IDSA News - June 2011
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IDSA Practice Guideline Translations Now Online

All of IDSA’s translated practice guidelines are now available online. Find foreign language versions of popular practice guidelines, including the two newest: Use of Antimicrobial Agents in Neutropenic Patients with Cancer (Turkish) and Management of Patients with Infections Caused by Methicillin-Resistant Staphylococcus Aureus (Italian). Download them now from the IDSA site.

For questions and comments regarding IDSA’s practice guideline translations, please contact Jen Padberg at jpadberg@idsociety.org.

EIN Update: Syphilitic Scleritis and Screening Dilemmas for Syphilis

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 ocular manifestations of syphilis and issues raised by new screening tests.

A member in Texas described a 60-year-old woman with six months of scleritis who was positive for syphilis by Treponema pallidum particle agglutination assay (TPPA) but negative by the rapid plasma reagin (RPR) test. The patient related a history of being treated in the 1970s for a sexually transmitted disease (STD) acquired from her husband, but she had no records and did not recall what the treatment was other than an injection. The woman’s current cerebrospinal fluid (CSF) exam was negative.

“Should she be treated for neurosyphilis or just for late latent syphilis?” the member asked.

The member noted that the Centers for Disease Control and Prevention (CDC), in its  2010 STD treatment guidelines, advises “syphilitic uveitis or other ocular manifestations . . . should be managed according to the treatment recommendations for neurosyphilis. Patients who have neurosyphilis or syphilitic eye disease (e.g., uveitis, neuroretinitis, and optic neuritis) should be treated with the recommended regimens for neurosyphilis.”

Given this recommendation, “Does scleritis with a positive TPPA equate to uveitis, neuroretinitis, or optic neuritis?” the member asked.

It is rare to have active syphilis, including late syphilis, with a negative nontreponemal test, such as RPR or a venereal disease research laboratory (VDRL) test, an EIN member in Washington state responded. “I’m not sufficiently attuned to ‘scleritis’ in general or in association with syphilis, and have not heard it described as a manifestation of syphilis,” the member continued. Uveitis is usually associated with early syphilis, not tertiary — and usually with a high RPR/VDRL titer.

“My bet is that the patient’s scleritis and reactive TPPA are unrelated,” wrote the member, who suggested treating the patient “with benzathine penicillin as for late latent syphilis. If the scleritis resolves, it would tend to support syphilis as a cause, and nonresponse probably would rule it out.”

A respondent in Texas noted similar issues. The new automated screens that have replaced RPR have raised questions, “as we often have patients with symptoms that fit, often barely, within the very wide range of clinical manifestations of syphilis, but have a negative RPR and positive ‘new screen.’  I have yet to see a convincing case of neurosyphilis (with diagnostic CSF findings) in this group, including those with scleritis or uveitis, but have treated several at the insistence of ophthalmology.”

“My inclination, with normal CSF (or in those where there is no reason to check), is to treat these as latent,” the member wrote.

Given the possibility that the scleritis is due to syphilis, an EIN member in Oregon favored re-treatment for latent syphilis as well. “If she has no evidence of intraocular inflammation and a negative CSF examination, then I would not classify her as neurosyphilis.”

The Washington state member also noted the challenges raised by newer screening tests for syphilis, which have complicated long-established diagnostic and treatment practice.

“The past few years have seen a scramble by CDC and other public health agencies to figure out the impacts and give guidance on use,” noted the member, who referenced a “superb review” published in the Sept. 15, 2010, issue of Clinical Infectious Diseases. The results of an EIN survey, conducted in late 2008 and published in Clinical Infectious Diseases, also address some of the relevant screening issues.


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.

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.

Report Details Participation and Payment Amounts for CMS Incentive Programs

A recent Centers for Medicare and Medicaid Services (CMS) report shows how many physicians, including ID specialists, participated in two key CMS incentive payment programs in 2009. The report also sheds light on the amount of incentive payments physicians and practices received for successfully meeting the programs’ requirements.

