IDSA News - January 2015
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New Resources Available for Accessing Guidelines
Chronic Kidney Disease Guideline Now Available in Pocketcard
Practice guidelines developed by IDSA on the Management of Chronic Kidney Disease in Patients Infected with HIV are now available in pocketcard format. The pocketcards are available in hardcopy (4x7) and for mobile devices (iOS and Android devices). IDSA members are eligible to receive a 35% discount when purchasing through the mobile guideline catalog via the IDSA website (discounts will be applied automatically at checkout).
New HCV Guidance Toolkit App
Check out the new, mobile optimized HCV Guidance Toolkit produced in partnership with Guideline Central based on recommendations developed by IDSA and the American Association for the Study of Liver Diseases (AASLD). In addition to the most current guidance, this free toolkit features a number of useful calculators and patient resources along with note-taking abilities and links to patient assistance programs. Users who create a free account will also gain access to all of the digital IDSA and AASLD pocket cards through their browser. The app is available at HCV.GuidelineCentral.com and also through the Guideline Central app in iTunes and Google Play.
Sanford Guide Mobile App for Lab Diagnosis of Infectious Diseases
Reminder: IDSA and the American Society of Microbiology (ASM), along with the Sanford Guide launched a mobile app last fall Lab Diagnosis of Infectious Diseases, in an effort to provide convenience and portability for physicians and lab personnel responsible for diagnosis of infectious diseases.
The app is an updated and newly organized adaptation of the 2013 Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases originally published by IDSA and ASM in Clinical Infectious Diseases. The app provides a guide for clinicians and lab personnel, specifying what tests should be used under which circumstances and how specimens should be collected and managed to achieve the most accurate results. Covering the key points related to diagnostic testing, the content of the app is organized by anatomic systems and selected pathogens for easy reference.Ideally suited for use on hospital rounds, in the examination room, and in the laboratory, the app combines portability with a wide range of functions: full-text search, bookmarks, notes, context-sensitive drop-down menus, and menu-based navigation. The app is available for both Apple and Android devices as an annual subscription for $19.99 per year.
The content of the app represents the collaborative scientific efforts of IDSA and ASM members supplying expertise in a variety of areas including infectious diseases, pathology, and microbiology. The adaptation of the original guidelines to this updated and re-organized mobile version resulted from the infectious diseases expertise and digital development experience of the Sanford Guide.
CDC Investigates U.S. Multi-State Measles Outbreak
The Centers for Disease Control and Prevention (CDC) issued an alert in late January on the multi-state outbreak of measles associated with travel to Disneyland Resort Theme Parks. The alert advised health care providers to ensure that all of their patients are current on MMR (measles, mumps, and rubella) vaccine and to consider measles in the differential diagnosis of patients with fever and rash. In addition, providers should ask patients about recent international travel or travel to domestic venues frequented by international travelers and about their history of measles exposures in their community.
IDSA offers two email services to help members stay informed of new drug approvals and similar updates from the Food and Drug Administration and CDC. Content includes a range of topics, including drug warnings, recalls, and outbreak investigations. Recent alerts have included:
Approval changes to the Kaletra (lopinavir/ritonavir) Label (dosing recommendations for pregnant women) 1/28/15
FDA approves a second vaccine to prevent serogroup B meningococcal disease 1/23/15
FDA warns health care professionals not to inject patients with IV solutions from Wallcur, of San Diego 1/14/15
FDA approves new antibacterial drug Zerbaxa 12/19/14
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 firstname.lastname@example.org.
New HIVMA Website Offers Resources for HIV Medical Providers and Clinics
HIVClinician.org–a new website from the HIV Medicine Association (HIVMA)—is the home for resources to help HIV medical providers and clinics adapt to health care financing and system reforms. Information is available on a number of health reform topics, from accountable care organizations to contracting with health insurers. It includes webinar recordings, billing and coding guides for outpatient HIV services, and links to additional resources on the web. The resource will continue to be updated as new tools are developed for HIV providers and clinics.
CMS Publishes Final Rule for Physician Fee Schedule
The Centers for Medicare and Medicaid Services published the Final Rule for the Physician Fee Schedule on November 13, 2014. This Final Rule addresses changes to physician payment under the Medicare program that took effect on January 1, 2015. Specifically, the Final Rule details changes to the Physician Quality Reporting System (PQRS), Physician Compare website, and the Value-Based Payment Modifier, among other changes. Find the comments to the Final Rule submitted by IDSA here. IDSA expressed to CMS its concerns over how performance data will be presented to the public, including the potential use of national benchmarking, which may not take into account regional variation in practice patterns and differences in patient populations. For example, there are regional variations in the causes of pneumonia (specifically Legionellosis) and holding providers to a rigid national standard may not serve Medicare beneficiaries’ best interests.
