underscores the work still needed to address one of the world’s leading infectious disease killers, which has formed a deadly synergy with HIV/AIDS over the last decade.
Thanks to a generous grant from the Bill & Melinda Gates Foundation to the IDSA Education and Research Foundation, the Center for Global Health Policy was created in 2008 to support and promote U.S. efforts to combat HIV/AIDS and TB around the world. This project promotes the effective use of U.S. funding to address these epidemics by providing scientific and policy information to policymakers, federal agencies, nongovernmental organizations, and the media. The Center provides an important mechanism for IDSA and HIVMA members to share their expertise and experience with policymakers and federal government leaders about the U.S. response to global HIV and TB.
A major Center undertaking is Science Speaks, a highly popular blog featuring news, interviews, analysis, and updates from Center staff about the latest developments in TB and HIV/AIDS. In a recent post, Kevin M. DeCock, MD, director of the Center for Global Health at the Centers for Disease Control and Prevention (CDC), discussed the global research agenda for TB, including how best to implement new technology such as the Gene Xpert rapid TB test.
The Center also organizes visits so that physicians from developing countries can meet with policymakers on Capitol Hill to show how global health programs are having an important impact. In August 2010, the Center hosted congressional staff members on a trip to South Africa and Zambia to visit U.S. government-funded programs addressing HIV and TB to provide them a firsthand view of the important strides these programs are making and the areas where additional support is needed. The Center plans to host another congressional delegation trip to Africa this summer.
In just one example of the critical support U.S. funding provides, the President’s Emergency Plan for AIDS Relief (PEPFAR) directly supported the distribution and administration of lifesaving antiretroviral treatment for more than 3.2 million men, women, and children worldwide in the 2010 fiscal year (FY), an increase from less than 2.5 million people treated in FY 2009.
The Center also publishes timely issue briefs. A June 2009 report detailed the scope of HIV/TB co-infection worldwide and called for an aggressive U.S. response from policymakers. (To download the report as a PDF, click here.) A December 2010 report focused on the use of medical male circumcision for HIV prevention. The brief, available online (PDF), makes a strong case for rapidly expanding these services in countries with high HIV prevalence, low rates of male circumcision, and a predominantly heterosexual epidemic. Studies in sub-Saharan Africa have already shown that circumcision can reduce a man’s chance of acquiring HIV infection through vaginal sex by up to 60 percent and can have a substantial impact on HIV incidence.
For more about the Center’s recent activities, read the related articles in this issue of IDSA News and check out Science Speaks, the Center’s blog, for regular updates. To become involved in the Center’s important advocacy work, please visit the Center’s website for more information.
WHO will highlight another critical public health issue on World Health Day, April 7, which this year will focus on raising global awareness about antimicrobial resistance; the theme is “No action today, no cure tomorrow.” IDSA will mark the day with a press conference and a congressional staff briefing in Washington, D.C. to highlight the problem and the urgent need to take action to address it. Check the IDSA website in April for details about these events.
Looking ahead, IDSA leaders will identify and discuss additional potential opportunities and roles for the Society in global health during the June Board of Directors meeting.
EIN Update: An ARDS Cluster and a Candida parapsilosis Outbreak
EIN members recently discussed a cluster of acute respiratory distress syndrome cases and a possible outbreak of Candida parapsilosis, highlighting how EIN can help members respond to public health threats, identify new infections or outbreaks, and connect with appropriate authorities.
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.
EIN members recently discussed a cluster of acute respiratory distress syndrome (ARDS) cases in Montana and a possible outbreak of Candida parapsilosis in Connecticut. Both highlighted how EIN can help members respond to public health threats, identify new infections or outbreaks, and connect with appropriate public health authorities.
A member in Montana began the first discussion: “There are five individuals in the past four weeks,” ranging from 53 to 86 years old, “with a viral-upper respiratory tract syndrome that lasts about five days, then progresses into a multilobar pneumonia with significant hypoxemia, an ARDS-type pattern,” the member wrote. “One patient has been on the ventilator for over 30 days.”
Rapid influenza testing had been negative for all of the patients, and serum influenza antibodies for immunoglobulin M (IgM) were not elevated. No positive viral, bacterial, or fungal cultures had been found. In addition, there had been no positive Hantaviral serologies, no positive serum (or cerebrospinal fluid) cryptococcal antigens, and no positive Epstein-Barr virus or cytomegalovirus serologies. Legionella and pneumococcal antigens were negative.
“We have had some influenza A (H3) in the area, and a pertussis outbreak,” the member said. There had been “no positive pertussis PCR in these patients so far, and no response to broad spectrum antimicrobial therapy. I was wondering if anyone else has seen a similar syndrome.”