CMS paid out approximately $382 million in incentive payments in 2009 through the Physician Quality Reporting System (PQRS) and the Electronic Prescribing (eRx) Incentive Program, compared to only $92 million in total incentive payments in 2008, according to the report. CMS attributed the more than two-fold increase to the expanded number of quality measures, more reporting options, and the decision to increase the incentive amounts from 1.5 percent to 2.0 percent of eligible professionals’ (EPs) total Medicare charges.

Nearly 120,000 physicians and other EPs in 12,647 practices received PQRS incentive payments totaling more than $234 million. While EPs who reported on PQRS measures still accounted for a relatively small proportion of program participants (33,055), more than 90 percent of these individuals earned incentive payments. Only 50 percent of the 185,154 EPs who chose the claims-based reporting option earned incentive payments. Ultimately, 57 percent of PQRS participants received incentive payments (averaging $1,956) for the 2009 reporting period, representing about 9 percent of the total eligible professionals.  Of the 5,141 ID physicians who were eligible to report on PQRS measures in 2009, 605 (about 12 percent) attempted to do so, and 373 of these earned PQRS incentive payments averaging $2,185. 

Approximately 48,000 EPs (54 percent of EPs who participated), representing about 10,000 practices, received $148 million in eRx incentive payments in 2009. The average payment was just over $3,000 per eligible professional and about $14,000 per practice, CMS reported. Of the 4,364 ID physicians who were eligible to report on the e-prescribing measure in 2009, 524 (approximately 12 percent) attempted to do so, and 185 of these earned eRx incentive payments averaging $3,155. The full CMS report is available in the "Downloads" section of the “Overview” page on the PRQS web page, at http://www.cms.gov/PQRS/.

IDSA has concerns that many ID physicians who may be considered EPs under the eRx Incentive Program may not be able to meet the reporting thresholds due to their practice characteristics. See the May 2011 IDSA News and IDSA’s website for information on claiming an exemption from the eRx requirements. IDSA also recently submitted comments (PDF) to CMS related to this issue.

 

 

 

UN AIDS Declaration Sets Ambitious Goals, Falls Short in Some Areas

Earlier this month, the United Nations (UN) General Assembly set several ambitious HIV/AIDS goals—including putting 15 million people on lifesaving antiretroviral therapy in low- and middle-income countries by 2015 (about twice the number currently on therapy) and halving the number of tuberculosis-related deaths among people with HIV. But advocates also noted some weaknesses in the UN declaration, adopted following the UN High-Level Meeting on AIDS in New York City, related to human rights and other issues.

“The declaration does call for member states to reduce transmission of HIV among injecting drug users by 50 percent by 2015, but UNAIDS is already on record calling for a reduction to zero infections, so this seems to be a step back,” Zoe Hudson, senior policy analyst at the Open Society Policy Center, told Science Speaks, the blog of the Center for Global Health Policy. “These provisions are further weakened by a paragraph that only requires member states to ‘give consideration’ to harm reduction programs. Every other prevention intervention is embraced outright.”

The declaration also addressed the recent HPTN 052 trial findings, which show that starting antiretroviral therapy earlier among HIV-infected individuals reduces sexual transmission of HIV to their uninfected partners by more than 96 percent. The declaration calls for intensifying national HIV testing campaigns and urges countries to deploy new biomedical interventions as soon as they are validated, including earlier access to treatment as prevention, according to a press release from UNAIDS. The HPTN 052 study results have emboldened many advocates to call for additional action to finally end the pandemic.

The UN agreement also makes a commitment to investment in accelerated basic research, specifically including female-controlled prevention methods, such as microbicides and other new prevention technologies.

In addition, UN member states agreed to increase AIDS-related spending to between $22 billion and $24 billion in low- and middle-income countries by 2015. During the UN meeting, representatives of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program, along with UNAIDS, also announced a goal of virtually eliminating mother-to-child transmission of AIDS by 2015 (see related blog post). For more coverage of the UN meeting, visit the Center’s blog, Science Speaks.