Further, the comments outlined IDSA’s concerns that due to the paucity of measures that can be reported via claims-based reporting, many of our members in solo/small practices may face the potential administrative burden and anxiety of being subject to the measure-applicability validation (MAV) process since most claims-based measures that even remotely apply to the clinical practice of infectious disease medicine lie in the Effective Clinical Care domain or the Community/Population Health domain.
IDSA continues to work to build a robust portfolio of relevant quality measures that will allow our members to demonstrate their value in the treatment of severe infections, such as Clostridium difficile-associated enterocolitis and Staphylococcus aureus septicemia. In its comment letter, IDSA requested that CMS recognize these ongoing efforts by more gradually retiring measures from the PQRS so that specialties are not left scrambling to find less than meaningful ways to satisfy reporting requirements at the “11th hour.” Alternatively, or in parallel, IDSA requested that CMS offer more flexible reporting options for those who do not have a large number of relevant measures to report.
Obama Requests Doubling of Funds to Combat Antibiotic Resistance
President Obama’s budget request for fiscal year 2016 devotes significant new resources to combat antimicrobial resistance. The request doubles current federal funds dedicated to drug resistance to over $1.2 billion and would address key recommendations from the 2014 President’s Council of Advisors on Science and Technology (PCAST) Report to the President on Combating Antibiotic Resistance.
Specifically, the president’s budget would revitalize the pipelines for new antibiotics and diagnostics, with over $650 million to the National Institutes of Health (NIH) and Biomedical Advanced Research and Development Authority (BARDA) to jumpstart research and development through increased partnerships with academia and industry. Further, it would provide long overdue investments in the Centers for Disease Control and Prevention (CDC) and other agencies to strengthen antibiotic use and resistance surveillance in humans and food-producing animals. The president’s budget also reflects the need for appropriate stewardship of existing antibiotics as a strategy to preserve their utility.
IDSA strongly supports the president’s proposal and will continue to advocate for the passage of important legislation, such as the Promise for Antibiotics and Therapeutics for Health (PATH) Act, and the Antibiotic Development to Advance Patient Treatment (ADAPT) Act, to speed patient access to the most desperately needed antibiotics, and tax credits to spur antibiotic and diagnostic research and development.
You can support IDSA’s antimicrobial resistance funding advocacy efforts by taking three minutes to sign on to our Action Alert.
In a separate statement, HIVMA expressed support for the continued, and in some instances, increased funding for HIV/AIDS domestically. The budget proposal includes an increase in NIH funding by $1.2 billion as well as increases at the CDC of $31.5 million for viral hepatitis and $12.6 million for domestic HIV prevention. The president would consolidate Ryan White Part D into Ryan White Part C and would increase funding for the consolidated programs by $4 million. Other Parts of the Ryan White HIV/AIDS program would be flat funded.
Unfortunately, proposed funding for global health issues is disappointing. The president’s budget would flat-fund the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and would cut spending on global tuberculosis response. In a statement, IDSA’s Center for Global Health Policy urged Congress to fund these programs at higher levels.
IDSA and HIVMA staff will continue to examine the budget for potential impacts on initiatives important to antimicrobial resistance and infectious diseases including HIV/AIDS both domestically and internationally.
New Report, The Promise of Next Generation Diagnostics, Targets Policymakers
IDSA has released a new policy report, Better Tests, Better Care: The Promise of Next Generation Diagnostics. A non-technical adaptation of IDSA’s 2013 Better Tests, Better Care: Improved Diagnostics for Infectious Diseases, the report is geared toward congressional policymakers and related stakeholders. The report highlights the enormous potential of high quality, rapid, point-of-care diagnostics to improve patient care and public health, as well as existing barriers to the development and appropriate use of such tests. It also recommends policies to stimulate diagnostics research and development and clinical integration. The report was developed by IDSA’s Diagnostics Task Force.
To launch the policy report, IDSA sponsored a congressional briefing to highlight infectious disease diagnostics and recommendations from the report. Task Force Chair, Angela M. Caliendo, MD, PhD, FIDSA, and member Kimberly H. Hanson, MD, spoke at the briefing, along with Diagnostic Task Force industry advisor, Fred Tenover, PhD, FIDSA, from Cepheid, and speakers from the Centers for Disease Control and Prevention and Biomedical Advanced Research Development Authority. In addition, Drs. Caliendo and Hanson met with key congressional offices to discuss recommendations from the report.
