IDSA News - October/November 2011
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MRSA Guidelines Slide Set Available

A new slide set (PDF) created by Catherine Liu, MD, lead author of IDSA’s first-ever methicillin-resistant Staphylococcus aureus (MRSA) practice guidelines, focuses on the management of MRSA in adult patients, with accompanying notes. IDSA welcomes feedback on the slides at idsaguidelines@idsociety.org.

The slide set (PDF) is available online.

Drug Approvals, Recalls, Adverse Events Update

IDSA offers two email 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. Once logged in, click on the “My Alerts” tab to subscribe to the alerts. To subscribe, check the appropriate boxes to receive CDC’s Health Alert Network (HAN) messages and/or alerts from FDA, and provide your email address and name where indicated.)

Is Your Facility Experiencing Antibiotic Shortages?

IDSA members are urged to report drug shortages directly to FDA and to copy IDSA staff at schang@idsociety.org.

Sec. Clinton Calls for “AIDS-free Generation”

Check out Science Speaks, the blog of the Center for Global Health Policy, for coverage of U.S. Secretary of State Hillary Clinton’s recent speech on HIV/AIDS at the National Institutes of Health.

More recent news from Science Speaks:

Global Fund to Fight AIDS, TB, and Malaria Halts New Grants Until 2014

Read more on the Science Speaks blog about the Global Fund’s announcement.

More recent news from Science Speaks:

Vaginal Gel Arm of HIV Prevention Study Halted

The National Institutes of Health recently halted one arm of an HIV prevention study examining tenofovir vaginal gel. Check out the Science Speaks blog for more.

More recent news from Science Speaks:

CDC Issues New Roadmap for Preventing ID Threats

A new roadmap from the Centers for Disease Control and Prevention (CDC) lays out how to improve the nation’s ability to prevent and control infectious disease threats. Last issued in 1998, CDC’s updated Framework for Preventing Infectious Diseases was developed to guide CDC’s ID activities and outlines three main elements in these efforts: strong public health fundamentals, including surveillance, laboratory detection, and epidemiologic investigation; high-impact interventions; and sound health policies.

The framework and a two-page summary are available on CDC’s website: www.cdc.gov/OID/framework.html.

IDSA Responds to Proposed Common Rule Reforms

The Society’s comments on sweeping changes proposed by the Department of Health and Human Services to rules that govern research on human subjects, often known as the Common Rule, focused on four areas: strengthening data protections, streamlining Institutional Review Board (IRB) review of multi-site studies, harmonizing adverse events reporting, and informed consent for biospecimens. IDSA’s comments are online (PDF).

FDA Influenza Antiviral Guidance for Industry Improved, But Concerns Remain

Revised guidance from the Food and Drug Administration for industry for the development of influenza antiviral drugs is improved, but IDSA remains concerned about the document’s study design recommendations and its interpretation of the available clinical outcomes data. The Society’s comments are online (PDF).

Increased Funding for NIH Vital to Nation’s Health

A $1 billion funding increase for the National Institutes of Health is critical for millions of Americans battling deadly and costly diseases. IDSA, HIVMA, and more than 100 other organizations supported the proposed increase in a letter (PDF) to lawmakers.

FDA Needs More Funding

Critical activities—anti-infective drug review, detecting resistant pathogens, vaccine licensure, addressing drug shortages, and food safety—need more resources at the Food and Drug Administration. IDSA urged lawmakers to adopt a higher funding level for the agency in a recent letter (PDF).

Check Out “My IDSA” for Latest Member News

Find the latest membership news, including IDSA members recently elected to the Institute of Medicine, IDSA election results, and the winners of the 2011 Society awards, under the My Membership News tab after logging into My IDSA with your user ID and password.

New ID and HIV MOC Modules Available

Two new Maintenance of Certification (MOC) modules—one in general ID and one in HIV—are now available online from IDSA and the HIV Medicine Association (HIVMA). The 2011 modules were developed by panels of experts from both organizations and consist of 25 multiple-choice questions. Each module is worth 10 points toward MOC by the American Board of Internal Medicine (ABIM).

The modules are online: idsa.knowledgedirectweb.com.

IDSA Fellows In-Training Exam: Dec. 6 Registration Deadline

Registration for the 2012 IDSA Fellows In-Training Exam closes Dec. 6. The exam gives fellows an opportunity to identify areas in which they need additional programmatic instruction and self-directed learning. The exam is offered over a two-day window, Feb. 7-8, 2012. Register online now.

