IDSA News - May 2012
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Guidance for Increasing Adult Pneumococcal Vaccination Rates

A set of “Call to Action” documents outlining the burden of pneumococcal disease among adults and the role of various health care providers in increasing vaccination rates is available online. The documents were developed by a task force of health care professionals from several organizations, including IDSA, convened by the National Foundation of Infectious Diseases to discuss barriers to pneumococcal vaccination among U.S. adults and identify solutions.

Pneumococcal Disease Calls to Action

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. (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.

Legislation Would Repeal Flawed Physician Payment Formula

Bipartisan legislation recently introduced in Congress would repeal Medicare’s flawed Sustainable Growth Rate (SGR), provide payment increases to physicians, and require the federal government to develop and evaluate new payment and delivery models. Under the existing SGR, which is used to calculate Medicare physician payments, physicians have faced periodic payment cuts for several years. IDSA supported the legislation in a recent letter (PDF) to lawmakers.

Physician Groups: “Meaningful Use” Rule Should Encourage EHR Use

Several medical societies, including IDSA, recently commented on the Centers for Medicare and Medicaid Services’ proposed rule for “meaningful use” of electronic health records (EHRs). The organizations called for changes to the EHR incentive program to help physicians adopt and meaningfully use EHR technology. Read the full comments online (PDF).

Combination HIV Drug Recommended for Approval to Prevent HIV Infection

Check out Science Speaks for updates on recent recommendations from two Food and Drug Administration advisory committees to approve a rapid, at-home HIV test for sale over the counter and to approve the use of a combination HIV drug that includes emtricitabine and tenofovir as pre-exposure prophylaxis (PrEP) for high-risk individuals not infected with HIV to reduce the risk of sexually acquired HIV infection. Science Speaks is the blog of the Center for Global Health Policy.

More recent news from the blog:

Global Health Funding Updates from Capitol Hill

Science Speaks, the blog of the Center for Global Health Policy, has been covering the federal budget process as bills that will affect global health funding, including the President’s Emergency Plan for AIDS Relief (PEPFAR) program and the Global Fund to Fight AIDS, Tuberculosis and Malaria, move their way through Congress. Check out recent updates from the House and the Senate.

More recent news from Science Speaks:

Study: HIV Funding Does Not Undermine Response to Other Diseases in Rwanda

Despite concerns that the influx of funding devoted to fighting HIV globally may undermine health care services for other diseases, this funding has not diverted attention from fighting unrelated health issues, according to a six-year study of health clinics in rural Rwanda published in the May issue of the American Journal of Tropical Medicine and Hygiene. See Science Speaks, the blog of the Center for Global Health Policy, for more on the study’s findings.

More recent news from Science Speaks:

Society Continues to Push for Adult Immunization

The Society recently joined the Campaign for Adult Immunization, an effort organized by the National Foundation for Infectious Diseases. The campaign’s goals are to close the funding gap for adult vaccination, support an Immunization Congressional Caucus, and ensure that all adults are fully aware of and have access to appropriate vaccinations.

The Society’s work in this area, an important IDSA priority, is ongoing. Earlier this month, IDSA staff attended the first-ever National Adult Immunization Summit, co-hosted by the American Medical Association, the Centers for Disease Control and Prevention, and the National Vaccine Program Office. The event, to be held annually, convened various stakeholders to begin identifying specific actions to improve adult vaccination rates and increase awareness of recommended vaccinations. Speaker presentations from the summit are available online.

IDSA, HIVMA Defend Prevention and Public Health Fund

The Prevention and Public Health Fund, a critical and overdue 10-year, $12.5 billion investment in public health programs, provides vital support for the preservation and promotion of the nation’s public health, IDSA and the HIV Medicine Association argued in a letter (PDF) to congressional leaders this month. The organizations urged lawmakers to protect the fund and oppose efforts to reduce or eliminate it.

IDSA Comments on FDA Draft Guidance for Developing cUTI Drugs

The Society praised several elements of new draft guidance for industry from the Food and Drug Administration for the development of drugs to treat complicated urinary tract infections (cUTIs). However, IDSA raised concerns about precluding prior antimicrobial therapy, the long duration of therapy, the maintenance of IV therapy for the duration of treatment, patient inclusion criteria, and the non-inferiority margin. Read IDSA’s full comments (PDF).

