IDSA News - May 2011
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 how to treat a highly resistant non-tuberculosis mycobacterial infection, including how to deal with a shortage of a key antibacterial drug.
A member from Florida described a 73-year-old retired physician with refractory acute myeloid leukemia and prolonged neutropenia with fevers, who developed M. abscessus bacteremia, followed 10 days later by skin nodules that were biopsy-proven to be caused by the same organism on culture. The organism was susceptible only to amikacin, kanamycin, clofazimine, cefoxitin, imipenem, azithromycin, clarithromycin, and tigecycline.
The patient also had a severe allergy to cephalosporins and penicillin, the member wrote, along with a history of intolerance with tetracyclines taken by mouth, including very bad nausea and vomiting.
“The patient is hemodynamically stable and wants to be treated at home,” the member continued, and the patient had been on azithromycin and linezolid until testing revealed resistance to the latter. “Considering that he has been bacteremic, what would you recommend?” The member also inquired about how to acquire amikacin, given a current U.S. shortage of the drug, and whether to desensitize the patient to cefoxitin.
A respondent in Maryland shared information from the drug shortages webpage maintained by the Food and Drug Administration (FDA), which provides details about current shortages, how to report new ones, and how limited supplies of these drugs can be obtained. (See related article in this issue.) EIN is also conducting a survey of members about shortages and how they are affecting practices. A March 2011 white paper (PDF) provides additional background about the problem.
A member in Florida cited a March 2011 article in Infectious Diseases in Clinical Practice describing “a case almost exactly like your own, including the retired physician part. The patient had disseminated M. abscessus in which antibiotics alone (eight weeks of meropenem, amikacin, azithromycin, and levofloxacin and four weeks of tigecycline with other antibiotics prior to the former) were unsuccessful and only after adding interferon gamma was he cured and is still alive today, two years later.”
Another member in Florida suggested using tigecycline, in addition to ondansetron to help with nausea. The member was treating a patient with a deep tissue infection secondary to M. abscessus using this approach. “My patient has systemic mastocytosis and significant allergy history,” the member wrote, and so far, the patient was tolerating the treatment.
“We successfully treated a similar case with a combination of amikacin, tigecycline, clarithromycin, and cefoxitin,” a New York EIN member reported. “The cefoxitin was probably superfluous, but I would use at least three meds.”
Given the patient’s beta-lactam allergy, a respondent in Oregon agreed with the original poster’s suggested therapy, and advised a regimen of tigecycline 50 mg daily, amikacin 10 mg/kg TIW, and azithromycin 250 mg daily. “Eventually you will need to drop his parenteral therapy and mop up for several months with an oral regimen of two to three drugs,” the member continued. “Imipenem is another good option, and he might not cross-react. I would leave this to try for later if needed.”
A Colorado respondent suggested using imipenem/cilastatin, amikacin, and azithromycin. “I would apply for clofazimine through the FDA as well,” the member added, referencing a drug that is not FDA approved but which may be obtained under FDA’s compassionate use process pending approval by the relevant institution’s Institutional Review Board (IRB).
The Florida member who posted in the initial question later reported that a supply of amikacin had been allocated, the patient remained on azithromycin, and the institution was “in process to get the clofazimine through the IRB and FDA.”
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.
IDSA provides E&M coding resources
Both Medicare payments to ID physicians and patient volumes increased in 2010, according to claims data from the Centers for Medicare and Medicare Services (CMS), a trend seen across other specialties. IDSA’s analysis of the data suggests that ID specialists are being paid at least as much as they were before CMS began eliminating payments for consultation codes.
Analysis of the claims data suggest that these payment increases cannot be attributed to increases in patient volume alone. It appears ID physicians have been able to successfully “crosswalk” the inpatient and outpatient consultation codes to other Evaluation and Management (E&M) service codes. See the “Frequently Asked Questions” (PDF) document for codes the Society recommends for this process and for additional information. (You must be logged in to access this link.) Members can also submit specific coding questions to IDSA’s “Ask the Coder” e-mail portal (see related article).
It is important to ensure that the E&M coding level you select is supported by your documentation and your record of medical decision making. Failure to do so could lead to Medicare audits for the individual practitioner and for the ID specialty in general. A pattern of inappropriate coding could be fodder for Medicare’s Recovery Audit Contractors (RAC), who have begun to look at E&M coding patterns following Medicare’s decision to eliminate payments for consultations.