Implementing CLSI Breakpoints for Antimicrobial Susceptibility Testing

Visit IDSA’s website for information about implementing new breakpoints for antimicrobial susceptibility testing from the Clinical and Laboratory Standards Institute (CLSI). An alert developed by IDSA’s Antimicrobial Resistance Work Group includes information about when and how the revised CLSI breakpoints will be implemented in clinical microbiology laboratories and what role IDSA members can play. The alert is online: www.idsociety.org/Antimicrobial_Susceptibility_Testing.

From the President: Staying Focused in Challenging Times

IDSA’s commitment to serving the needs of its diverse membership remains as strong as ever. The Society will continue to pursue key priorities in the year ahead on behalf of members in a rapidly evolving environment that includes challenging fiscal realities.

As I begin my term as IDSA president, I want to assure you the Society’s commitment to its diverse membership remains as strong as ever despite the challenging fiscal realities we face. Because of the rapidly changing world of health care delivery and economics, many believe we could be entering an era of diminished opportunities for ID specialists. Yes, these are changing and challenging times but I believe we can be leaders in the new era by continuing to demonstrate our expertise in research, public health, and patient care, as well as by identifying new opportunities in the field.

From clinicians, educators, or researchers in academic settings, to practicing clinicians providing direct patient care, as well as ID specialists in other settings, such as public health, infection control, and international health, IDSA members perform an impressive and essential range of work. In the year ahead, IDSA will continue to draw on this diversity as we pursue our key priorities in a rapidly evolving environment. Federal funding for research, public health infrastructure, and patient care will all likely be affected by efforts to control the federal budget deficit.

Supporting adequate funding for critical public health and prevention programs in ID—and promoting ID-related research—have been top priorities for IDSA, and this focus will continue. In this climate, it will be more important than ever for members to help us refine the Society’s policy messages and carry them to lawmakers and policymakers, in addition to our ongoing efforts to educate Congress and others about the long-term value of these investments and the lives they save.

The Society will also continue to advocate for regulatory and legislative action to address antimicrobial resistance. This includes urging Congress to pass legislation creating incentives and removing economic and regulatory barriers to spur antimicrobial development, strengthening surveillance programs, requiring antimicrobial stewardship efforts, and fostering research on resistance, in addition to other strategies.

Ongoing efforts to document the value ID specialists provide to patients and the health care system, through improved patient outcomes and reduced health care costs, will remain an important focus in the coming year. Presented at the IDSA Annual Meeting in Boston, the initial results of a Society-commissioned study of Medicare data by a health services research firm indicate that early involvement of ID specialists in the care of patients with conditions such as bacteremia, meningitis, infective endocarditis, prosthetic joint infections, and others is associated with lower patient mortality, lower readmission rates, and lower costs of providing care. More analysis of the data and manuscript preparation are underway.

IDSA will continue to help practicing ID physicians navigate changes in the nation’s health care delivery system with updated information and practical tools. Promoting the need for ID physicians to be compensated for the services they provide, including non-patient care activities, such as antimicrobial stewardship and infection control, will be an important Society priority, particularly in light of the new payment mechanisms, including gain sharing, possible under health care reform.

Another key area of focus will be enhancing the development of IDSA’s practice guidelines, including making timely revisions, standardizing guideline formats, and ensuring guidelines are concise and easy to use, Executive summaries will continue to be published in Clinical Infectious Diseases, and complete guidelines will be available online.

All forms of viral hepatitis and the array of new drugs being developed to combat these infections present an opportunity for ID physicians to demonstrate their expertise and assume a leadership role in the diagnosis and management of these diseases. With this in mind, IDSA has appointed a task force to develop educational programs and resources to assist members and promote the important role of ID physicians in this area.

The HIV Medicine Association (HIVMA) will continue its leadership role in promoting quality HIV care that follows an evidenced-based approach, including as a local scientific partner with the National Institutes of Health for the 2012 International AIDS Conference, July 22-27, in Washington, D.C. IDSA will also continue to have a voice in advocacy on global ID through the efforts of the Center for Global Health Policy.

Perhaps most importantly, planning is well underway for IDWeek 2012, the first-ever joint meeting of IDSA, the Society for Healthcare Epidemiology of America, HIVMA, and the Pediatric Infectious Diseases Society, Oct. 17-21, 2012, in San Diego. With a diverse range of bench-to-bedside programming, speakers, and participants, IDWeek will be a must-attend event for professionals in ID and health care epidemiology that hopefully will establish the tradition of IDWeek as the world’s premier ID meeting.