Presenting at Congressional briefing (L to R): Drs. Kim Hansen, Angela Caliendo, Robin Robinson, Fred Tenover, and Beth Bell.
Further information on IDSA’s policy efforts on diagnostics can be found at http://www.idsociety.org/Diagnostics/.
Progress on the Road to 10 x ‘20
IDSA members can support IDSA’s goal of having 10 new antibiotics by 2020 by taking three minutes to sign the latest Action Alert urging the Senate to pass the recently reintroduced PATH Act. PATH, or Promise for Antibiotics and Therapeutics for Health, would establish a new limited population antibacterial drug approval pathway for antibacterial drugs to treat serious or life-threatening infections where there exists an unmet medical need. This important legislation was recently reintroduced in the Senate by Sens. Orrin Hatch (R-UT) and Michael Bennet (D-CO).More good news on the antibiotic front was announced late last year with the approval of ceftolozane/tazobactam from Cubist Pharmaceuticals. This is the fifth antibiotic approved since the launch of the 10 x ’20 initiative in 2010.
Although IDSA applauded the new drug’s approval, the Society’s press statement pointed out that patients still face life-threatening infections for which additional new antibiotics are urgently needed. The PATH Act would help by reducing regulatory burdens to new drug development.
FDA Moves to Replace Lifetime MSM Blood Donation Ban with One-Year Deferral
The Food and Drug Administration (FDA) announced in December that it would replace its 30-year lifetime ban on blood donation by men who have sex with men (MSM) with a one-year deferral period. This move comes more than a decade after HIVMA took a stand against the agency's policy and recommended a six-month deferral based on risk behavior rather than sexual orientation. In response to the FDA announcement, HIVMA acknowledged that this progress represents a first step, but also emphasized that further work is needed to develop a policy that is scientifically sound. The FDA is expected to issue its full policy proposal for public comment in the coming months.
Science Speaks: Neglecting ID Anywhere Poses a Threat Everywhere
Here is a look at the top 2014 stories from Science Speaks on developments, setbacks and coming challenges in global HIV and TB responses.
The blog also covered some of the global health and disease issues that will be center stage in 2015, including:
Science Speaks is the official blog of IDSA’s Center for Global Health Policy.
- An update on the West Africa Ebola outbreak from Centers for Disease Control and Prevention Director Tom Frieden following his December visit to the region, and from frontline responders
- An update on policy and research developments that may extend the reach of a cure for hepatitis C and improve treatment options for people coinfected with HIV
Members on the Move
IDSA Board Member, R. Michael Buckley, MD, FIDSA, retired last fall from his position as executive director of Pennsylvania Hospital (PAH) after 37 years of service. Dr. Buckley was responsible for the clinical, research, and education activities of PAH, overseeing more than 1,000 physicians and 2,700 employees. He became chief medical officer of PAH in 2000 and was named executive director in 2010. Dr. Buckley began his term on the IDSA Board of Directors in 2012 and will serve until this fall.
David Classen, MD, a member of the IDSA Quality Improvement Committee, was recently named to the National Quality Forum’s Health Information Technology (HIT) Safety Committee. This committee will explore the intersection of HIT and patient safety in order to create a report that will provide a comprehensive framework for assessment of HIT safety measurement efforts, a measure gap analysis and recommendations for gap-filling, and best practices and challenges in measurement of HIT safety issues to-date.
Are you a member on the move? Do you know someone who is? Contact Jennifer Morales at email@example.com so we can announce it to our membership.