Medicare’s RAC program, which began in 2009, is designed to identify improper Medicare payments and recover overpayments or disburse underpayments. Information to help ID practices understand and navigate the RAC claims review process is available on IDSA’s website. (You must be logged in to access this link.)
The Society will continue to monitor Medicare payment data and share important information with IDSA members. IDSA also continues to work to ensure that ID physicians are paid appropriately for their work and that their value to the health care system is recognized.
A key deadline, with a penalty attached, is approaching for eligible providers participating in Medicare’s electronic prescribing (eRx) incentive program.
Eligible physicians must report at least 10 e-prescriptions on their Medicare claims by June 30 to avoid a 1 percent Medicare payment penalty starting in 2012. Physicians who do not generate at least 10 percent of their total Medicare charges from the applicable outpatient Evaluation and Management (E&M) service codes included in the eRx measure’s denominator (or do not have at least 100 Medicare cases containing the applicable denominator codes) will not be subject to the 2012 payment penalty nor will be they be eligible for the 2011 payment incentive.
To be eligible for the +1 percent eRx incentive payment in 2011, physicians must successfully e-prescribe at least 25 times during the calendar year. But be careful: Physicians who are eligible for the 2011 payment incentive could have it taken away for failure to report the 10 e-prescriptions on their Medicare claims by June 30 that are necessary to avoid the 2012 payment penalty. IDSA’s “Quality Improvement Resources and Tools” webpage has additional information about the eRx program and how to participate, including:
Note: In late May, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that would make significant changes to the eRx program by adding more exemption categories so that physicians are not unfairly penalized for failing to meet the program’s requirements. These would include allowing exemptions for physicians who:
Until these proposed changes are final, however, IDSA strongly urges eligible physicians to comply with current eRx requirements. The CMS proposed rule is open for public comment online until July 25.
Other eRx resources include the CMS website and a CMS help desk, reachable at 866-288-8912 or Qnetsupport@sdps.org, 7 a.m. to 7 p.m. central time, Monday through Friday. For information about additional Medicare incentive programs, see IDSA’s website. A schedule of Medicare payment incentives and penalties is also available online.
IDSA has learned that some ID practices outfit Medicare patients with preprogrammed portable pumps to administer antibiotic therapy, using current procedural terminology (CPT) code 96521. Use of this code may be a legitimate way that some practices provide outpatient therapy to Medicare beneficiaries, given the Centers for Medicare and Medicaid Services’ (CMS) lack of coverage for home infusion services.
However, IDSA has received reports that while some Medicare Administrative Contractors pay for intravenous antibiotic therapy services billed in this way, others are denying payment.
Last year, the Society sought clarification from the Medicare contactor that oversees the National Correct Coding Initiative (NCCI) on how these services should be billed but did not receive a definitive answer on the issue. As this remains a gray area under current Medicare payment policy, IDSA recommends caution in using the 96521 code for IV antibiotic therapy.
It is important to note that a denial of payment from Medicare for a service associated with this code could lead to not only the recovery of payment for that service and associated medication “J” codes, but also for past services billed and medications provided.
IDSA has long championed extending coverage of home infusion therapy to Medicare beneficiaries and will continue to monitor this issue. The Society and other advocates believe that these services reduce hospital stays, decrease costs, and keep patients out of the hospital, putting them at less risk for hospital-acquired infections. See IDSA’s website for more information.
“I remember reading it very clearly. It was the first time in my medical career I actually got goose pimples. I no longer dismissed it as a curiosity. There was something very wrong here,” said Anthony S. Fauci, MD, FIDSA, director of the National Institute of Allergy and Infectious Diseases, recalling the first reports of what would become known as HIV/AIDS in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report in 1981.
Dr. Fauci’s comments come from a recent interview with the Center for Global Health Policy’s Science Speaks blog, part of a series commemorating the 30th anniversary of AIDS on June 5. Dr. Fauci discussed how he first learned of the disease, his surprise at President George W. Bush’s commitment to combating AIDS globally, and the continuing unmet needs. Stay tuned for upcoming interviews in the series, including one with John Bartlett, MD, FIDSA, a past president of IDSA; long-time AIDS activist Gregg Gonsalves; and others.