Check Out “My IDSA” for Latest Member News

Find the latest membership news on “My IDSA” on the IDSA website, including new IDSA members, members on the move, an update on a survey on the journals, and information about proposed revisions to IDSA’s bylaws.

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.

Meet Your Match With the ID/HIV Career Center

Whether you are hunting for the ideal position or tracking top candidates, IDSA and HIVMA have recruitment tools for job seekers and employers. As a job seeker, you are only a few clicks away from a new career opportunity. Visit the ID/HIV Career Center to:

  • post your résumé/CV
  • search hundreds of job listings
  • sign up for emails alerting you to available jobs within your interests, whether you are actively searching for a job or only curious about other opportunities
  • review articles and other resources relevant to your field

As an employer, your open positions are exposed to numerous job seekers every month. Visit the ID/HIV Career Center and benefit from:

  • a 30 percent discount on job postings for all IDSA/HIVMA members
  • pre-screened, qualified candidates
  • one source to post jobs on regional and national websites
  • email notifications of job seekers matching your posted positions
  • competitive advertising options
  • dedicated customer support

We have the job or candidate you are looking for and the tools to help both connect. Our partnership with HEALTHeCAREERS Network makes it easier to connect with the right candidates and the right jobs.

Visit the ID/HIV Career Center to learn more.

Updated Guideline for Diabetic Foot Infections Now Available

The update of IDSA’s 2004 guideline on the diagnosis and treatment of diabetic foot infections is available online, along with an audio podcast featuring a discussion with the guideline’s lead author.

An updated IDSA guideline for the diagnosis and treatment of diabetic foot infections is now available online. It also appears in the June 15 issue of Clinical Infectious Diseases.

The guideline is a revision and update of IDSA’s 2004 diabetic foot infections guideline. Research since then has proven that many foot infections are treated improperly, including prescribing the wrong antibiotic or not addressing underlying conditions such as peripheral arterial disease.

The guideline’s primary focus is appropriate therapy for treating infected wounds on the feet of persons with diabetes, including surgical removal (debridement) of dead tissue, appropriate antibiotic therapy, removing pressure on the wound, and assessing (and potentially improving) blood flow to the foot. The guideline also provides suggestions regarding when and how long antibiotics should be administered for soft tissue and for bone infections.

Substandard treatment of infected foot wounds in people with diabetes can lead to lower extremity amputation, the guideline explains. Individuals with diabetes typically have poor circulation and little or no feeling in their feet; thus, a sore caused by a rubbing shoe or a cut can go unnoticed and worsen. “People who have had a foot amputated often can no longer walk, their occupational and social opportunities shrink, and they often become depressed and are at significant risk for a second amputation. Clearly, preventing amputations is vital, and in most cases, possible,” said Benjamin A. Lipsky, MD, chair of the guideline review panel.

The guideline provides key recommendations on the preferred clinical methods to use when diagnosing a diabetic patient with foot infection. For example, clinicians should evaluate a diabetic patient presenting with a foot wound at three levels: the patient as a whole, the affected foot or limb, and the infected wound. The guideline also provides advice on when and how to culture a diabetic foot wound. Also, several recommendations are provided regarding when consultation for a patient with a diabetic foot infection is needed and from whom, and when to hospitalize (and to discharge) the patient.

As with other IDSA guidelines, the diabetic foot infections guideline will be available in a smartphone format and a pocket-sized quick-reference edition. A podcast with Dr. Lipsky, the lead guideline author, is available on IDSA’s website. The full guideline is available online. Visit the practice guidelines section of the IDSA website for additional guidelines and related resources.

Antibiotic Incentives Legislation Nearing Passage

As IDSA News went to press, legislation that includes incentives to spur new antibiotic research and development was nearing passage in Congress. 

As IDSA News went to press, legislation that includes incentives to spur new antibiotic research and development was nearing passage in Congress. IDSA voiced its support for provisions in the Food and Drug Administration Prescription Drug User Fee Act (PDUFA) reauthorization bill in letters earlier this month to Senate (PDF) and House (PDF) committees. IDSA also offered additional proposals for consideration, including the Society’s proposed Limited Population Antibacterial Drug (LPAD) pathway, which would provide an important new approval option for companies interested in developing drugs for serious resistant infections with few or no existing treatment options.