Affonso, Mario, MS
Azeem, Salman, PharmD
Cervantes, Sandy, PharmD, RPh
Charnot-Katsikas, Angella, MD
Crank, Jill, BSN, FNP, MPH
Cusano, Elizabeth, NP
Diuk-Wasser, Maria, PhD
Frost, Loran, PA-C
Gazelle, G Scott, MD, MPH, PhD
Geisler, Michael, PharmD
Giancola, Stephanie, PharmD
Helgeson, Matthew, PharmD, RPh
Htwe, Pwint, MD
Igboekwe, Emmeline, PharmD
Johnson, Gerard, PhD
Kufelnicka, Anna, MD
Lanzi, Maria, MPH, MS, NP
Lindsey, Deidre, PharmD
Moore, Tim, PharmD
Pham, Christine, PharmD
Pham, Christine, PharmD
Saga, Tomoo, MD, PhD
Tavodova, Milada, MD
Tejaswi, Diwakar, MBBS, MPH, PhD
Udwadia, Zubin, MD
Waraich, Kanwaljit, MD
Willits, Jamie, MD
Barber, Katie, PharmD
Britton, Sumudu, MBBS
Bruno-Murtha, Lou Ann, DO
Francois, Bruno, MD
Garg, Amit, MD
Ge, Yu, PharmD
Gill, Michelle, MD, PhD
Gordon, Aubree, PhD
Hugentobler, Emmanuelle, MD
Jeng, Arthur, MD
Keller, Sara, MD, MPH, MS
Koh, Tse, MBBS
Liu, Su-Hsun, MD, MPH, PhD
Moskowitz, Gail, MD
Moyer, Darilyn, MD
Read, Timothy, PhD
Rihana, Nancy, MD
Robinson, Philip, MD
Rubin, Harvey, MD
Vinnard, Christopher, MD
Walsh, Thomas, MD
Amir, Sadia, MBBS
Bagla, Prabhava, MBBS, MD
Buller, Megan, MD
Cabrera, Karely, MD
Chida, Natasha, MD
Cohen, Seth, MD
Doyle, Richard, MD, PhD
Hale, Andrew, MD
Ishaque, Sadia, MBBS
Jillellamudi, Suresh, MD
Khan, Aisha, DO
Khan, Areej, MD
Largen, William, MD
Mallo, Ryan, FNP
Olafsostin, Louisa, MD
Otto, Caitlin, PhD
Qureshi, Sonia, MBBS
Ristagno, Elizabeth, MD
Saito, Hiroki, MD
Saleveino, Francisco De Matos, MD
Shah, Payal, MD
Singh, Hanish, MD
Trinh, Sonya, MD, MPH
Vanchhawng, Lisa, MBBS, MD
VanEperen, Alison, DO
Yogo, Norihiro, MD
Cooper, Joseph, MD
Eddy, Jared, MD
Iovleva, Alina, MD
Haydek, John, MD
Robert W. Armstrong, MD
Charles P. Craig, MD
Richard M. Krause, MD
S. M. Marcy, MD
Akira Saito, M
From the President
The apparent decline in the number of medical students choosing a career in ID has grabbed the attention of the ID community, myself included. IDSA is engaged on many levels examining the data behind the decline and through initiatives to attract the best and the brightest to our field.
Addressing the Decline in the Match: We Can Reverse the TrendIt has been 37 years since I chose to specialize in infectious disease, and I still feel the same commitment and passion for the field as I did when I started out. Few specialties offer the challenges, the variety or the opportunities to save lives and improve public health. Why then, does the number of medical students and residents choosing this field appear to be dwindling? I can assure you that this issue is of great concern to me personally and to IDSA. I also want to assure you that the leadership of IDSA is committed not only to examining the potential causes of the decline, but also to taking action to reverse the trend.
In the unlikely event that you have not seen the numbers, in the most recent cycle of the National Resident Matching Program, 99 of the 327 (30%) ID positions offered were not filled, continuing a trend we’ve seen in recent years. According to analysis by ID colleagues published in Clinical Infectious Diseases (CID), the contributing factors are the relatively low pay, a shrinking pool of international medical graduates, concerns about the job market, and the rise of the hospitalist. This analysis provides a solid basis for our efforts to address the match, but we also need to consider other data from the American College of Graduate Medical Education and the American Board of Internal Medicine showing that ID fellowships are, in fact, being filled—just not through the match.
IDSA is already engaged on many fronts in addressing what we do know is holding students and residents back from choosing ID, such as compensation and perceptions about career opportunities:
Medical Education: IDSA is focusing on approaches to improve upon the way medical microbiology is taught in medical school in order to better demonstrate the appeal of a career in ID. This is an ongoing theme with the training program directors and the Education Committee. We are hopeful that this could be a way to impact early career decisions.
Mentorship: We know from IDSA’s own survey of fellows that having a mentor plays a tremendous role in choosing the field of ID. Nearly 90 percent of those surveyed said that mentors influenced their decision to choose the speciality, and 47 percent said they had a “great impact.” IDSA is committed to expanding our mentorship efforts. In addition to our two Fellows’ meetings every year, we launched a new Mentorship Program at IDWeek through which students, residents and fellows are teamed up with seasoned ID professionals to explore the meeting together. We also have expanded the number of scholarships under IDSA’s Medical Scholars program, which gives medical students the opportunity to work with an ID mentor.
Scholarships: The IDSA Education and Research Foundation supports medical students and young investigators with scholarships, fellowships, travel grants, and research funding to help recruit more young doctors into our specialty and to help with their early career development.