Center staff will also be attending and blogging next month from the United Nations (UN) High-Level Meeting on AIDS, likely to be the last UN meeting on AIDS, in New York City, June 8-10. The meeting’s goal is to develop a declaration that will speak to progress against HIV/AIDS and unmet need in reaching universal access goals. Check out Science Speaks for the latest news from New York.
Study results announced earlier this month unequivocally link early antiretroviral therapy (ART) for HIV-infected people with a dramatically reduced chance of transmitting the virus to an uninfected partner, as well as a decreased risk of contracting tuberculosis (TB). HIV-infected men and women who were treated when their immune systems were relatively healthy were 96.3 percent less likely to transmit HIV to their un-infected partners than those whose treatment was delayed. In a joint press release (PDF), the Center for Global Health Policy and HIVMA underscored the importance of the findings and the implications for HIV treatment and prevention.
A review board halted the randomized, controlled study, a $73 million endeavor set to run until 2015, due to clear evidence of the protective effect of starting HIV therapy early. The National Institute of Allergy and Infectious Diseases (NIAID)-sponsored clinical trial, HPTN 052, was led by study chair Myron Cohen, MD, FIDSA, a member of the Center’s Scientific Advisory Committee and of HIVMA, who is also director of the Institute for Global Health and Infectious Diseases at the University of North Carolina, Chapel Hill. “We think these results will be important to help improve both HIV treatment and prevention,” Dr. Cohen said in an NIAID press release.
For more about the results of the trial, which involved more than 1,700 HIV-discordant couples at 13 sites in Botswana, Brazil, India, Kenya, Malawi, South Africa, Thailand, the United States, and Zimbabwe, visit Science Speaks, the Center’s blog.
Global AIDS experts hand-delivered a letter (PDF) from 127 Massachusetts-based medical, nursing and public health professionals to Sen. Scott Brown (R-MA) in Boston in early May, outlining the importance and impact of global health programs and urging him to stand up in support of these crucial programs.
Dan Kuritzkes, MD, FIDSA; Joia Mukherjee, MD, MPH; and Rochelle Walensky, MD, MPH, FIDSA, highlighted the impact and ongoing importance of U.S. investment in global health and encouraged Sen. Brown to work to ensure that global health programs remain a U.S. priority in a meeting in the senator’s office. Sen. Brown acknowledged the value of these programs but made it clear that federal deficit reduction measures were paramount and that global health programs were likely to sustain funding cuts as the fiscal year 2012 budget process moves forward.
In other advocacy news, IDSA member Donald Murphey, MD, met with Rep. Kay Granger (R-TX) in Fort Worth this month to discuss the global HIV and tuberculosis (TB) epidemics, including the spread of TB to the United States through immigrants and visitors. The congresswoman was particularly receptive to protecting women and children in the developing world from HIV and continuing to fund U.S. programs for HIV and TB care in resource-limited countries. Congresswoman Granger chairs the House subcommittee charged with determining funding levels for global health and foreign assistance programs annually.
Next month, IDSA member Kathleen Gensheimer, MD, MPH, FIDSA, will meet with Sen. Susan Collins (R-ME) in Portland, Maine, to discuss the value of U.S. investment in global infectious diseases programs and related biomedical research. Members wishing to advocate for global health programs are encouraged to contact the Center to learn more about how you can become involved.
With tick season upon us in many parts of the country, IDSA is working to promote awareness about Lyme disease.
To help clinicians and other health professionals recognize and diagnose Lyme disease, and treat it promptly and effectively, the Society offers a free, online CME course. The course consists of a series of case studies and is based on IDSA’s clinical practice guidelines, with support through an educational grant from the Centers for Disease Control and Prevention. See lymecourse.idsociety.org for more information.
To raise awareness in the lay public, IDSA developed a list of “Top 10 Facts about Lyme Disease” that includes information on prevention, diagnosis, and treatment. See www.idsociety.org/lymedisease.htm under “Fact Sheets.”
In all of IDSA’s outreach, the Society continues to stress its concern that patients who believe they may have Lyme disease receive an appropriate diagnosis and the best possible care, with treatment that is safe, effective, and supported by the scientific evidence.
That’s particularly important in state legislatures, many of which have considered bills that sanction the use or mandate insurance coverage of prolonged antibiotic therapy to treat Lyme disease, despite evidence that such therapy is ineffective and potentially harmful. Such laws have been enacted in Massachusetts, Rhode Island, Connecticut, and California. Similar bills have surfaced in other states, including New Hampshire, New Jersey, New York, Oregon, Pennsylvania, Vermont, Virginia, and West Virginia.
