IDSA News - January 2017
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Advances in Testing Prompt First New TB Guidelines in 17 Years

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Patients at risk for latent or active tuberculosis (TB) infection should be assessed with newer tests, including interferon-gamma release assays (IGRAs) and molecular diagnostics, according to new guidelines on TB diagnosis published by IDSA with the American Thoracic Society (ATS), and Centers for Disease Control and Prevention (CDC) in Clinical Infectious Diseases. Advances in testing prompted the first new guidelines on TB diagnosis in 17 years.

TB spreads through the air and can be challenging to diagnose and treat. Up to 13 million Americans have latent TB. Only 5 to 10 percent ultimately go on to develop the disease itself, about half of those within two years of being infected. Treatment varies depending on whether the TB is latent or becomes active.

Because TB disease is less common in the United States, healthcare providers may overlook it as a possible diagnosis. The guidelines recommend healthcare providers consider testing for latent TB in patients who:

  • Live with a person who has TB disease,
  • Immigrated to the United States from a country where TB disease is common,
  • Are in high-risk settings, such as prison.

If the patient does not have active signs of TB disease, the guidelines recommend testing be performed with one of two Food and Drug Administration-approved IGRAs, rather than using a tuberculin skin test (TST). If an IGRA is not available, a TST is acceptable. IGRAs test the blood and are more effective at detecting TB disease infection than a TST. IGRAs also are more practical because they can be done in one patient visit. The TST requires two visits and patients often don't return within the allotted two or three days to have results assessed.

If a person has a positive TST or IGRA, has no symptoms and the chest X-ray is normal, latent TB treatment to prevent progression to TB disease should be considered. If the X-ray suggests active disease, the doctor should order a combination of tests of sputum including smears, cultures and a nucleic acid amplification test. Molecular diagnostic testing results are more specific for TB disease than smears and available more quickly than cultures.

If a patient has active signs of TB disease, doctors should order smear, cultures and molecular diagnostic testing, particularly in patients at higher risk, such as those who have HIV or live with a patient with TB disease, the guidelines recommend. Symptoms of TB disease include ongoing fevers, night sweats, weight loss and coughing. If tests confirm TB disease, patients should be treated appropriately in conjunction with infectious disease and/or pulmonary physicians, as well as with the public health department. Much more intensive than treatment for latent TB, the regimen for TB disease includes a combination of four medications taken for six months. Treatment of antibiotic-resistant TB disease is even more complex.

Drug-resistant TB disease is becoming a significant problem, with about 500,000 cases of multi-drug resistant TB disease from 127 countries and extensively drug resistant TB disease reported in 105 countries.

Because TB is a complex disease, treatment should be provided by physicians with TB experience, such as infectious disease specialists or pulmonologists.

The guidelines have been endorsed by the European Respiratory Society.

In addition to lead author, David M. Lewinsohn, MD, PhD, the guidelines panel includes: David L. Cohn, MD, FIDSA; Charles L. Daley, MD; Ed Desmond, PhD; Joseph Keane, MD; Michael K. Leonard, MD, FIDSA; Deborah A. Lewinsohn, MD; Philip A. LoBue, MD; Ann M. Loeffler, MD; Gerald H. Mazurek, MD; Richard J. O'Brien, MD; Madhukar Pai, MD, PhD; Luca Richeldi, MD, PhD; Max Salfinger, MD, FIDSA; Thomas M. Shinnick, PhD; Timothy R. Sterling, MD, FIDSA; David M. Warshauer PhD; and Gail L. Woods, MD.

Your Voice in Washington

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IDSA continues bringing issues of concern to the infectious diseases community to the attention of policymakers in Washington, DC:

Antimicrobial Drug Shortages: IDSA is alerting Congress about persistent antimicrobial drug shortages and their impact on patient care, including results from a 2016 Emerging Infections Network survey, in which 73 percent of respondents reported that a drug shortage had affected patient outcomes. "As the threat of antimicrobial resistance grows, the revelation that almost four of five physicians surveyed had to use a broader spectrum drug due to drug shortages is particularly disturbing," wrote IDSA President William G. Powderly, MD, FIDSA. IDSA will continue urging Congress to take additional steps to prevent and address drug shortages.