Compensation: All of our efforts to improve medical education and foster students and residents through mentorship programs are important, but we also know that improving compensation is critical. IDSA continues to advocate for better compensation for ID services and how to value their input differently under health reform. A valuable resource is available to all IDSA members to advocate for appropriate compensation through the Value Toolkit (member login required), a collection of presentations, videos and documentation using the data from The Value of the ID Specialist study published in CID. Using these tools, members can make the case to employers, hospital administrators and health plan executives that ID consults result in better outcomes and lower costs. We will also be undertaking in the near future a survey to IDSA members on their compensation, in order to get better data than that available through other sources, and help direct our efforts most appropriately.
Funding for Research and Public Health: IDSA’s policy and government affairs team works diligently, advocating for the reversal of federal funding cuts that impact our field and encouraging the White House and Congress to commit more funding to infectious disease research and public health. These are advocacy efforts that each and every IDSA member can lend a voice to by signing onto IDSA’s action alerts.
Our commitment to reversing this trend will not cease. I’m pleased to announce that the IDSA Board of Directors has approved the creation of a Task Force on ID Recruitment. Under the leadership of Wendy Armstrong, MD, FIDSA, chair of IDSA’s ID Training Program Directors Committee, this task force will be examining the match results and other existing data, reviewing current efforts to recruit young physicians into the field, and making recommendations on additional efforts the Society should undertake in the short and long term. We recognize that this effort is broader than medical education, and accordingly, the Task Force will seek input from other IDSA committees and task forces, including the Clinical Affairs, Research, Public Health and Education Committees among others. We need specific and actionable ideas to address these issues, and we need to act as quickly as possible. It will take a commitment from each of us to get involved, to share our passion for our specialty with the bright, curious, driven and altruistic young doctors around us. If you have specific suggestions for actions we might take, please don’t hesitate to forward them to me directly and/or to Wendy Armstrong.
IDWeek 2015 – Sneak Preview of Keynote Speakers
Join us in San Diego at IDWeek and hear the recently announced Named Lectures. Lynne Mofenson, MD will discuss her work in pediatric, adolescent and maternal HIV/AIDS research and clinical trials; Alan Magill, MD, FIDSA, will tell about his work for the Bill and Melinda Gates Foundation towards the eradication of malaria. Read more about the Named Lecture Series.
The Named Lectures are a highlight of IDWeek and a long standing IDSA tradition. Please join us at IDWeek 2015, October 7-11 in San Diego, to hear these outstanding lectures. Look for early registration for IDSA members in March at www.idweek.org.
Roger I. Glass, MD, PhD, FIDSA
of the Centers for Disease Control and Prevention
gave the 2014 John F. Enders Lecture.
The John F. Enders lecture will be given by Lynne Mofenson, MD, formerly branch chief of the Maternal and Pediatric Infectious Disease Branch at the Eunice Kennedy Shriver National Institute of Child Health and Human Development. She was responsible for overall program planning and the development and scientific direction of research studies and clinical trials in domestic and international pediatric, adolescent, and maternal HIV infection, disease, and AIDS, until her retirement in 2014.
The Maxwell Finland lecture will be given by Henry “Chip” Chambers, MD, FIDSA, of the University of California, San Francisco. Dr. Chambers is chief of Infectious Diseases at San Francisco General Hospital and director of the UCSF Infectious Diseases Fellowship Training Program. The Finland lecture is given by a leader in the areas of bacterial pathogenesis, antimicrobial resistance, emerging infections and hospital acquired infections.
The Joseph E. Smadel lecture will be presented by Alan Magill, MD, FIDSA of the Bill & Melinda Gates Foundation. Dr. Magill oversees the development and implementation of strategies for the Foundation’s ultimate goal of the eradication of malaria, including developing new generations of vaccines, diagnostics, and anti-malarial therapies to be used in novel and innovative ways. The Joseph E. Smadel lecture is intended to honor someone who has made a significant impact in global public health.
The Edward H. Kass lecture will be given by Karen C. Caroll, MD of the Johns Hopkins School of Medicine. She serves as the director of the Medical Microbiology Division and the director of the medical microbiology fellowship program for Department of Pathology. The Kass lecture was initially established as a “history of medicine” lecture and has traditionally been given by a recognized educator and thought leader with a broad understanding of societal influences in medicine.
Each year at IDWeek, the Society recognizes the exemplary and outstanding legacies left behind by those for whom the memorial lectureships are named. The Named Lectureships continue to honor the significant contributions these individuals made to the fields of infectious diseases and public health throughout the world. They have set standards that challenge and inspire those involved in the work of infectious diseases. Presenting a Named Lecture is among the very highest of IDSA honors, and we are proud to announce the lecturers for IDWeek 2015.