IDSA continues to work on many fronts to address the anemic antibacterial pipeline. A recently launched IDSA webpage, www.AntibioticsNow.org, centers on patients affected by resistant infections and provides an easy way for concerned physicians to urge Congress to act. Visit IDSA’s “Take Action” webpage to send messages to your representatives in Congress on this issue and urge your colleagues to do the same. Members can also help IDSA identify patients and families who are willing to share their experiences with the media, policymakers, and the public. (Several stories are featured on IDSA’s website. Contact IDSA staff for more information.) 

EIN Update: Cryptococcal Disease and Diagnostic Issues

Two patients with an “unusual circumstance” spark a discussion among EIN members about cryptococcal testing and related diagnostic issues.

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 cryptococcal testing and related diagnostic issues. A member in Texas described two patients with an “unusual circumstance.” The first was a patient with alcoholic cirrhosis, with fevers but no headaches or neurological symptoms. “Blood cultures grew Cryptococcus neoformans, but serum antigen was negative (repeated twice). There was no dissemination to the central nervous system (CNS)—no growth from cerebrospinal fluid (CSF); cryptococcal antigen was also negative.”

The second case was a patient with lymphoma who had undergone chemotherapy (with resultant neutropenia) and developed pneumonitis. According to the pathology report, no granulomas were present. Findings from a chest CT involved both lungs. Bronchoalveolar lavage specimens grew Cryptococcus neoformans. “Again, there was no involvement of the CNS proven by culture, and cryptococcal antigen was negative as well,” the member noted.

The patients were seen in different hospitals, and assays were performed by different labs. “According to the literature and guidelines, the Cryptococcus antigen assay is supposed to be very sensitive and specific,” the member wrote, asking for comments.

“Was the prozone phenomenon ruled out?” a respondent in Michigan asked. “The titers may have been very high. Though rare, the other possibility is a non-capsular Cryptococcus isolate causing this patient’s disease.”

Another member suggested the “postzone phenomenon—an antigen version of the prozone phenomenon has been described with latex agglutination CrAg.” The member cited a letter to the editor in the Aug. 13, 1982, issue of the Journal of the American Medical Association. “Try diluting the serum and then repeat the test.”

An EIN member in Florida, referencing a December 2003 Chest article, noted that “primary cryptococcoma of the lung usually has a negative serum cryptococcal antigen (CA). In a study of cryptococcal meningitis, the sensitivity of serum CA was 91.4 percent, and the specificity 83.3 percent (J Med Assoc Thai. 1999;82:65-71). So it is possible to have negative serum CA with fungemia and disseminated infections. Also, a capsule deficient strain of Cryptococcus will be serum CA negative,” the member wrote, citing a letter to the editor in the April 1985 issue of Lancet.

A respondent in Oregon offered another possibility: “Are you sure it’s neoformans and not gattii? In Oregon we’ve found serum crypto Ag to be relatively insensitive for C. gattii lung infection.”

“Small colony variants have been described as a potential cause of this uncommon occurrence,” an EIN member in California wrote, citing a 2006 article from the Scandinavian Journal of Infectious Diseases. “We have had few such cases: One occurring in a 74-year-old non-immunocompromised patient with positive CSF and blood cultures for Cryptococcus neoformans (not gattii) with negative enzyme-linked immuno assay (EIA) and latex agglutination antigen, and another in a 64-year-old female with adrenocortical carcinoma, positive serum cryptococcal antigen (1:375 EIA), negative CSF cryptococcal antigen (EIA), and positive CSF culture for Cryptococcus neoformans (not gattii).”

A recent letter published in Emerging Infectious Diseases summarizes the results of a related EIN survey of ID physicians. The survey focused on the clinical approach to diagnosing cryptococcal infections, the relative regional frequency of C. gattii, and the capacity of clinical laboratories to differentiate cryptococcal species.