Drs. John G. Bartlett, Wafaa El-Sadr, Eric Goosby, and Others Reflect on 30 Years of AIDS

This month the Center for Global Health Policy concluded its series of interviews in commemoration of 30 years of HIV/AIDS on its blog, Science Speaks. The Center interviewed John G. Bartlett, MD, FIDSA, a past president of IDSA, who spoke frankly about hiding his treatment of AIDS patients from hospital administrators in the early 1980s, key scientific breakthroughs over the years, and his views on the President’s Emergency Plan for AIDS Relief (PEPFAR) program moving forward. Wafaa El-Sadr, MD, MPH, FIDSA, discussed the parallels in treating populations in the U.S. and in Africa, the greatest achievements in the pandemic’s 30 years, and what drew her to the cause. Other interviews included the Peace Corps’ Buck Buckingham, former U.S. Global AIDS Ambassador Mark R. Dybul, MD, and reflections from Global AIDS Coordinator Eric Goosby, MD. Check out the series at Science Speaks.

IDSA Addresses Adult Vaccination

IDSA continues to be a strong advocate on vaccination issues, particularly policies to improve adult immunization rates, such as by adding adult vaccines to immunization registries. In related news:

  • The Advisory Committee on Immunization Practices (ACIP) this month recommended that pregnant women be vaccinated against pertussis in the late second or third trimester rather than immediately after delivery to better protect newborns against pertussis. The new recommendation complements guidance that adults and teens who have close contact with infants also be vaccinated (see related article from MedPage Today).
  • IDSA recently noted its strong support for collaboration across the federal government to improve adult vaccination rates, in response to a draft report from the National Vaccine Advisory Council. IDSA’s full comments are available online (PDF). Notably, the barriers, conclusions, and recommendations identified in the report closely align with those IDSA identified in its own 2007 policy principles document—a sign of progress on this important issue.  
  • IDSA also recently responded to a draft white paper from NVAC evaluating the federal vaccine safety system. The Society supported the evaluation of the system, but also provided suggestions to strengthen the recommendations. The full comments are available online (PDF).
  • The Society commended the Joint Commission in May for proposing to expand the types of facilities required to have influenza vaccination programs for health care workers (HCWs), and further strengthen existing standards around influenza vaccination. In its comments (PDF), IDSA also supported the inclusion of licensed independent practitioners, a group of providers not always captured in influenza vaccination policies.

IDSA urged the commission to strengthen the measures even further by requiring facilities to have a mandatory influenza HCW vaccination policy as a core patient safety practice, establishing an ultimate goal of a 100 percent influenza vaccination rate for all eligible health care providers. IDSA also recommended that a facility offer HCW influenza vaccination to workers free of charge. The Society supports mandatory HCW influenza vaccination policies as part of a comprehensive influenza infection control program to protect patients (see IDSA’s policy statement (PDF)).

HHS Seeks Input on HIPAA’s Regulatory Burden on Research

The U.S. Department of Health and Human Services (HHS) is seeking comments on a  proposal to exempt research activities from one requirement of the Health Insurance Portability and Accountability Act (HIPAA)–specifically, the duty to produce for individuals a full account of whether their health information has been disclosed for research purposes.

The Institute of Medicine (IOM), the HHS Secretary’s Advisory Committee on Human Research Protections, and IDSA support the proposal, contending that the HIPAA requirement provides little value to patients while placing undue burden on research investigators and institutions.

HHS is seeking comment on what benefit an accounting of disclosures provides to individuals and what burdens it places on research institutions (see pages 31432-31433 of the proposed regulation).  

IDSA plans to submit comments on this requirement and on the other impediments HIPAA places on research, and is encouraging IDSA members and their institutions to do so as well. Comments are due Aug. 1. See the e-mail IDSA sent to members earlier this month.)

For more information, or to share comments with IDSA, contact Audrey Jackson, PhD, at IDSA (ajackson@idsociety.org).

Additional Resources:

IDSA policy statement: Grinding to a Halt: The Effects of the Increasing Regulatory Burden on Research and Quality Improvement Efforts

IOM report: Beyond the HIPAA Privacy Rule: Enhancing Privacy, Improving Health Through Research


New Bills Focus on Incentives for Antibiotic Development and Home Infusion Therapy Coverage

Two bipartisan bills recently introduced in Congress represent important first steps in addressing two key IDSA policy priorities: spurring the development of new antibiotics and extending coverage of home infusion therapy to Medicare beneficiaries.