View past lectureship award recipients.
The 2014 IDWeek HIVMA Chair, Rochelle Walensky, MD, FIDSA,
presented the Maxwell Finland Award to Liise-Anne Pirofski, MD, FIDSA
of the Albert Einstein College of Medicine.
IDSA Foundation Offers Research Awards to Young Investigators
Applications are now being accepted for the Young Investigator Award in Geriatrics and the Pfizer Young Investigator Award in Vaccine Development. Deadline: April 9.
The IDSA Education and Research Foundation (ERF) has joined forces with the National Foundation for Infectious Diseases (NFID) to offer the 2015 IDSA ERF/NFID Joint Research Awards.
Two awards will be granted this year and applications are due April 9.
The Young Investigator Award in Geriatrics provides funding for young investigators who develop and implement a basic, clinical, or health services research project focused on a geriatric aspect of infectious diseases. Applicants must have applied for the GEMSSTAR award and received a fundable score as defined by the National Institutes of Health. The award is administered by IDSA and the Alliance for Academic Internal Medicine (AAIM)/Association of Specialty Professors (ASP).
The Pfizer Young Investigator Award in Vaccine Development provides funding for outstanding research in vaccine development, either through clinical or laboratory investigation.See the IDSA website for eligibility requirements, checklists, and applications. Contact the award staff at firstname.lastname@example.org if you have any further questions regarding the application process.
IDSA Journal Club
Prior Urine Cultures: Does the Past Predict the Present?; Treating Pyogenic Vertebral Osteomyelitis: 6 Weeks or 12 Weeks of Antibiotics?; Recurrent SSTIs in Pediatric Patients: Persistent Colonization or Hidden Environmental Reservoirs?; Making Fecal Microbiota Transplantation for Recurrent C. difficile Easier to Swallow; Antibiotics and Hypoglycemia Risk Among Older Patients Taking Sulfonylureas.
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.
For a review of other recent research in the infectious diseases literature, see “In the Literature,” by Stanley Deresinski, MD, FIDSA, in each issue of Clinical Infectious Diseases.
Prior Urine Cultures: Does the Past Predict the Present?
Reviewed by Christopher J. Graber, MD, MPH, FIDSA
When prescribing therapy for urinary tract infections prior to urine culture results becoming available, clinicians often look to prior urine cultures to get an idea of whether or not the current infecting organism will be susceptible to a particular antibiotic, despite limited data to support this approach.
In a recent article in Clinical Infectious Diseases, authors from two health care systems in Toronto and Chicago examined 22,019 consecutive pairs of positive urine cultures from 4,351 patients. Patients had a mean age of 72 years with a 184-day mean interval between cultures; 78 percent of the paired cultures were from females. The organism was the same in 9,590 pairs (44 percent); these were included in an analysis of antimicrobial susceptibility.
Organism correspondence was approximately 80 percent within 1 week between cultures, declining to 57 percent at 4-8 weeks and still remaining at 49 percent at >32 weeks. Among the paired isolates growing the same organism, the susceptibility profile was the same or better in 83 percent at 4-8 weeks and 75 percent at >32 weeks, rising to 87 percent and 80 percent, respectively, if no antibiotics were prescribed in the interim, and falling to 80 percent and 73 percent, respectively, if E. coli was the infecting organism. In a subset of paired cultures for which ciprofloxacin susceptibility and utilization data were available and the initial isolate was ciprofloxacin-susceptible, the likelihood of ciprofloxacin susceptibility in the subsequent isolate remained above 80 percent if no fluoroquinolones had been prescribed in the interim, regardless of time interval. If fluoroquinolones had been prescribed in the interim, ciprofloxacin susceptibility fell to approximately 50 percent at 1-2 weeks but increased to 60-75 percent with longer timeframes between cultures.
While these data should be carefully interpreted, they usefully inform empiric prescription of antibiotic therapy for urinary tract infections but still reinforce the need for follow-up on urine culture results to guide definitive therapy.
(MacFadden et al. Clin Infect Dis. 2014;59(9):1265-71.)
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Treating Pyogenic Vertebral Osteomyelitis: 6 Weeks or 12 Weeks of Antibiotics?
Reviewed by Manie Beheshti, MD
Lack of robust evidence to guide the treatment of osteomyelitis poses a common clinical challenge for ID physicians. Duration of therapy is typically backed by observational data and expert opinion. In an article published online in the Lancet on Nov. 5, researchers reported findings of their randomized, controlled trial assessing the non-inferiority of 6 versus 12 weeks of therapy for pyogenic vertebral osteomyelitis.