Additional resources related to cryptococcal disease and diagnosis include:


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

May 2012

This month, studies investigating: valacyclovir and the suppression of herpes simplex virus type 2 meningitis recurrences; single-pill antiretroviral regimens and effects on adherence and hospitalizations; oral fluoroquinolones and the risk of retinal detachment; and performance of a rapid oral HIV test in high HIV prevalence settings.

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.


Herpes Simplex Virus Type 2 Meningitis: Can Valacyclovir Suppress Recurrences?
Reviewed by Kathryn E. Stephenson, MD, MPH

Herpes simplex virus type 2 (HSV-2) is one of the most common causes of aseptic meningitis and can lead to significant neurologic morbidity, including recurrent meningitis. Suppressive antiviral therapy with valacyclovir is effective at diminishing the frequency of genital HSV-2 recurrences but has not been tested for the suppression of meningitis recurrences.

In the May 1 issue of Clinical Infectious Diseases, researchers report the results of a prospective, randomized, double-blind, multicenter trial in Sweden comparing 0.5 gm of valacyclovir twice daily (N=50) versus placebo (N=51) for one year for the prevention of recurrent HSV-2 meningitis. Subjects were followed for two years. Surprisingly, recurrence of HSV-2 meningitis was more frequent in the valacyclovir group than in the placebo group during the treatment phase of the study, though the increase was not significant. After treatment was discontinued, recurrence of HSV-2 meningitis was significantly higher among patients previously exposed to valacyclovir (HR, 3.29 [95 percent CI, 10.06-10.21]. This difference remained significant when non-compliant subjects were excluded from the analysis. Of note, a cluster of cases of recurrent meningitis was observed shortly after valacyclovir was stopped.

The authors conclude that antiviral suppression with 0.5 gm of valacyclovir twice daily does not prevent the recurrence of HSV-2 meningitis. They speculate that the dose might not have been adequate to achieve sufficient penetration of the central nervous system. The authors also note that there appeared to be a rebound effect of cessation of active drug, which indicates that the drug may have had some activity during the treatment phase. The suggestion is that antiviral therapy with higher doses of valacyclovir may yet be beneficial for patients with frequent recurrences.

(Aurelius et al. Clin Infect Dis. 2012:54:1304-13.)

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Single-Pill ART Regimens and Effects on Adherence and Hospitalizations
Reviewed by Sheila Mitsuma, MD

Antiretroviral treatment (ART) regimens consisting of a single pill per day have been shown to be associated with increased adherence, patient satisfaction, and better virologic outcome. In the February 2012 issue of PLoS ONE, researchers presented the results of a retrospective database review that aimed to assess the effect of ART as a single pill on adherence and hospitalization.

Data from approximately 7,000 commercially insured patients who received care from 1997 to 2008 were reviewed. Subjects were divided into three cohorts: those receiving a single-pill-per-day ART regimen (n = 2,365), those receiving two pills per day (n = 411), and those receiving three or more pills per day (n = 4,297). Though age, insurance status, and concomitant co-morbid conditions including mental health and substance abuse issues did not vary greatly between the three cohorts, there was a significantly greater number of treatment-naïve patients in the single-pill-per day cohort. All subjects completed at least 60 days of their ART regimen. Multivariate logistic regression was used to analyze the association between treatment regimens, adherence, and hospitalizations.

Adherence was significantly improved in the single-pill-per-day cohort. Forty-seven percent of these patients achieved ³95 percent adherence to their regimens compared to 41 percent in the two-pills-per-day cohort and 34 percent in the three or more pills per day cohort (p = 0.019 and <0.001). Additional factors associated with achieving ³95 percent adherence were receipt of two pills per day rather than three or more, being treatment naïve, and receiving treatment in 2008 versus 2006. Subjects who achieved ³95 percent adherence, regardless of the number of pills in their regimen, had significantly fewer hospitalizations. A separate analysis showed that the likelihood of hospitalization was significantly lower for those who received a single pill per day versus three or more.

The authors do note that they were unable to identify all potential confounding variables. Specifically, clinicians may have preferentially prescribed boosted protease inhibitor regimens (which contain three or more pills per day) to less adherent patients, as multiple trials have shown that such regimens are associated with improved virologic outcomes. Notwithstanding such minor limitations, this study found that single-pill-per-day regimens are associated with increased adherence and decreased hospitalizations. Single-pill-per-day regimens may therefore be linked to improved clinical outcome and economic benefit.