Other states, such as Massachusetts, are considering legislation that would establish commissions or task forces on Lyme disease; such a task force is holding hearings in Virginia. A bill in Texas would provide educational resources on appropriate treatments for Lyme disease.
IDSA frequently weighs in on state Lyme bills, often working with state and local ID societies and other groups. For more information, see IDSA’s State and Regional Societies Legislative Map and Advocacy Resources.
A new campaign launched earlier this month aims to raise awareness among mothers with young children about the need to preserve the effectiveness of antibiotics in part by limiting their use in animal agriculture. Developed by the Pew Campaign on Human Health and Industrial Farming, “Moms for Antibiotic Awareness” gives parents tools they can use to contact policymakers, retailers, and others about this public health issue. This includes urging lawmakers to pass the Preservation of Antibiotics for Medical Treatment Act (PAMTA), which would phase out the non-judicious use of important antibiotics in animal agriculture.
In an online survey commissioned by Pew, of 804 mothers who are registered voters and have children aged 16 or younger, 80 percent said they were “concerned” about giving antibiotics to animals that are being produced for meat and poultry, and 42 percent said they were “very concerned” about the practice. More than three-quarters of those polled favored—and more than half strongly favored—federal regulations that would eliminate the use of antibiotics for growth promotion in food animals and place additional requirements on the use, and the reporting of use, of antibiotics on the farm. The results are available online (PDF).
IDSA, also a supporter of PAMTA, has worked with Pew on this issue, which remains a concern. Last year, the Society testified before Congress, noting the extensive evidence demonstrating that antibiotic use in food animals contributes to the spread of resistant bacteria to humans and leads to drug-resistant infections (see July/Aug. 2010 IDSA News). IDSA also weighed in on draft guidance from the Food and Drug Administration (FDA) and called for FDA to issue regulations to further limit inappropriate uses of these critical medicines in food animals (see Sept. 2010 IDSA News).
IDSA, HIVMA, and the Center for Global Health Policy recently weighed in with lawmakers about federal funding for the 2012 fiscal year (FY) for infectious diseases, HIV/AIDS, and global health programs addressing HIV and tuberculosis (TB). In congressional testimony (PDF), IDSA supported strong funding levels for ID efforts within the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the Biomedical Advanced Research and Development Authority, particularly on antibiotic resistance. IDSA called for funding that would:
HIVMA called on lawmakers to increase funding for the Ryan White program, including Part C, which funds comprehensive HIV care and treatment, and research programs at NIH, including the Office of AIDS Research, to ensure that vital research continues. In its testimony (PDF), the Association urged lawmakers to support, at a minimum, the increased funding levels proposed by President Obama in his FY2012 budget. HIVMA also urged increased funding for HIV prevention and surveillance, and viral hepatitis and TB prevention efforts at CDC.
The Center’s testimony (PDF) noted the great progress—both humanitarian and diplomatic—achieved by the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The Center underscored the urgent need to sustain U.S. funding for these and related programs, which provide lifelines for millions of people in some of the poorest places on earth, and for continued research on HIV/AIDS and TB.
Carol D. Hamilton, MD, MHS, FIDSA, has been selected to represent Family Health International (FHI) in the TB/HIV Core Working Group of the World Health Organization’s Stop TB Partnership. Dr. Hamilton is senior scientist at FHI, which implements HIV and other global health and development programs in developing countries around the world, and is professor of medicine at Duke University. She currently serves as co-chair of the Center for Global Health Policy’s Scientific Advisory Committee.
Martin S. Hirsch, MD, FIDSA, received the International Antiviral Society-USA (IAS-USA) Lifetime of Leadership Award, an award that recognizes individuals who have made significant and lasting contributions to the field of HIV medicine through scientific and academic leadership, as well as physician education and training, to improve the treatment and care for people infected with HIV or other viral infections. Dr. Hirsch is currently professor of medicine at Harvard Medical School. He is also editor-in-chief of The Journal of Infectious Diseases, a position he has held since 2003.
Are you a member on the move? Do you know someone who is? Contact Stephanie Cox at firstname.lastname@example.org so that we can announce it to our membership.