Role of ID in Stewardship: Dr. Powderly also gave a presentation to the Presidential Advisory Council on Combating Antibiotic Resistant Bacteria earlier this month on ID physician workforce issues and the value ID physicians bring to infection prevention and antimicrobial stewardship.

Common Rule for Protecting Human Subjects of Research: In its final days, the Obama administration released a final revised Federal Policy for the Protection of Human Subjects (Common Rule). IDSA and sister societies commented repeatedly on proposed revisions, emphasizing the need to allow researchers access to biospecimens. While IDSA is still reviewing the final rule, it does include key IDSA recommendations: (1) does not subject research on nonidentified biospecimens to the Common Rule; (2) allows the use of broad consent for storage, maintenance and secondary research of identifiable private information and biospecimens; and (3) does not adopt new privacy safeguards for identifiable private information and biospecimens.

Quarantine Rule: The Centers for Disease Control and Prevention (CDC) finalized its quarantine rule earlier this month, incorporating recommendations from IDSA. The new rule: (1) clarifies that quarantine protocols for individual outbreaks will change based upon most current scientifically verified epidemiological evidence; (2) requires CDC to provide accommodations, communication capabilities and medical care to quarantined individuals; and (3) states that federal quarantine orders shall be reassessed no later than 72 hours after issuance.

Laboratory Developed Tests (LDTs): The Food and Drug Administration (FDA) has issued a discussion paper on the proposed regulation of LDTs. The paper's goal is to further public discourse on LDTs; it is not enforceable, is not an official agency position, and it's unknown whether it reflects the new administration's thinking. IDSA had previously expressed concerns about the impact of new regulations on lab tests that ID physicians rely upon to guide treatment decisions (see IDSA's position statement in CID). While the discussion paper's approach would expand FDA regulation of LDTs, it differed in important ways from the initial FDA proposal. For example, the discussion paper proposed: 1) "grandfathering," or exempting from regulation, most existing LDTs; 2) expediting the premarket review process for LDTs by leveraging accepted reference and review standards for analytical validity and permitting clinical validity to be established by sources (such as literature and well-curated databases) that meet the valid scientific evidence standard; and 3) speeding up the phase in of FDA regulation over four years instead of nine. IDSA is reviewing the discussion paper and preparing a comprehensive response.

Updated Resources for Managing Your Clinical Practice from IDSA

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With the implementation of the Medicare's new Quality Payment Program, the increased interest in telehealth and telemedicine, and the continued urgency of the development antimicrobial stewardship programs, IDSA's Clinical Affairs Department has recently updated several webpages under the "Manage Your Practice" section of the IDSA website.

In addition to information about the Merit-Based Incentive Payment System, IDSA has updated information on quality improvement, compensation, and ID physician leadership of population health services. The new sections of the website are available at Manage Your Practice and include information on the following:

If you have any questions about the information on these updated webpages, please contact the Clinical Affairs Department at ClinicalAffairs@idsociety.org

Science Speaks Follows 115th Congress, White House Transition

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The IDSA Global Health Science Speaks blog is covering changes in leadership and policy impacting global infectious disease research and responses with reporting on the 115th Congress and the 2017 Transition, including:

  • The Trump Administration's decision to keep United States Global AIDS Coordinator Ambassador Deborah Birx and National Institutes of Health Director Dr. Francis Collins in their posts at least until the appointment of new Cabinet officials;
  • The return and expansion of President Reagan's 1984 "Mexico City" policy prohibiting international and local nonprofits receiving U.S. funding from providing counseling, referrals or services to terminate pregnancies;
  • Introductions to new members of the Senate Foreign Relations, Appropriations, and HELP Committees.

The blog also takes a look at President Obama's global disease response legacy.