The Generating Antibiotics Incentives Now (GAIN) Act (H.R. 2182), introduced by U.S. Rep. Phil Gingrey (R.-Ga.) in the House of Representatives in June, is intended to encourage pharmaceutical companies to create desperately needed new antibiotics. Co-sponsors include Reps. Gene Green (D-Texas), Diana DeGette (D-Colo.), Anna Eshoo (D-Calif.), Mike Rogers (R-Mich.), Ed Whitfield (R-Ky.), and John Shimkus (R-Ill.). IDSA supports the bill as a foundation for moving forward and believes it is an excellent starting point for discussing the incentives needed to spur antibiotic and related diagnostics development. IDSA shared its support and additional ideas for the legislation in a letter (PDF) to Rep. Gingrey. (See related press release.)

Also this month, lawmakers introduced the Medicare Home Infusion Therapy Coverage Act of 2011, which would give Medicare beneficiaries access to the same life-saving drug therapies in the home setting that most privately insured patients already enjoy. Sen. Olympia J. Snowe (R-Maine) introduced the bill (S. 1203) in the Senate; Rep. Eliot L. Engel (D-N.Y.) did so in the House (H.R. 2195). Both versions would also require high quality standards to ensure the safe and effective provision of home infusion therapies, which can reduce hospital stays, limit complications, and lower health care costs.

“Unfortunately, today, we have two standards of care,” said IDSA President-Elect Thomas Slama, MD, FIDSA, in an IDSA press release about the legislation. “Patients who have good private health insurance usually have this benefit covered. Most patients who have fee-for-service Medicare do not.” Click here for more information about IDSA’s advocacy in support of Medicare coverage of home infusion therapies.

In other policy and advocacy news:

  • IDSA recently joined the Pew Charitable Trusts and other groups in a letter (PDF) asking the Food and Drug Administration to prohibit extra-label use of cephalosporins in food-producing animals, noting the link to human health. Public health authorities in Canada recently showed that a voluntary extra-label ban on cephalosporins in poultry hatcheries resulted in a reduction in cephalosporin resistance in Salmonella isolates from sick humans. Once the voluntary ban was lifted, resistance rose again. According to the Centers for Disease Control and Prevention, approximately 3 percent of the estimated 1 million human Salmonella cases in the U.S. each year are resistant to cephalosporins. The groups believe that an extra-label ban in the U.S. could help.
  • In a June letter (PDF), the Society supported the National Institute of Allergy and Infectious Diseases’ (NIAID) plan for a new clinical trials network primarily focused on bacterial antibiotic resistance. IDSA also proposed the establishment of an ID clinical specimen repository, which could be housed at NIAID and linked to clinical trials conducted through the network and other sites.
  • The Society responded to a recent Medicare regulation that proposed four additional exemption categories to the E-Prescribing (eRx) Incentive Payment Program. The exemptions are designed to allow eligible professionals who have difficulty meeting the eRx reporting requirements to avoid a payment penalty.  IDSA’s comments (PDF) are available online.
  • The Centers for Medicare and Medicaid Services (CMS) has reconsidered a potentially burdensome paperwork rule that would have required physicians to provide their signatures on requisitions for laboratory tests. In late June, CMS took the first step in retracting the policy by issuing a proposed rule. The signature requirement was originally included in Medicare’s 2011 physician fee schedule but never enforced. Several lawmakers and the American Medical Association had criticized the policy, and CMS acknowledged in late March that physicians, laboratories, and other providers were having difficulty complying with the requirement, according to Inside Health Policy, and postponed the rule.  See the April 2011 IDSA News for additional information.

Members on the Move

Mark E. Rupp, MD, FIDSA, has been appointed chief of the division of infectious diseases in the University of Nebraska Medical Center (UNMC) Department of Medicine, effective July 1. Since 1998, Dr. Rupp has served as medical director of the UNMC Department of Health Care Epidemiology - Infection Control. He also initiated the hospital’s Antimicrobial Stewardship Program and is past medical director of its Clinical Trials Office. He is a past president of the Society for Healthcare Epidemiology of America (SHEA) and served as an IDSA Board liaison during his term in 2009.