Feucht, Eric, MD
Gildow, Jeffrey, PharmD
Klein, Nicola, MD, PhD
Mangiola, Massimo, PhD
Popp, Adrian, MD
Rijnbrand, Cornelis, PhD
Savard, Patrice, MD, MSc
Tramontana, Adrian, MBBS
Vetticaden, Santosh, MD, PhD
Alves, Maysa, MD
Frech, Sarah, DVM
Hagiya, Hideharu, MD
Jan, Verhaegen, PhD
Kharbosh, Abdullah, RPh
Kokotis, Kathy, MBA
Lambe, Mary, MD
Lindsey, Deidre, PharmD
Mack, Benjamin, MD
Nasim, Jawed, MD
Ng, Tak-Keung, MBBS
Parimon, Tanyalak, MD
Quintero, Julio, MA
Saba, Rabin, MD
Schlamm, Haran, MD
Schulz, Thomas, MBBS
Seija, Veronica, MD
Tipple, Margaret, MD
Anderson, Margot, MD
Burns, Matthew, MD
Dimondi, Vincent, PharmD
Hammond, Karsten, MD
Huppler, Anna, MD
Korpe, Poonum, MD
McBride, Joseph, MD
Mindru, Cezarina, MD
Mpieri, Richard, MD
Norton, Brianna, DO
Schwenk, Hayden, MD
Vallieres, Emilie, MD
Vivekanandan, Renuga, MD
Wagner, Gabriel, MD
Zakhour, Ramia, MD
Connect with IDSA through its growing collection of social networking tools. You can follow IDSA, HIVMA, and the Center for Global Health Policy on Twitter and Facebook for the latest in ID, HIV/AIDS, and global health news, along with important organization updates. Find colleagues and correspond online through these services:
We hope that members will find these tools valuable in collaborating with their colleagues and with IDSA. If you have questions or comments, please e-mail email@example.com.
Have tough coding questions? Picking the right code level can be difficult due to the complicated rules governing inpatient consultations, subsequent hospital visits, prolonged serves, and incident-to billing (see related article). If IDSA’s many coding resources aren’t enough, “Ask the Coder” can help. This online resource was developed to assist IDSA members and their office staff. If you have a question about evaluation and management (E&M) or current procedural terminology (CPT) service codes, take advantage of this member benefit by filling out the form on the “Ask the Coder” portal, and your question will be sent to a certified professional coder for a response.
The training, experience, and career paths of infectious diseases specialists cover a unique cross-section of medicine. It’s not surprising, then, that IDSA’s membership includes a diverse group of professionals performing an impressive range of clinical and public health work, research, scholarship, and teaching.
The training, experience, and career paths of infectious diseases specialists cover a unique cross-section of medicine. It’s not surprising, then, that IDSA’s membership includes a diverse group of professionals performing an impressive range of clinical and public health work, research, scholarship, and teaching that spans generational lines and international borders.
One of the Society’s challenges is ensuring that IDSA draws from this great diversity as we strive to meet the needs of members, whether they are clinicians, educators, or researchers in academic settings, practicing clinicians who are on the frontline providing direct patient care, or ID specialists working in other settings. IDSA’s leadership is committed to this task, a critical one for a specialty as diverse as ours.
IDSA’s membership statistics reveal the broad range of members’ work. Fifty-four percent of members report patient care as their primary professional activity, followed by clinical research (14 percent), basic research (8 percent), and teaching (7 percent). Members’ secondary professional activities include teaching (28 percent), patient care (20 percent), clinical research (19 percent), and hospital epidemiology (10 percent), among others.
This work happens in many settings—hospitals and clinics, universities and medical schools, private practices, and industry labs—across the United States and in nearly 100 other countries on six continents.
One of the ways IDSA works to reflect this diversity is through the Annual Meeting, the premier meeting in the ID field. The Annual Meeting Program Committee, currently led by Barbara D. Alexander, MD, FIDSA, works each year to develop an in-depth and diverse program with the latest updates on ID research, clinical advances, HIV/AIDS, global health issues, and more. The slate of speakers and presenters helps meet this goal, representing a spectrum of backgrounds, expertise, and geography, hailing from more than 20 different countries outside the United States and Canada at the 2010 meeting in Vancouver.
Annual Meeting attendance in recent years shows a similar diversity, with a range of physicians, scientists, and other health care professionals involved in research, patient care, public health, disease prevention, and education. (For important updates about the 49th Annual Meeting of IDSA, Oct. 20-23 in Boston, see the related article in this issue.)