A Utah respondent stressed contacting public health authorities. “The most important thing with an ARDS cluster is to involve the Montana Department of Health and the CDC,” the respondent said, advising the member to “save as much acute and convalescent serum, nasopharyngeal (NP) swabs in viral media, and bronchoalveolar lavage (BAL) fluid as you can. CDC has new protocols for unknown pathogen discovery that should be brought to bear.”
An EIN member in Maryland agreed, noting that the National Respiratory and Enteric Virus Surveillance System “lists the Montana health department lab as part of their network. I would definitely get them involved.”
A Tennessee member advised testing for adenovirus by PCR, noting “there have been some recent reports of severe pneumonia due to novel adenovirus serotype 14. Clusters have been popping up off and on in different regions,” as described on CDC’s website.
“We have seen ‘pandemic’ H1N1 influenza diagnosed only by BAL PCR testing in our area over the last several weeks fitting your patients’ descriptions,” an EIN member in Indiana responded, while a North Carolina member recommended running a respiratory viral panel (RVP) and repeating it if the result was negative. “We have had very severe (some needed extracorporeal membrane oxygenation) viral pneumonias last influenza season, with similar features and with initial negative RVP that showed positive in a repeat test,” the N.C. member said.
Other suggestions included testing for human metapneumovirus (hMPV), Q fever, and tularemia, in addition to checking serum procalcitonin levels. The Utah respondent also noted that “in severe influenza disease, the lower airway can be positive while the upper airway is negative by PCR, so you should ideally test BAL or tracheal aspirate in addition to NP.”
“Ideally, the lower airway samples should be sent for some type of multiplex PCR that can look for influenza, adenovirus, hMPV, parainfluenza, and perhaps respiratory syncytial virus and rhinovirus,” the member added. “If a few days have elapsed from onset, repeating influenza PCR may be helpful if copy number is low, to get around sampling issues.”
The original poster from Montana also responded that he had been contacted by public health officials and that any new cases would have BAL specimens sent for viral culture and PCR testing.
Another recent discussion also resulted in contact with public health officials for an EIN member concerned about a possible outbreak. “Our microbiology lab has had four joint fluid cultures obtained from outpatients at three different rheumatology practices which have grown Candida parapsilosis, from the broth specimen,” a member in Connecticut wrote. “I am wondering whether others have noted this recently in higher than usual numbers, suggesting the possibility of a contaminated product that is being used by rheumatologists (or others) to do aspirations.”
An EIN member in Iowa responded, “It’s highly unlikely that this is a coincidence, and you are already investigating the possibility of a lab-generated pseudo-outbreak. Assuming you didn’t turn up anything to implicate the lab, which it seems you did not, this definitely merits further investigation.”
An investigation could be coordinated by public health personnel, with assistance as needed from CDC, the member noted. “From a lab standpoint, typing the organisms to assess for a common source would be a good next step.”
The original poster from Connecticut later responded that “Within days, I received very helpful information from my colleagues around the country and, as an added benefit, due to the participation of public health organizations in the Network, I was also contacted by the Centers for Disease Control and Prevention within a day of the inquiry and an investigation was promptly initiated.”
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.
IDSA Journal Club
This month, studies investigating: chronic HIV infection and the impact of pulmonary disease; extended courses of voriconazole, fluoride excess, and periostitis in transplant patients; H1N1 vaccine safety in China; an increase in herpes zoster among the insured; and combination and monotherapy for Staphylococcus aureus foreign body osteomyelitis.
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.
Click here for the previous edition of Journal Club. 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.
Refining the Picture of Chronic HIV Infection: The Impact of Pulmonary Disease
Reviewed by Christian B. Ramers, MD, MPH
While the importance of pulmonary infections is well known to HIV providers, the burden of non-infectious pulmonary disease is less clear. Studies suggest that HIV-infected patients have higher rates of emphysema, pulmonary hypertension and lung cancer, even after controlling for tobacco exposure. A study in the February 2011 issue of the American Journal of Respiratory and Critical Care Medicine adds to this evidence, providing a broad view of the changing spectrum of pulmonary disease in a large HIV-infected cohort.
The authors analyzed data from 33,420 HIV-infected veterans and compared incidence rates of various pulmonary diseases with a carefully selected age, sex, race, ethnicity, and site-matched control group of 66,840 veterans. Groups were well matched demographically, but the HIV-infected group has significantly higher rates of hepatitis C infection, alcohol and drug abuse, smoking history, and baseline lung disease. To obtain more accurate information on tobacco exposure, a nested sample of 3,707 HIV-infected and 9,980 uninfected subjects was created, using additional survey data on self-reported tobacco use.