Are you a member on the move? Do you know someone who is? Contact Stephanie Cox at scox@idsociety.org so that we can announce it to our membership.

Welcome, New Members!

Members

Adams, Eleanor, MD, MPH
Bergelson, Jeffrey, MD
Bishai, Raafat, MD
Frei, Christopher, PharmD
Kim, Juliette, PharmD
Koval, Christine, MD
Krasan, Graham, MD
Levitz, Ruth, PhD
Metzger, Dennis, PhD
Poporad, George, MD
Ramirez, Mario, PhD
Wang, Jennifer, MD
Zamiri, Seyed Amin, MD

Associates

Chapman, Jessica, MD
Davidson, Ian, PhD
Donnelly, J. Peter, PhD
Dufresne, Simon, MD
Foster, John, MD
Freche, Antoine, MS
Greenberg, Alan, MD
Keedy, Kara, PhD
McGarry, Greg, MSN
McPherson-Terras, Stuart, PhD, DSci
Mlynarski, Diana, PA-C, MPH
Painter, Wendy, MD, MPH
Perera, Chandrika, MD, MBBS
Rizzo, Gabriella, MD
Seidel, Joan, BSN, MA
Stidham, Donna, RN
Stronska, Julita, MD
Terra, Matthew, MD

Members-in-Training

Abraham, Bisrat, MD
Ali, Faiza, MBBS
Al-Shaibani, Wifaq, MD
Angelo, Kristina, DO
Bae, Tracy, MD
Burke, Leah, MD
Colpan, Aylin, MD
Crews, Jonathan, MD
Daniels, Kelly, PharmD
Day, Shandra, MD
Downes, Kevin, MD
DuBray, Kara, MD
Felsenstein, Susanna, MD
Gorostiaga, Federico, MD
Hahn, Andrea, MD
Jeon, Christie, ScD
Jeremiah, Cameron, MBBS
Jogi, Vikas, MD
Johnson, Steven, PharmD
Labreche, Matthew, PharmD
Le, Katherine, MD
Mansour, Michael, PhD
McCarthy, Matthew, MD
Muranaka, Kiyoharu, MD
Nabha, Linda, MD
Nead, Jennifer, MD
Patil, Sarla, MD
Sekar, Poorani, MD
Shah, Dhara, PharmD
Sharff, Katie, MD
Smith, Jennifer, MD
Sogi, Misa, MD
Tavalone, Natascha, DO
Uwamino, Yoshifumi, MD
VanSant, Janine, MD
Walker, Durane, MD
Yassa, David, MD

In Memoriam

Rahal, James J., MD

ID and HIV Maintenance of Certification Modules Available

Two 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 in 2010 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 two 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 kmatikonis@idsociety.org or (703) 299-0200.

To get started, just follow the simple directions below:

  1. Go to idsa.knowledgedirectweb.com and click “Register” to register as a new user/“student.”
  2. On the “Welcome” page, select one module, and then click “Purchase Course.”
  3. Review the learning objectives and disclosure information, then click “agree.” 
  4. Check “ABIM Eligibility.”
  5. Review the documents in the General Information section.
  6. Start the examination and select the corresponding correct answers.
  7. Complete the course evaluation.
  8. Select “Request ABIM Credit” to submit answers to ABIM.
  9. Select “Certificate of CME” to print your CME certificate. Each module earns two AMA PRA Category 1 Credits™.
  10. 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).
  11. If you need technical help with the online modules, send an e-mail to moctechsupport@idsociety.org.

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 as well as 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. Searching and applying for jobs is free. 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: Improving Communication With Members

Later this summer, IDSA and HIVMA will launch redesigned websites, part of our broader commitment to improve communication with members and provide the valuable services that members expect. The main goals are to improve the sites’ functionality, make them easier to use, and allow members to more easily access the content that is most relevant to them and to customize their online experience.

Later this summer, IDSA and HIVMA will launch redesigned websites, part of our broader commitment to improve communication with members and provide the valuable services that members expect. The main goals are to improve the sites’ functionality, make them easier to use, and allow members to more easily access the content that is most relevant to them and to customize their online experience.