Another way IDSA strives to reflect its wide-ranging membership is through its nearly 30 committees, task forces and work groups, which are comprised of IDSA member volunteers. These groups play an instrumental role in the Society’s work in areas such as education, clinical affairs, practice guideline development, and public health issues, including pandemic influenza preparedness and response and antimicrobial resistance. I am grateful to these volunteers for their commitment to these efforts.
IDSA’s membership also includes health care professionals dedicated to the field of HIV/AIDS. Nested within the Society, the HIV Medicine Association (HIVMA) marks its 10th year in 2011 promoting quality in and access to HIV care founded upon the best science. More than 3,700 of IDSA’s roughly 9,300 members are also members of HIVMA. In recognition of the great needs in global health, the Center for Global Health Policy was created in 2008 to support and promote U.S. efforts to combat HIV/AIDS and tuberculosis around the world, drawing on the expertise of many Society members who work in the developing world. (See March 2011 IDSA News.)
IDSA also recognizes the need to reflect the demographic diversity of members, including women, minorities, and international representatives. Current membership statistics indicate that, among members who chose to provide such information, 36 percent are women, 17 percent are Asian, 4 percent are African American, and 7 percent are Hispanic/Latino. The Society has made considerable progress in recent years; however, we clearly have more work to do to diversify Society leadership. We know that we must also do a better job making sure that all of the Society’s members—IDSA’s greatest asset—are engaged and that their contributions are valued and appropriately recognized. The Society’s leadership is committed to this effort.
Don’t miss the pre-eminent meeting in infectious diseases—IDSA’s 49th Annual Meeting, Oct. 20-23, 2011, in Boston.
Don’t miss the pre-eminent meeting in infectious diseases—IDSA’s 49th Annual Meeting, Oct. 20-23, 2011, in Boston. Learn more at www.idsa2011.org, our newly redesigned website.
For a complete listing of sessions and learning objectives, see the Preliminary Program (PDF) or check out the Interactive Program Planner. The Interactive Program Planner allows you to search the program by session titles, speakers, date and time, or session tracks to create your own customized schedule. Abstracts will be online in the fall.
A special Presidential Plenary Session on Sunday, Oct. 23, from 9:15 to 11:45 a.m., will feature a talk by IDSA President James M. Hughes, MD, FIDSA, and three lectures on cholera by Stephen J. Calderwood, MD, FIDSA, of Massachusetts General Hospital; Jean Pape, MD, of GHESKIO; and Scott F. Dowell, MD, MPH, of the Centers for Disease Control and Prevention. Please note the timing when booking hotel and flight reservations.
IDSA or HIVMA members interested in hosting affiliated events like alumni receptions or allied-society meetings may now apply online.
Register now to take advantage of the best deals on registration and housing.
For a virtual tour to help you navigate the new website, see this related article.
Late Breaker Abstract Submission Site Opens.........Friday, May 27
Late Breaker Abstract Submission Site Closes........Friday, August 12*
*5:00 p.m. Eastern Daylight Time
Early Registration Deadline....................Friday, July 29
Regular Registration Deadline.................Friday, September 23
49th Annual Meeting of IDSA..................Thursday, October 20 – Sunday, October 23
IDSA’s new Annual Meeting website gives IDSA and HIVMA members quick and easy access to all the features of the Annual Meeting in Boston.
IDSA’s new Annual Meeting website—www.idsa2011.org—gives IDSA and HIVMA members quick and easy access to all the features of the Annual Meeting in Boston.
To find information for attendees, simply click the button at the top right. The bar down the right-hand side also includes quick links to our program information, our abstract submission process, and the schedule-at-a-glance. Any new resources will be posted under “Latest Updates”—so check back often!
To find IDSA, you can connect to us via our Facebook, Twitter, or LinkedIn pages. Or, click “Contact Us,” a link which can always be found at the bottom of the page, to contact the meetings department directly.
Interested in hosting an affiliated event, like an alumni reception or an allied-society meeting? Register for an Affiliated Event at the bottom of each page on the Annual Meeting site.
As we get closer to October 20th, the IDSA Program Guide will get more in-depth. We’ve placed up-to-date program information on one convenient page. The Interactive Program Planner—which is updated daily—allows you to search for speakers, presentation titles, and session titles. In early October, you’ll also be able to search for abstracts. Quick access to the Interactive Program Planner tool and other program information is available from any page on the site: just click “Scientific Program” in the upper right-hand corner.