Overall, the incidence of COPD, lung cancer, pulmonary hypertension, and pulmonary fibrosis was higher in the HIV-infected cohort than controls throughout age groups. When adjusted for self-reported smoking history and stratified by age, the incidence rate ratios (IRR’s) for COPD (1.25, 95 percent CI 1.08-1.43), and lung cancer (2.28, 95 percent CI 1.29-4.02), remained significant in HIV-infected persons < 50 years of age, albeit at lower ratios than pulmonary infections such as bacterial pneumonia (4.24, 95 percent CI 3.55-5.05), tuberculosis (4.96, 95 percent CI 2.96-8.29), and pneumocystis (>100).
This large cohort study highlights the growing importance of chronic, non-infectious pulmonary diseases in the management of HIV patients throughout their lifespan. As more patients bring their HIV viremia under control, providers will be increasingly faced with managing chronic pulmonary conditions. Given these changes, a preventive medicine perspective including tobacco cessation will become increasingly important for those caring for HIV patients.
(Crothers et al. Am J Resp Crit Care Med. 2011 Feb 1;183(3): 388-95.)
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Extended Courses of Voriconazole, Fluoride Excess, and Periostitis in Transplant Patients
Reviewed by Christopher J. Graber, MD, MPH
Long-term voriconazole use in transplant patients may be associated with fluoride excess and periostitis, according to a report published in the March 1 issue of Clinical Infectious Diseases.
The authors initially describe a 64-year-old female heart transplant recipient who began experiencing painful bony growths on her fingers, wrists, elbows, and legs after receiving voriconazole, a fluorine-containing compound, for six months following an episode of pulmonary aspergillosis. These findings were associated with high bone turnover markers and plasma and bone fluoride levels. Within two months of replacing voriconazole with itraconazole, serum alkaline phosphatase and plasma fluoride levels had markedly decreased, as had her bony pain.
The authors subsequently measured alkaline phosphatase and fluoride levels in 10 other transplant patients who had received voriconazole for > 6 months (five with renal insufficiency and five without) and compared them to 10 control transplant patients who had not received voriconazole. All patients in the voriconazole group had elevated plasma fluoride levels versus none of the controls (p < .001), and alkaline phosphatase levels were significantly higher in the voriconazole group (p=.003). Five of the voriconazole patients had symptoms consistent with periostitis, and two had evidence of multiple exostoses. Among the four symptomatic patients who received follow-up after voriconazole discontinuation, all had improvement in bone pain and reduction in alkaline phosphatase and fluoride levels within two months.
While the exact mechanism by which long-term voriconazole use may cause fluoride excess and periostitis is unknown, this issue clearly deserves larger study, particularly since long-term voriconazole therapy has gained acceptance at many transplant centers for varying indications.
(Wermers et al. Clin Infect Dis. 2011; 52: 604–11.)
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H1N1 Vaccine Safety in China: A Large Surveillance Study
Reviewed by Rachel Simmons, MD
Despite influenza vaccination recommendations, some patients and health care workers, citing concerns about side effects, continue to choose not to get vaccinated. The results of a large, post-marketing surveillance safety study of the H1N1 vaccine in China during the 2009 pandemic, published in the Feb. 17 issue of the New England Journal of Medicine, may aid in discussions with both groups about the safety of influenza vaccination.
During the country’s massive vaccination campaign, almost 90 million people were vaccinated over six months. Targeted populations included those at higher risk of complications from influenza, teachers, health care workers, and children. Ten Chinese vaccine manufacturers produced split-virion H1N1 vaccine. Twenty-nine provinces reported adverse events to the National Immunization Information System's National Adverse Events Following Immunization Surveillance System.
Administration of 89.6 million doses of H1N1 vaccine, manufactured by 10 different Chinese companies, resulted in 8,067 adverse events, for a rate of 90 events per 1 million vaccine doses (weekly cumulative event rates ranged from 90 to 265 events per 1 million doses). Serious adverse events occurred in 711 people (7.9 events per 1 million doses). The majority of the adverse events were fever and local skin reactions; 1,050 people (11.7 events per million doses) had moderate to severe allergic reactions including urticaria and, more rarely, anaphylaxis. Eleven cases of Guillain-Barré syndrome (GBS) developed following vaccination. Eight cases were thought to be related to the vaccine, one case was felt to be a coincidental illness, and an additional two cases were unclassifiable. The total rate of GBS among all children during the vaccination campaign was actually lower compared to the same interval during the prior year (1.9 cases per million persons versus 2.7 cases per million). Ten deaths occurred after vaccination (0.1 deaths per 1 million doses). Of those 10, nine had a pre-existing health condition or were found to have a heart condition or skeletal malformation on autopsy.