Conducted across multiple centers in France, the study randomized more than 350 patients to 6 versus 12 weeks of therapy with antimicrobial regimens selected in agreement with French guidelines. Patients across both arms had similarities in (1) anatomical vertebral site of involvement, (2) rates of concomitant infective endocarditis and blood culture positivity, and (3) number of patients with neurological signs.
Clinical cure was equal in both arms (90.9 percent in both the 6- and 12-week groups) exhibiting non-inferiority of the 6-week regimen compared with the 12-week. In their post-hoc analysis, the authors highlighted that, likely due to low sample size, non-inferiority was not met in certain subgroups: age greater than 74, presence of immunosuppression or diabetes, endocarditis, or neurological signs. Conversely, superiority of the 12-week regimen was not demonstrated in any subgroup. While there was no difference in the types of antimicrobials used between groups, most patients received less than 2 weeks of intravenous therapy, and the most common oral regimen included rifampin with a fluoroquinolone.
In an era of increasing need for stewardship to help avoid collateral damage from antimicrobials, this study provides rare data in the realm of osteomyelitis that suggests in the right clinical setting a shorter course of therapy is non-inferior for patients with pyogenic vertebral osteomyelitis.
(Bernard et al. Lancet, early online publication, Nov. 5, 2014.)
Back to TopRecurrent SSTIs in Pediatric Patients: Persistent Colonization or Hidden Environmental Reservoirs?
Reviewed by Terri Stillwell, MD
Recurrent methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections (SSTIs) are common referrals for pediatric ID physicians. It is often thought that these infections are due to persistent colonization versus reinfection with diverse strains. Current recommendations speak to decolonization protocols but are often met with varying success. If recurrent infections are caused by similar strains, then are subsequent infections due to failed decolonization or ongoing exposure from an unseen source? Two recent studies attempt to shed additional light on this topic.
In an article from the September issue of the Journal of the Pediatric Infectious Diseases Society, the authors utilized molecular epidemiology to characterize the strain relatedness of MRSA isolates from recurrent SSTIs in otherwise healthy children. The objective was to determine whether subsequent MRSA SSTIs were reinfections by isolates similar to previous infections or new infections with distinct strains. From January 2005 to January 2011, 105 patients had 248 discrete MRSA infections. Ninety percent of repeat infections were attributable to strain types that were identical to those causing prior infections. Data regarding possible decolonization efforts were not available. The authors suggested that, given this degree of relatedness, decolonization should theoretically impact recurrences, but perhaps current decolonization schemas are too brief to achieve true eradication.
In a second article, from the November JAMA Pediatrics, investigators took a slightly different approach, hypothesizing that perhaps environmental contamination leads to recurrent infections. The authors obtained cultures from 21 household surfaces and pets (dogs and cats) to assess the potential for environmental contamination. Cultures of patients’ nares, axilla, and inguinal folds were also obtained to determine presence of colonization. These samples were then compared with one another and with infection isolates to determine strain relatedness.
From January 2012 to February 2013, 50 children with culture-proven MRSA infections participated; 35 had their MRSA-infection strains available for analysis. Of the 50 participants, 64 percent (32/50) had at least one environmental sample positive for S. aureus, with a median of three positive surfaces overall. Twenty-three percent (6/26) of dogs and 7 percent (1/14) of cats were also found to be positive. Forty-two percent (21/50) of the participants themselves were colonized with S. aureus at the time of the study; 28 percent (14/50) had an environmental sample that matched their colonizing strain. Of those that had their MRSA-infection strains available for study, 31 percent (11/35) had concordance between their infection strain and their colonizing strain, and 37 percent (13/35) had concordance between their infection strain and an environmental strain. Only one pet isolate and infection/colonization isolate pair were concordant.
Given these studies’ findings, attempts to optimize decolonization techniques should continue. However, potential environmental reservoirs for reinfection also deserve consideration, in order to break the chain of transmission, in the hopes of preventing recurrent infections.
(Al-Zubeidi et al. J Ped Infect Dis. 2014;3(3):261-264. and Fritz et al. JAMA Pediatr. 2014;168(11):1030-1038.)