The left-hand menu features links to the most recent continuing education credit info and our meeting policies. These areas will be updated periodically, so stay tuned.
IDSA is excited about the features of this year’s meeting. We’ll be highlighting some of our showcase sessions and special panels in the Featured Session area.
We welcome your feedback on the new site!
This month, studies investigating: the impact of vancomycin exposure on patients with MRSA bacteremia, antibiotic resistance in the environment, the prevention of health care-associated MRSA infections, and alternate hepatitis B vaccine strategies for HIV-infected patients.
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.
The 2009 guidelines for vancomycin therapeutic monitoring suggest achieving trough concentrations of 15-20 mcg/ml when treating serious infections due to methicillin-resistant Staphylococcus aureus (MRSA) isolates, especially those with vancomycin minimum inhibitory concentrations (MICs) > 1 mcg/ml. This recommendation was based on mathematical modeling, animal data and limited human evidence. (Also see IDSA’s 2011 practice guidelines for MRSA treatment.)
A study published in the April 15 issue of Clinical Infectious Diseases provides more clinical data in support of this practice. In this retrospective case series, 320 patients with MRSA bacteremia were studied for risk factors for vancomycin failure (defined as death at 30 days, blood culture positivity at seven days or more, and persistent signs and symptoms of bacteremia at the end of therapy).
Perhaps the authors’ most striking finding was an overall composite failure rate of 52.5 percent. Statistically significant independent risk factors for failure included infective endocarditis (adjusted odds ratio 4.6), nosocomial-acquired infection (AOR 2.2), an initial vancomycin trough < 15 mg/L (AOR 2.0), and a vancomycin MIC > 1 (AOR 1.5). There was also support for the guideline position that patients whose area under the serum drug concentration-versus-time curve (AUC)/MIC ratio is less than 400 will be more likely to suffer a clinical failure. In this paper, the authors’ analysis found higher failure rates among those whose AUC/MIC was < 421 (failure rate 61 percent vs. 49 percent, p = 0.38).
In addition to confirming the significant morbidity and mortality associated with MRSA bacteremia, this study provides additional evidence to support recommendations both to take into account MRSA vancomycin MICs when treating bacteremia and to dose vancomycin to achieve serum trough levels of 15-20 mg/L, especially in MRSA endocarditis.
Two studies, one in the May issue of Lancet Infectious Diseases and one in the May 15 issue of Clinical Infectious Diseases, highlight the growing problem of antimicrobial resistance in bacteria that reside outside of the human host.
The first study addresses the startling emergence of the New Delhi metallo-β-lactamase 1 (NDM-1) carbapenemase initially described in Enterobacteriaceae among patients in or recently returned from India and Pakistan (see October 2010 IDSA Journal Club). To follow up on the finding that some patients from whom bacteria carrying the NDM-1 gene had no health care exposure, this study sampled seepage water (i.e., water pools in streets and rivulets) and tap water from 171 and 50 sites, respectively, within a 12 km radius of central New Delhi for the presence of the NDM-1 gene by PCR and DNA probing.
The NDM-1 gene was found in 51 (30 percent) of the seepage samples and in two (4 percent) of the tap water samples. Bacteria with the NDM-1 gene could be cultivated from 12 seepage samples and two tap water samples, not only including Enterobacteriaceae but other species not previously described as NDM-1-positive, including Shigella boydii, Vibrio cholerae, Aeromonas, and several nonfermenters (including multiple Pseudomonas species) where the gene appeared to be less stable.
The second study sampled a total of 136 retail beef, chicken, pork, and turkey products from 26 grocery stores in Chicago; Washington, D.C.; Fort Lauderdale, Fla.; Los Angeles; and Flagstaff, Ariz. for the presence of S. aureus. Seventy-nine unique isolates were found in 64 samples; turkey (20/26, 77 percent) was mostly frequently contaminated. While oxacillin resistance was found in only three isolates, tetracycline resistance was widespread (63 percent overall), particularly among isolates from turkey and pork. Ciprofloxacin resistance was frequent among isolates from chicken (61 percent). Intermediate resistance to vancomycin was found in one isolate from pork.