Members have provided invaluable input to guide this process, including through member surveys, a focus group of representative members, and usability testing conducted at the 2010 Annual Meeting in Vancouver. A consistent theme has been members’ need for a filter to help them sort through the constant stream of information they face every day.

Building on this feedback, the redesign will include improved site navigation, a revamped search function for quickly finding the content you want, a robust A-Z index for topical searches of the site, and the ability to personalize your experience. An enhanced “MyIDSA” page will allow members to indicate content topics they are interested in, receive alerts when new content in these areas is available, and connect with colleagues with similar interests.

Customization is a key part of the new websites. As I wrote last month (see May 2011 “From the President”), IDSA members are a diverse group who perform a variety of clinical and public health work, research, scholarship, and teaching in many different settings. What is relevant to one member is not necessarily relevant to another. The websites’ new functionality is intended to address this by allowing members to self-select the areas that interest them most.

You will be hearing more about the new websites in the months ahead, including tip sheets, video tours, handouts, and other support to help you make the most of the sites’ new functions and capabilities. Members can also visit the IDSA/HIVMA booth at IDSA’s 49th Annual Meeting, Oct. 20-23, in Boston (see the Annual Meeting website) for an in-person tutorial or to ask questions. By then, we hope you will have had the opportunity to experience the sites and provide more feedback, which will be crucial as the websites evolve to meet members’ needs, a process that will be ongoing.

In the meantime, don’t forget the social networking tools IDSA, HIVMA, and the Center for Global Health Policy have developed to share information and help members collaborate and interact with all three organizations (see May 2011 IDSA News). An increasing number of members are connecting with us—and with each other—using these services.

As these new ways to share information and network continue to evolve, IDSA’s broader commitment to improving how we communicate with you will remain unchanged. In this fast-paced digital age, these efforts will be ongoing.

Changes Needed to Allow Reimbursement for ID Physicians’ Systems-Level Activities, IDSA Says

IDSA continues to advocate for changes to assist ID physicians in receiving adequate reimbursement for providing infection prevention, antimicrobial stewardship, and other services that may not involve direct patient care but that avoid complications and their associated health care costs.

IDSA continues to advocate for changes to assist ID physicians in receiving adequate reimbursement for providing infection prevention, antimicrobial stewardship, and other services that may not involve direct patient care but that avoid complications and their associated health care costs. In June, IDSA called on the Centers for Medicare and Medicaid Services (CMS) and the Office of the Inspector General to establish waivers, safe harbors, and/or exceptions to federal anti-trust laws as a means to incentivize a range of innovations in health care delivery, including these ID-related services. Federal law currently imposes strict limits on compensation arrangements between physicians and hospitals.

The Society’s comments (PDF) came in response to proposed regulations that would waive anti-trust laws in certain situations involving Accountable Care Organizations (ACOs), a proposed new model of care that would allow integrated groups of providers to share in savings generated by providing more efficient, high-quality care. IDSA is also working with a law firm to develop legal arguments necessary to help ID physicians in negotiating incentive-based or “gainsharing” arrangements with local facilities for physicians’ activities that do not involve patient care, including infection prevention and antimicrobial stewardship. 

Evidence suggests that a large proportion of ID physicians accept reimbursement levels that are well below their market value. In a 2007 survey by the Society for Healthcare Epidemiology of America, 37 percent of respondents who provide infection control services and 74 percent of those who provide antimicrobial stewardship services said they were not getting paid for this work.

IDSA also urged CMS to make changes in proposed regulations for the Medicare Shared Savings Program, which is intended to encourage the formation of ACOs that are able to reduce costs while also improving the quality of patient care. IDSA called on CMS to minimize the administrative burden and maximize flexibility to encourage innovative ACOs to form. The regulations, if finalized in their current form, would likely discourage many, if not most, provider groups from forming ACOs and would limit their impact, IDSA said. Several other medical groups have raised similar concerns. IDSA’s comments are available online (PDF).