Back to TopMaking Fecal Microbiota Transplantation for Recurrent C. difficile Easier to Swallow
Reviewed by Nina Kim, MD, MSc
Recurrent Clostridium difficile infection (RCDI) can be a major scourge for patients and clinicians faced with the failure of conventional antibiotic therapy. Fecal microbiota transplantation (FMT) has emerged as a promising strategy to restore the disrupted gut microflora of patients with RCDI. However, widespread use of FMT has been hampered by the lack of controlled studies or standardization, and the practical challenges of balancing thorough donor screening with the need for prompt treatment while dealing with fresh samples of limited viability—not to mention the distasteful nature of the procedure and the risks of nasogastric or endoscopic delivery. A study published in the Nov. 5 issue of the Journal of the American Medical Association offers a noninvasive and feasible alternative to an otherwise cumbersome therapy.
In this open-label, single-arm study, investigators prepared fecal suspensions from carefully pre-screened healthy donors, pipetted samples into acid-resistant capsules, and stored these at -80°C prior to administration. Twenty patients aged 11 to 89 years old who met their criteria for RCDI (three or more episodes of mild to moderate CDI and failure of vancomycin taper, or two or more episodes of severe CDI requiring hospitalization) ingested a total of 30 capsules over 2 consecutive days. In the end, all but two patients (90 percent) achieved clinical resolution of diarrhea in a mean of 4 days without relapse during 8 weeks of follow-up, comparable to response rates of freshly prepared FMT reported in the literature. The capsules were generally well tolerated aside from transient abdominal cramping and bloating observed in six patients. Notably, no patient vomited after capsule administration.
Despite its limitations as a small, short-term, single-center study, this trial has demonstrated that oral administration of frozen fecal microbiota is a safe, feasible, and cost-effective route of delivery that opens the door for potentially greater access and ideally more rigorous study of FMT.
(Youngster et al. JAMA. 2014(17);312:1772-1778.)
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Antibiotics and Hypoglycemia Risk Among Older Patients Taking Sulfonylureas
Reviewed by Michael T. Melia, MD
Sulfonylureas stimulate pancreatic insulin secretion and can cause hypoglycemia, which in turn can be associated with significant morbidity. While concurrent use of certain antibiotics has been shown to increase the risk of hospitalization for hypoglycemia, this association has been incompletely explored.
In a recent issue of JAMA Internal Medicine, investigators used Texas Medicare claims data to analyze this association. They reviewed glyburide or glipizide prescriptions that overlapped by at least one day with those for one of 16 commonly prescribed antibiotics. For persons prescribed one of seven antimicrobials previously associated with hypoglycemia, they collected data on hypoglycemic events resulting in emergency department evaluation or inpatient hospitalization within 14 days of antibiotic use. To calculate the excess cost of these episodes, they averaged the cost of hypoglycemia management among patients prescribed one of five antimicrobials associated with hypoglycemia and subtracted the average post-antibiotic costs of the non-interacting antibiotics.
The investigators analyzed 133,535 episodes of overlapping prescriptions; rates of hypoglycemia ranged from 0.17 percent to 1.87 percent. When compared with antimicrobials not associated with hypoglycemia, clarithromycin, levofloxacin, trimethoprim-sulfamethoxazole, metronidazole, and ciprofloxacin each significantly increased the risk of hypoglycemia; the number of prescriptions needed to harm ranged from 71 for clarithromycin to 334 for ciprofloxacin. Each prescription for one of these five agents was associated with an increased Medicare cost of $30.54.
While studies based upon claims data have inherent limitations, the investigators controlled for a number of variables, including age, sex, race/ethnicity, Medicaid eligibility, comorbidities, prior hospitalizations for hypoglycemia, and nursing facility residence. Their results were unchanged when stratifying data by the antibiotic indication, as well as when patients with renal disease or receiving insulin were excluded. Their study makes an important contribution to our knowledge about clinically important drug-antibiotic interactions among older patients, and it highlights the hidden costs—both financial and medical—associated with antibiotic prescriptions.
(Parekh et al. JAMA Intern Med. 2014;174(10):1605-1612.)
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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:
- Seals as the Original Source of Tuberculosis in the Americas
- Staphylococcal Small-Colony Variants and Prosthetic Joint Infections
- Case Vignette: White Urine—Albinuria
- Case Vignette: Malaria: Monkey to Human
- Growing Risk of Viral Hemorrhagic Fever in India: Crimean-Congo Hemorrhagic Fever
- Growing Risk of Viral Hemorrhagic Fever in India: “Monkey Fever”
- Case Vignette: Hepatic Echinococcosis and Pulmonary Embolism
- After the “Blood Diamond” Conflict: Lassa Fever in Sierra Leone
- Case Vignettes
- Molecular Epidemiology of Ebola Virus in Sierra Leone, 2014
- Febrile Illness in Sierra Leone: A Predictor of the Ebola Epidemic?
- Infection Apparently Acquired During Travel