(Sax et al. PLoS ONE. 2012;7(2):e31591.)

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Oral Fluoroquinolones and the Risk of Retinal Detachment
Reviewed by George R. Thompson III, MD

Fluoroquinolones are one of the most commonly prescribed antibiotics and, although generally well tolerated, they have been associated with a wide array of adverse events including arrhythmia, tendinopathy, neuropsychiatric events, and dysglycemia. Additionally, case reports have suggested ocular toxicity may uncommonly occur and these findings have been verified in animal models.

In a study in the April 4 issue of the Journal of the American Medical Association, investigators performed a pharmacoepidemiological nested case-control study to examine the association between oral fluoroquinolone use and the risk of retinal detachment. From a cohort of close to 1 million patients, the current use of fluoroquinolones was associated with a statistically significant risk of developing retinal detachment (3.3 percent of cases vs. 0.6 percent of controls). Recent use, defined as the receipt of an oral fluoroquinolone within 1-7 days of event, and past use did not predispose to retinal detachment—findings suggesting retinal detachment as an acute adverse event.

Fluoroquinolones interfere with collagen synthesis, and these fibers are known to play a pivotal role in the structure and integrity of the vitreous body. Breakdown of collagen from concurrent fluoroquinolone use may thus promote the development of posterior vitreous detachment—a mechanism with biologic plausibility from known side effects of this antimicrobial class. 

The authors estimate 1,440 cases of retinal detachment in the United States may be attributed to fluoroquinolone use annually, with a number needed to harm of approximately 2,500 patients. The individual risk of this potential event is therefore low. However, patient counseling and attention to symptoms may be altered by the findings of this study. 

(Etminan et al.  JAMA. 2012;307(13):1414-1419.)

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Rapid Oral HIV Test Performs Best in High HIV Prevalence Settings
Reviewed by Jonathan Li, MD

In the United States, approximately 1 in 5 HIV-infected individuals do not know that they are infected. In addition, of those who receive traditional HIV testing, it is estimated that nearly a third of those who test positive do not return for their results. The increased utilization of rapid HIV testing represents an important strategy in expanding the coverage of HIV testing in the United States and worldwide. How these rapid oral and blood-based tests will be used will be heavily influenced by their test characteristics. In the May issue of Lancet Infectious Diseases, researchers performed a systematic review and meta-analysis to compare the diagnostic characteristics of a rapid HIV point-of-care test when used on oral or blood-based specimens (Oraquick advance rapid HIV-1/2).

Using the studies that directly compared oral versus blood-based testing, the authors found that sampling oral fluid alone led to a lower test sensitivity (98.03 percent vs. 99.68 percent). The studies were also categorized into those tested in high HIV prevalence (>1 percent) or low prevalence (≤1 percent) settings. In high-prevalence settings, the positive predictive value (PPV) was similar between oral and blood-based tests (98.65 percent vs. 98.50 percent), but in low-prevalence settings, the PPV was lower for oral versus blood-based testing (88.55 percent vs. 97.65 percent).

This study confirms the excellent diagnostic accuracy of the Oraquick rapid HIV test in high HIV prevalence settings, but makes the important point that there is an increased risk of both false positive and false negative results in low prevalence scenarios. However, the deficiencies of the rapid oral fluid-based test have to be weighed against its advantages, namely its convenience, ease of use, and non-invasive nature. With these advantages in mind, the U.S. Food and Drug Administration’s (FDA) Blood Products Advisory Committee, a panel of outside experts, recommended earlier this month that FDA approve the test for sale over-the-counter as a home-based test. FDA regulators are expected to announce their decision later this year.

(Pai et al. Lancet Infect Dis. 2012;12(5):373-80.)

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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:

May 15

  • Fusobacterium and Colorectal Cancer
  • Procalcitonin and Antibiotic Escalation in Critical Care Patients—Not a Good Idea
  • Diabetic Foot Infection: Osteomyelitis or Not?

May 1

  • Prevention of Methicillin-Resistant Staphylococcus aureus Acquisition—Standard Measures With a Touch of Alcohol Are Enough
  • Another New Pathogen: Iquitos Virus