HIVMA Medical Students Program: Apply Now

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Know any medical students who are interested in HIV? Tell them to apply for the 2017 HIVMA Medical Students Program! Applications are due February 15. The program provides support for up to three years for HIV-related clinical research projects and mentorship. First-, second-, and third-year students at accredited U.S. medical schools are eligible to apply for the program, which includes free HIVMA/IDSA membership and a $3,500 yearly stipend for up to three years.

For more information on the program, including previous students, their projects, and mentors, visit the HIVMA Medical Students Program page on the HIVMA website. Mentors must be IDSA/HIVMA members. The online application is here. Please email HIVMA staff with questions.

Pertussis: An OFID Interview with Dr. James Cherry

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In this 12th installment of the Open Forum Infectious Diseases (OFID) podcast, Editor Paul Sax, MD, discusses pertussis epidemiology and prevention with James Cherry, MD. Dr. Cherry breaks down the evolution of pertussis vaccines over time, how to protect and prevent infection in those most at risk, and whether infections are truly on the rise.

IDWeek 2017 Sneak Preview of Named Lecturers

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Each year at IDWeek, the Society recognizes the exemplary and outstanding legacies of those for whom the memorial lectureships are named. Please join us at IDWeek 2017, October 4-8 in San Diego, to hear these outstanding lectures. Look for early registration for IDSA members in March at www.idweek.org.

The John F. Enders Lecture will be given by Connie Celum, MD, MPH, FIDSA, of the University of Washington School of Public Health. She is a professor of allergy and ID as well as global health, and an adjunct professor in epidemiology. Her research focus is on HIV prevention and vaccine trials with the objective to find effective strategies to reduce HIV acquisition and transmission. The John F. Enders Lecture is intended to honor someone who has made significant contributions in the field of medical virology.

The Maxwell Finland Lecture will be given by Steven M. Holland, MD, director of the Division of Intramural Research at the National Institute of Allergy and Infectious Diseases and chief of the Immunopathogenesis Section within the Laboratory of Clinical Infectious Diseases. The Finland Lecture is given by a leader in bacterial pathogenesis, antimicrobial resistance, emerging infections and hospital acquired infections.

The Edward H. Kass Lecture will be given by James M. Hughes, MD, FIDSA, of the Emory University School of Medicine. A past president of IDSA, Dr. Hughes holds joint appointments in the School of Medicine (Infectious Diseases) and the Rollins School of Public Health (Global Health) and is co-director of the Emory Antibiotic Resistance Center. 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.

The Joseph E. Smadel Lecture will be presented by Ruth Lynfield, MD, FIDSA, medical director of the Minnesota Department of Health and adjunct professor of medicine at the University of Minnesota. The Joseph E. Smadel Lecture is intended to honor someone who has made a significant impact in global public health.

The Named Lectureships honor outstanding contributions by individuals who have set standards that challenge and inspire those involved in the work of infectious diseases throughout the world. Presenting a Named Lecture is among the very highest of IDSA honors, and we are proud to announce the lecturers for IDWeek 2017.

View past lectureship award recipients.

A Year Ahead of Challenges and Opportunities

William G. Powderly, MD, FIDSA, President

We are merely days into a new Congress and Administration and there is much that remains to be seen. We do know that remaining true to our strategic priorities and advocating for a strong ID workforce, a sound public health system, robust funding for global and domestic research, and continuing the fight against antimicrobial resistance is a non-partisan pursuit—these are priorities we have to pursue no matter the political party in power. We also know that many of the issues that concern us will be unfamiliar to those new to Washington, and we must focus our efforts on helping them understand their importance.