I look forward to serving you in the coming year as the Society pursues these priorities, in addition to the other work IDSA does on behalf of members. I believe the membership needs to be kept abreast of all important developments, and I will do my best to do so with a variety of methods, including personal emails as well as messages through the IDSA website. I will welcome all of your comments and suggestions. Although we live in challenging times, I know one thing will not change: IDSA’s commitment to serving the needs of its diverse membership.

IDSA 2011: Annual Meeting Reminders

Claim CME/CPE credit for attending the 49th Annual Meeting of IDSA in Boston, order audio and synchronized speaker slides of meeting sessions, and access slides from the Presidential Plenary.

If you attended the 49th Annual Meeting of IDSA in Boston, you can claim continuing medical education (CME) or continuing pharmacy education (CPE) credit, print a receipt, and obtain a certificate of attendance online.

Audio and synchronized speaker slides from the Annual Meeting are also available for purchase online. A free copy of Dr. Jim Hughes’ slides from the Presidential Plenary, as well as reports from IDSA’s Secretary and Treasurer, are available under the My Membership News tab after logging into My IDSA with your user ID and password.

Thank you to all of the supporters of the 49th Annual Meeting of IDSA.

EIN Update: Pertussis Immunization and Protection in an Outbreak

Members of EIN recently discussed pertussis immunization and what level of protection can limit the spread of the disease during an outbreak. 

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.

Members of EIN recently discussed pertussis immunization and what level of protection can limit the spread of the disease during an outbreak. Several members’ comments highlighted the need for more information regarding efficacy of the vaccine at both individual and population levels.

A member in Montana began the discussion, describing a local, ongoing pertussis outbreak in an area where immunization “is not the best. Now I am trying to determine what level of immunization will actually protect the kids (and contacts) from getting pertussis.” 

How many doses of the diphtheria-tetanus-acellular pertussis (DTap) vaccine do children need “to give an adequate level of immunity against pertussis?” asked the member, who reported having pediatric patients who had had two doses in childhood, followed by the Tdap vaccine in junior high school within a year. “Is this going to confer enough protection so they don’t get sick or spread the disease?” the member asked. “These types of immunity questions are so vague that I can't find a close to solid answer. I hate to go with a gut feeling.”

Responding from Texas, an EIN member wrote that the current cellular vaccine, while safer, is not as efficacious as the previous vaccine. “In the long run we need a better vaccine.”

An Illinois respondent noted that “I don’t think there is a level of immunization that can be quoted to protect the kids and contacts from getting pertussis. My ‘gut feeling’ is to drive the immunization levels in the community as high as possible based on trying to get those eligible for immunization up to date,” the member continued. “That is the best I think we can do at this time, and ideally, it is what we should be doing in the absence of an outbreak to minimize the likelihood of one occurring.”

Currently, Tdap vaccine is approved only for a single dose, a respondent from California wrote, so giving additional doses in children 7 years of age and older is not an option. “I am sure this recommendation will change in the future,” the member added, “since we have seen a number of cases of pertussis in children who had a recent Tdap.”

A respondent from New Mexico noted that an August 2010 article in Clinical Infectious Diseases “suggests that the Tdap is about 66 percent effective for immunized children in an outbreak. More than immunization is needed for rapid outbreak control.”


An EIN member in Washington state also shared several journal articles that discuss “pertussis ‘herd’ and vaccine-induced immunity”:

Additional resources on pertussis are available from the Centers for Disease Control and Prevention:


HealthMap, a disease surveillance and mapping website created by a team at Children’s Hospital Boston, can also be searched for reports of pertussis outbreaks. The site brings together different data sources, including online news aggregators, eyewitness reports, expert-curated discussions, and official reports from public health authorities.


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

October/November 2011

This month: Studies investigating fecal transplant for recurrent C. diff infection; a novel hemoplasma species causing human fever and anemia; antibiotic resistance as an ancient phenomenon predating human use of antibiotics; when to start ART in HIV-infected adults on pulmonary TB therapy; and HIV-1 drug resistance across Africa.

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.


Fecal Transplant for Recurrent C. diff Infection: A Systematic Review

Reviewed by George R. Thompson III, MD

Reduced clinical response rates and increased recurrence rates in patients with Clostridium difficile infection (CDI) have prompted an exploration of treatment alternatives. One potential, although seldom used, alternative is intestinal microbiota transplantation (IMT), or stool transplantation. Safety and acceptability concerns have limited its use. A recent systematic review on the use of IMT published in Clinical Infectious Diseases provides a summary of current practice and outcomes and suggests future research on this poorly understood intervention.