Although reporting of adverse events in this prospective evaluation was via a voluntary, passive reporting system which could lead to under reporting of events, H1N1 vaccination was associated with minimal risk of adverse events.
(Liang et al. N Engl J Med. 364:638-47.)
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Increase in Herpes Zoster Among the Insured: Role of Varicella Vaccine Unclear
Reviewed by Nina Kim, MD, MSc
Herpes zoster (HZ), the clinical manifestation of varicella-zoster virus (VZV) reactivation, is a common condition and a significant cause of debility if accompanied by post-herpetic neuralgia. The varicella vaccine, introduced in the U.S. in 1995, has substantially reduced the incidence of primary VZV infection, but its impact on HZ remains unclear. Some have hypothesized that immunity is naturally boosted by periodic VZV exposure and that the reduced burden of VZV cases may result in a greater number of individuals with waning immunity and a rise in HZ. An ecological study, published in the Feb. 1 issue of Clinical Infectious Diseases, casts some doubt on this hypothesis.
Investigators from the Centers for Disease Control and Prevention examined medical claims data from 1993 (prior to the licensure of varicella vaccine) to 2006 (prior to licensure of HZ vaccine) that included more than 100 private and public insurance plans in all states. All patients with a first outpatient visit with an HZ ICD-9 code were counted as incident cases with total insurance plan enrollees in the denominator. Incidence of herpes zoster rose from 1.7 to 4.4 per 1000 persons from 1993 to 2006, an overall increase of 98 percent, a pattern observed across all age groups and in both sexes. Surprisingly, the rise was steeper in the early years predating licensure of varicella vaccine and did not differ between states with high versus low vaccine coverage. The authors controlled for secular trends in health care access and behavior, as well as immunosuppression and regional differences, and still observed these age-specific increases.
This increase in HZ incidence is a striking and robust finding in this large-scale population-based study and confirms observations in smaller cohorts. The lack of evidence implicating varicella vaccine, or even age or immunosuppression, for this trend is intriguing and highlights the gaps in our understanding of HZ susceptibility.
(Leung et. al. Clin Infect Dis. 2011; 52:332-340.)
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Combination and Monotherapy for Staphylococcus aureus Foreign Body Osteomyelitis
Reviewed by Ed Dominguez, MD
Staphylococcus aureus foreign body osteomyelitis is a common conundrum faced by clinicians. Staphylococci exploit the presence of biofilm on the foreign body to counter the effects of systemic antibiotics, often requiring a combined surgical and medical therapeutic approach. Yet there are cases where retention of the foreign body is necessary, and rifampin is often used as a second antibiotic. In the March issue of Antimicrobial Agents and Chemotherapy, investigators used an experimental animal model of methicillin-resistant Staphylococcus aureus (MRSA) foreign body osteomyelitis to study the effects of monotherapy with rifampin, and combination therapy with rifampin plus linezolid or rifampin plus vancomycin.
Using a reference strain of MRSA, investigators injected a standard inoculum into the tibias of rats, and then implanted titanium wires to act as foreign bodies. Four weeks afterwards, 61 rats were assigned to one of four study groups for treatment: no treatment; rifampin alone; rifampin plus vancomycin; and rifampin plus linezolid. Treatment was administered for 21 days. Within 12 hours of completing therapy, the animals were sacrificed, and the involved tibias were aseptically removed and processed for quantitative culture and for antibiotic resistance.
The median quantitative colony counts for all three antibiotic treatment groups were approximately 3.5 to 4 log10 colony-forming units/gram of bone less than the control group (P < 0.0001). However, there were no differences between the treatment groups. Titanium wire cultures were positive for all the control animals; treatment groups were negative in 86 percent (rifampin/linezolid) to 100 percent (rifampin/vancomycin). Rifampin resistance was 63 percent in the monotherapy group but 14 percent in the rifampin/linezolid group and 8 percent in the rifampin/vancomycin group (P ≤ 0.010).
Combination therapy with rifampin/vancomycin or rifampin/linezolid was effective in this animal model. These findings provide a good start for additional research in this area, including possible human trials.
(Vergidis et al. Antimicrob Agents and Chemother. 2011; 55(3): 1182-1186.)
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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:
Chagas Disease by Mouth
Itraconazole and Rituximab Do Not Raft Well Together
Falciparum Malaria—from Gorillas, not Chimpanzees