IDSA Journal Club

June 2011
This months, studies investigating: molecular assays to detect congenital cytomegalovirus infection, changes in the epidemiology of bacterial meningitis, the effect of corticosteroids on the clinical course of community acquired-pneumonia, and intraventricular antibiotics for post-neurosurgical meningitis or ventriculitis.

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.


 

Molecular Assays to Detect Congenital CMV Infection
Reviewed by Jason Weinberg, MD

Real-time PCR assays of saliva specimens are highly sensitive and specific for the detection of cytomegalovirus (CMV) in newborns, according to an article in the June 2 issue of The New England Journal of Medicine.

Approximately 30,000 children are born with congenital CMV infection each year, and 10 percent to 15 percent of CMV-positive children go on to develop sensorineural hearing loss. To determine whether a new real-time PCR-based assay would be an effective tool to detect congenital CMV infection, 34,989 subjects were prospectively enrolled in a study in which saliva specimens were collected from newborn infants. Results of real-time PCR testing of liquid saliva and dried saliva specimens were compared to results from a rapid culture assay for CMV.

A total of 177 (0.5 percent) infants were CMV-positive by at least one of the three methods. When compared to standard rapid culture, PCR testing of liquid saliva had a sensitivity of 100 percent and specificity of 99.9 percent, and PCR testing of dried saliva had a sensitivity of 97.4 percent and specificity of 99.9 percent. Positive and negative predictive values were greater than 90 percent for both PCR assays. There was 100 percent agreement between the two PCR assays when they were compared head-to-head in a subset of samples obtained from 5,276 patients.

Because the majority of infants with congenital CMV infection are not identified during the newborn period, a simple and reliable screening tool is needed. The results of this study suggest that real-time PCR assays of saliva, especially dried saliva, may provide such a tool that could be readily adapted to high-throughput platforms. No DNA extraction step was used for the samples in this study, further simplifying the assay. Early identification of CMV-positive newborns will facilitate the monitoring of, and early intervention for, infants at risk for hearing impairment.

(Boppana et al. New Engl J Med. 2011; 364:2111-2118.)

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Bacterial Meningitis in the United States, 1998–2007: Changes in Epidemiology
Reviewed by Ed Dominguez, MD

Haemophilus influenzae type b (Hib) conjugate vaccine, pneumococcal conjugate vaccine, and universal screening of pregnant women for group B streptococcus (GBS) have contributed to a steady decline in the incidence of bacterial meningitis in the United States. An evaluation reported in the May 26 issue of The New England Journal of Medicine sought to determine the influence of these interventions on the epidemiology of bacterial meningitis.

Between 1998 and 2007, the authors identified 3,188 cases of bacterial meningitis due to H. influenzae, S. pneumoniae, N. meningitidis, Group B streptococci, or L. monocytogenes within the Active Bacterial Core surveillance (ABCs) and the Foodborne Diseases Active Surveillance Network (FoodNet), surveillance systems in the Emerging Infections Program Network. The incidence of bacterial meningitis caused by these bacteria decreased by from 2.00 cases per 100,000 population in 1998 to 1.38 cases per 100,000 population in 2007, a decline of 31 percent. Despite this decreasing incidence, there was no significant change in the case fatality rate from bacterial meningitis (15.7 percent in 1998, 14.3 percent in 2007). A marked decline in the incidence of pediatric meningitis accounted for an increase in the overall median age of patients, from 30.3 years to 41.9 years. However, there was no change in the incidence in children under 2 months of age.

For each pathogen other than Group B streptococci (which increased slightly, by 4 percent), there was a significant decline, ranging from 26 percent for S. pneumoniae to 58 percent for N. meningitidis. S. pneumoniae caused 58 percent of meningitis cases. Importantly, the authors found the incidence of meningitis caused by strains covered in the heptavalent protein-polysaccharide pneumococcal conjugate vaccine declined precipitously, by 92 percent. However, the incidence of meningitis caused by non-vaccine strains increased by 61 percent. This lucid snapshot of bacterial meningitis provides a useful standard for future interventional and therapeutic studies.

(Thigpen et al. New Engl. J Med. 2011; 364:2016-25.)