More than 2,000 publications and abstracts were reviewed, with 27 titles selected for final analysis, representing 317 patients. IMT was highly effective, showing resolution of disease in 92 percent of cases. Although a single treatment is often used, resolution was lowest in patients receiving only one treatment (87.5 percent). Those receiving <3 and >3 treatment courses had slightly higher response rates (95.7 percent and 90.0 percent, respectively).

The lowest resolution rates were in patients receiving IMT via gastroscope or nasojejunal infusion (76.4 percent) compared to patients treated via colonoscopy (88.7 percent), enema (95.4 percent), or rectal catheter (95.6 percent).

Donor-related factors also appear to play an important role. Stool from a related donor showed a slightly higher resolution rate (93 percent) compared to unrelated donor stool (84 percent). Interestingly, IMT from a spouse or partner was associated with the highest resolution rates (96 percent).

Stool prepared in saline showed a slightly lower response rate (86.2 percent) then that prepared in water (98.5 percent). Pre-IMT treatment with vancomycin or metronidazole also appeared helpful, with response rates of 91.5 percent in these groups. Adverse events were uncommon, and none could be directly attributed to IMT.

Although the authors are to be commended for their exhaustive summary of the published literature, multiple questions remain given the lack of comparative trials and heterogeneity treatment protocols. However, their findings are a helpful resource when more “palatable” options have been exhausted.

(Gough et al. Clin Infect Dis. 2011;53:994-1002.)

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A Novel Hemoplasma Species Causes Human Fever and Anemia

Reviewed by Rachel Simmons, MD

A recent case report published in Clinical Infectious Diseases describes a novel human pathogen and highlights the potential of molecular diagnostics for both diagnosis and monitoring of new and difficult to culture pathogens. Investigators from the United Kingdom described the case of a middle-aged woman with chronic moderate neutropenia who developed fever and hemolytic anemia shortly after returning from a trip to Australia and Singapore. She had persistent fever, hepatosplenomegaly (liver biopsy was unrevealing), and hemolysis.

The patient improved somewhat after empiric treatment with multiple antibiotics including piperacillin/tazobactam and doxycycline and prednisolone for possible autoimmune disorder. However, approximately three weeks after antibiotics were stopped, she presented with fever, anemia, and thrombocytopenia. Ultimately, bone marrow biopsy showed hemophagocytosis. Doxycycline was restarted, and she improved quickly. Bone marrow tissue was submitted for 16s ribosomal PCR, and the PCR product was found to be very similar to Mycoplasma haemomuris (a veterinary hemoplasma species) and Candidatus Mycoplasma turicensis. The woman was treated with doxycycline for three weeks, and shortly thereafter, suffered another clinical relapse. She improved rapidly with resumption of doxycycline.

Repeat bone marrow biopsy was positive for hemoplasma DNA by qPCR, but cultures for mycoplasma and ureaplasma species were negative. Sequencing, phylogeny, and PCR confirmed that her illness was caused by a novel hemoplasma (hemotropic mycoplasma) species that is now called Candidatus Mycoplasma haemohominis. The patient was monitored with serial blood panhemoplasma qPCR and ultimately treated with six months of doxycycline and moxifloxacin with clinical improvement and no additional relapses. It is unclear how she acquired the infection, and both her husband and her dog tested negative.

(Tasker et al. Clin Infect Dis. 2011;53(11): e147-e151.)

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Antibiotic Resistance: Predating the Modern Antibiotic Era by 30,000 Years
Reviewed by Christopher J. Graber, MD, MPH

A research letter recently published in Nature highlights the omnipresence of antibiotic resistance by finding homologues to modern antibiotic resistance genes in 30,000 year-old permafrost in the Yukon territory.

At the Bear Creek site east of Dawson City, Yukon, Canada, the authors recovered sediment cores from an area of permafrost immediately overlain by distinctive volcanic ash estimated by carbon dating to be 30,000 years old. After a thorough process to exclude contamination and to confirm the presence of DNA derived from flora and fauna of the late Pleistocene age, the authors amplified gene fragments corresponding to the tetracycline resistance gene tetM, the vancomycin resistance operon vanHAX (which contains the vanA gene typically found in vancomycin-resistant enterococci), and the beta-lactamase bla (a member of the TEM group of beta-lactamases).

These findings confirm that antibiotic resistance is an ancient, naturally occurring phenomenon that significantly predates our use of antibiotics. The presence of pre-existing resistance determinants that have been present in the microbial pangenome for thousands of years may help to explain why resistance to newly developed antibiotics can occur so quickly and further emphasizes the importance of antimicrobial stewardship in resistance avoidance.

(D’Costa et al. Nature 2011;477:457-61.)