These articles provide stark reminders that antimicrobial resistance can be found not only in bacteria that colonize and infect us but also among bacteria in the water we drink and the food we eat. The findings strongly suggest that the effort to curb the spread of antimicrobial resistance should be expanded past the human host.
How to reduce health care-associated methicillin-resistant Staphylococcus aureus (MRSA) infections remains a challenge without a clear answer. By using an “MRSA bundle,” a Veterans Affairs (VA) center in Pittsburgh reduced these infections by 60 percent on a surgical ward and by 75 percent in a surgical ICU in a four-year pilot study, ending in 2007. The bundle included universal nasal surveillance, hand hygiene, contact precautions for patients colonized or infected with MRSA, and a change in infection control philosophy that places responsibility on all personnel with patient contact. A report in the April 14 issue of The New England Journal of Medicine describes the results of a much larger study conducted after this bundle was subsequently implemented at 150 VA centers nationwide.
During the study period, from 2007 to 2010, 1.9 million patient admissions/discharges/transfers occurred from ICUs and non-ICUs, accounting for 8.3 million patient-days. The mean age was 62.6 years, and 95 percent of the patients were men. By the end of the study, admission screening increased from 82 percent to 96 percent, and transfer/discharge screening increased from 72 percent to 93 percent. The mean monthly prevalence of colonization or infection upon admission was 13.6 percent. MRSA prevalence was greater in non-ICU patients than in ICU patients (15.7 percent vs. 14.5 percent, P<0.001).
In ICUs, the MRSA bundle decreased the rates of health care-associated infections by 62 percent, from 1.64 per 1,000 patient-days to 0.62 per 1,000 patient-days (P<0.001). The rates in non-ICUs fell 45 percent, from 0.47 per 1,000 patient-days to 0.26 per 1,000 patient-days (P<0.001). Furthermore, the rates of MRSA transmission fell in ICUs by 17 percent and in non-ICUs by 21 percent (P<0.001 for both). Finally, investigators observed declines in the rates of bloodstream infections (including catheter-associated), pneumonia (nosocomial and ventilator-associated), urinary tract infections, and wound infections. It is unclear which elements of the bundle were most effective and whether pre-existing infection control initiatives contributed to the observed improvement. Nonetheless, the results suggest a multifaceted approach is warranted and perhaps efficacious.
Chronic hepatitis B infection is more common in HIV-infected individuals than the general public and greatly increases the risk of liver-related mortality in these patients. Unfortunately, vaccination response rates are diminished in this population, especially in those with a low CD4 nadir, ongoing HIV replication, and older age. Several strategies have been employed to address these lower rates, including higher vaccine doses, alternate schedules, intradermal route for administration, and adjuvant use. A study in the April 13, 2011 issue of The Journal of the American Medical Association compares two of these strategies with the standard three-dose schedule in a randomized controlled trial.
Investigators enrolled and randomized 437 HIV-infected patients without hepatitis B immunity to receive the standard three shot (20 mcg) hepatitis B vaccine series (IM20x3, n = 145), a double-dose (40 mcg) four-shot series (IM40x4, n = 148), or a lower-dose (4 mcg) four-shot intradermal series (ID4x4, n = 144). Patients with CD4 counts < 200 cells/mm3 were excluded, as were those co-infected with hepatitis C. The main outcomes were the percentage of responders in each group, defined by the presence of > 10 mIU/mL of anti-HBs antibody at week 28 of the study.
A significantly higher percentage of patients in the double-dose group (IM40x4, 82 percent) and the intradermal group (ID4x4, 77 percent) developed protective antibodies than did the standard group (IM20x3 65 percent, p < 0.001 and p = 0.02, respectively). Female sex, lower age, no active smoking, higher baseline CD4 count, and undetectable viral load were associated with response at 28 weeks. Adjusted odds ratios for response rates compared to the standard IM20x3 regimen were 3.58 (95 percent CI 1.92-6.67) for the IM40x4 schedule and 2.09 (95 percent CI 1.18-3.68) for the ID4x4 schedule.
This study suggests two alternatives that could achieve higher rates of seroconversion in HIV-infected patients. Importantly, this trial did not address the notoriously difficult subgroup of patients with CD4 < 200. Also, of particular relevance to resource-limited settings, the intradermal route may achieve acceptably high protection rates using less reagent, allowing greater scale-up of this effective prevention tool. Given these results, future guidelines should consider these alternate strategies.