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Effect of Corticosteroids on the Clinical Course of CAP: An Ongoing Debate
Reviewed by George R. Thompson III

Despite advances in antimicrobial therapy and critical care medicine, community acquired-pneumonia (CAP) remains the number one cause of infectious disease related mortality. Recent clinical trials have shown respiratory, hemodynamic, and immunologic benefits of corticosteroid treatment in the critically ill. The reduced inflammatory response in corticosteroid-treated patients is thought to contribute to improvements in oxygenation and subsequently morbidity and mortality although prospective data is limited.

The authors of a study published in the March 15 issue of Critical Care performed a prospective, randomized, double-blind, placebo-controlled trial comparing patients treated with methylprednisilone (200 mg bolus followed by a nine day taper) and ceftriaxone plus levofloxacin to those receiving ceftriaxone plus levofloxacin alone. Omeprazole was administered to all patients, and insulin was initiated as needed.

The primary outcome of interest, respiratory failure requiring mechanical ventilation, was less common in the corticosteroid treated group, although differences were not statistically significant. However, patients in the corticosteroid-treated group showed a more rapid decrease of fever, radiologic improvement, and improvement in PaO2/FiO2 ratios than those in the control group (P=<0.05). Side effects of treatment were not significantly different between groups, although one patient in the corticosteroid-group required insulin therapy, and one suffered gastrointestinal bleeding that was managed conservatively and without significant sequalae.

The authors’ results are intriguing, although likely underpowered to reach their primary outcome of interest. Larger studies will be needed to determine the usefulness and specific populations that may benefit from adjunctive corticosteroid therapy in the treatment of CAP. 

(Fernandez-Serrano et al. Crit. Care 2011;15(2):R96.)

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Intraventricular Antibiotics for Post-Neurosurgical Meningitis or Ventriculitis
Reviewed by Khalil Ghanem, MD, PhD

The use of intraventricular antibiotics to treat post-neurosurgical ventriculitis and meningitis is controversial. A recent study published in the June 1 issue of Clinical Infectious Diseases suggests that intraventricular gentamicin, in addition to intravenous antibiotics, enhances cure rates in Gram-negative bacillary meningitis.

This was a retrospective case series of 31 consecutive patients at a single center who were diagnosed with post-neurosurgical ventriculitis or meningitis and who were followed for three months. Thirteen patients were given combination intravenous antibiotics with intraventricular gentamicin (4–8 mg once daily), while the remainder were only treated with intravenous antibiotics. Cure was defined as resolution of clinical and laboratory signs of meningitis, negative cerebrospinal fluid (CSF) culture results (if performed), and no relapse within three months after stopping antibiotics. Treatment failure was defined as death attributable to meningitis or relapse within three months.

The bacteria isolated from the CSF were Enterobacter (55 percent), Pseudomonas (16 percent), Klebsiella (10 percent), Xanthomonas (6 percent), and Escherichia (3 percent). The main intravenous therapies used were meropenem, cefotaxime, ceftazidime, imipenem, and trimethoprim-sulfamethoxazole. Relapse occurred in none of the 13 patients treated intraventricularly and in six of 18 patients treated with systemic antibiotics alone. All patients who experienced relapse eventually recovered with prolonged intravenous antibiotic treatment or treatment with intraventricular gentamicin. Mortality at three months was similar in both groups. No toxicities due to the intraventricular use of gentamicin were reported.

Given the difficulty in treating some of these infections, this study does provide some reassurance as to the safety and possible benefits of intraventricular gentamicin use in select patients with Gram-negative ventriculitis. The study, however, was a small retrospective case series. Certain group differences may have impacted the outcome. Larger controlled trials are needed before recommendations for the routine use of intraventricular antibiotics are made.

(Tangden et al. Clin Infect Dis.  2011;52:1310-16.)

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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:

June 15

  • Mycobacterium Tuberculosis and the Host Response: A Story That Seems to Keep Getting Stranger
  • Acute HCV in HIV-Infected Patients; To Treat or Not To Treat, That Is The Question

June 1

  • Clostridium Difficile Toxins
  • Tigecycline and Hospital-Acquired Pneumonia
  • Anaplasma and Ixodes: Keeping warm with Snuggling and Antifreeze