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When to Start ART in HIV-Infected Adults on Pulmonary TB Therapy
Reviewed by Ed Dominguez, MD

The most common infectious cause of death in HIV-infected individuals is tuberculosis (TB). The optimal time to integrate antiretroviral therapy (ART) with pulmonary TB therapy is unknown. Three studies in the Oct. 20 issue of The New England Journal of Medicine investigated this issue.

In South Africa, 642 patients with CD4+ T-cell counts less than 500/cu mm were randomized to one of three different treatment sequences for commencing ART. Two sequences were analyzed: earlier integrated-ART (within four weeks after initiation of TB treatment) and later integrated-ART (within four weeks after completion of the intensive phase of TB treatment). While there were no differences in the rate of AIDS-defining illness or death, the 72 patients with a baseline CD4+ count of less than 50/cu mm experienced a lower rate of  AIDS illness and death but a higher rate of immune reconstitution inflammatory syndrome (IRIS), with two attributable deaths.

A second study randomized 809 patients with CD4+ counts less than 250/cu mm to ART within two weeks after initiation of TB treatment or ART between eight and 12 weeks after initiating TB treatment. As in the first trial, the rate of AIDS-defining illness or death was reduced in the 285 patients with CD4+ counts below 50/cu mm, but the rate of IRIS was increased.

Finally, a Cambodian study of 661 HIV-infected patients with TB and CD4+ counts of less than 200/cu mm randomized patients to one of two treatment groups: ART initiated two weeks or eight weeks after the start of TB treatment. Unlike the previous studies, this study showed a reduction in mortality in the early-ART group, but with an increased frequency of IRIS, including six fatalities. Taking the different study designs into consideration, an accompanying editorial suggests initiating ART two to four weeks after TB therapy may be beneficial for patients with lower CD4+ counts. For those with higher counts, deferring therapy until patients are on a two-drug regimen may be more practical. Unfortunately, when to initiate ART in patients with extra-pulmonary TB remains unanswered.

(Blanc et al. N Engl J Med. 2011; 365:1471-1481; Havlir et al. N Engl J Med. 2011; 365:1482-1491; Karim et al. N Engl J Med. 2011; 365:1492-1501; and Török and Farrar. N Engl J Med. 2011; 365:1538-1540.)

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Appearance of HIV-1 Drug Resistance Across Africa: Time Is of the Essence

Reviewed by Christian B. Ramers, MD, MPH

Wherever antimicrobial therapy is introduced, drug resistance almost uniformly follows. In the United States, an estimated 16 percent of newly acquired HIV infections harbor important resistance mutations, a steady rise since the introduction of anti-retroviral therapy. These rates make pre-treatment genotype testing an important and cost-effective intervention. Because the large-scale introduction of antiretroviral therapy (ART) began in Africa only in 2004, resistance has not generally been an immediate concern. A study in the October issue of Lancet Infectious Diseases investigating resistance rates across Sub-Saharan Africa shows some surprising heterogeneity.

This large, cross-sectional study across six countries (Kenya, Nigeria, South Africa, Uganda, Zambia, and Zimbabwe) included 2,436 treatment naïve individuals from 2007 to 2009. The authors performed population-based sequencing of the pol gene on all plasma specimens with more than 1,000 copies per mL of HIV RNA. They identified known resistance mutations, calculated the prevalence of mutations by site, and using logistic regression, determined risk factors for resistance.

Overall prevalence of HIV-1 drug resistance was 5.6 percent (95 percent CI 4.6-6.7 percent), but varied widely by sites. Uganda, the nation with the longest ART history, had the highest rates of resistance (11.6 percent overall and 12.3 percent in urban Kampala). The most common mutations (in decreasing order of prevalence) were: K103N, TAM’s, M184V, and Y181C. The authors calculated an odds ratio for the appearance of drug resistance of 1.38 (95 percent CI 1.13-1.68) for each additional year of ART availability. Despite the use of single-dose nevirapine for the prevention of mother-to-child transmission in some settings, women did not seem more likely than men to harbor resistance.

These results have important implications for deciding how best to allocate limited resources in HIV-related care. While individualized genotypic testing is not currently available in Africa, perhaps national HIV-1 resistance surveillance should be considered. In addition, routine virologic monitoring and potency of first- and second-line regimens are important factors in the struggle against these rising rates of drug resistance.

(Hamers et al. Lancet Infect Dis. 2011; 11(10):750-59.)

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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:

November 15

  • Missing mec
  • Rapid Diagnosis of Extrapulmonary Tuberculosis

November 1

  • Corticosteroids as Adjunctive Therapy for Community-Acquired Pneumonia
  • Mechanism of Action of a Probiotic