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William G. Powderly,
MD, FIDSA, President

Shortly after the US elections in November I posted to MyIDSA my thoughts on what lies ahead for the future of healthcare broadly and ID specifically. Then, as now, we are in many ways limited to speculation. But, we do know that remaining true to our strategic priorities and advocating for a strong ID workforce, a sound public health system, robust funding for global and domestic research, and continuing the fight against antimicrobial resistance (AMR) is a non-partisan pursuit—these are priorities we have to pursue no matter the political party in power. We also know that many of the issues that concern us will be unfamiliar to those new to Washington, and we must focus our efforts on helping them understand their importance. IDSA and HIVMA are hard at work promoting our societies’ priorities with the new Administration and Congress, including:

  • Reaching out to the Trump transition team and new White House health policy advisor, Katy Talento (who has a background in infectious diseases and epidemiology);
  • Working with IDSA members in key states to urge Senators to ask HHS Secretary nominee Tom Price about his positions on ID priorities (as a result, Price was asked about his support for antibiotic research and development and for increased NIH funding);
  • Leading our Stakeholder Forum on Antimicrobial Resistance (S-FAR) to urge the President-elect to prioritize AMR;
  • Preparing our response to proposed significant cuts to federal funding of a wide variety of programs relevant to IDSA and HIVMA priorities;
  • Emphasizing the overwhelming science demonstrating the safety and benefit of routine childhood immunizations in response to reports that Trump was considering creating a vaccine commission to be chaired by known vaccine critic Robert Kennedy, Jr.

HIVMA leaders have also written the President-elect and will write to Ms. Talento to ensure that we do not lose ground in our response to the HIV pandemic. Specifically, that includes full implementation of the National HIV/AIDS Strategy; robust funding for the Ryan White HIV/AIDS Program; sustaining and expanding access to affordable health insurance; programs and incentives to support the HIV and ID medical workforce; robust funding for HIV research; a strengthened commitment to ending the global AIDS pandemic; and a comprehensive, evidence-based response to the opioid epidemic.

HIVMA organized a petition endorsed by more than 1,000 HIV medical professionals urging Congress not to repeal the Affordable Care Act (ACA) without simultaneously having an equivalent replacement plan. While not perfect, the ACA has dramatically reduced the uninsured rates in many HIV clinics and provided access to health insurance coverage and non-HIV care and treatment to many patients for the first time. Two examples shared by HIVMA members illustrate why this issue is so important to our patients:

  • At the Bluegrass Clinic in Lexington, the uninsured rate dropped from 42 percent to 7 percent when ACA came online in Kentucky. With expanded healthcare coverage, the clinic has seen an uptick in patients accessing primary care, including for vaccinations and HIV testing, and in the number of referrals they receive for HIV care.
  • At the John T. Carey Special Immunology Unit of University Hospitals of Cleveland, with implementation of the ACA, the uninsured rate in the HIV clinic dropped from nearly one-third to 7 percent.

Check the IDSA website periodically to learn updates in our efforts to work with the new administration and Congress.

Also, please remember to share your thoughts and views with IDSA leadership and your fellow members on MyIDSA. We are a membership of over 10,000 and we are certain to have differing political views and opinions on how to address issues facing our nation, but we stand together in our view that one thing the nation cannot do without is a strong ID workforce. Meeting the strategic goals of the Society will require member engagement at every level. Learn about how you can get involved.

Apply for FIDSA by April 3

Applications are now being accepted for IDSA Fellowship (FIDSA). IDSA Fellowship honors members who have achieved professional excellence and provided significant service to the profession in clinical practice, research, administration, or education.

The advancement to fellow application is now available online. Each application must be accompanied by two letters of nomination from current IDSA Fellows. To be eligible, nominees must have completed training at least five years ago and must have been full IDSA members for the last five years.

Advance your career by applying for IDSA Fellowship. If you’re already a FIDSA, encourage your colleagues to apply and be recognized as leaders in the field. The deadline is April 3.

For more information, contact Member Services at membership@idsociety.org or 703-299-0200.

New 2017 Society Awards

Help us recognize inspirational colleagues who are stellar clinicians, preeminent educators, influential researchers and public heath champions by nominating someone today for a Society Award. Nominations are due March 1.

Two new Society awards will be presented for the first time ever at ID Week 2017:

The Clinical Practice Innovation Award will recognize IDSA members who devote the majority of their time to patient care and have significantly advanced the clinical practice of infectious diseases.

The D.A. Henderson Award for Outstanding Contributions to Public Health will recognize a lifetime of achievement in public health. By naming this award in Dr. Henderson's honor, we hope to inspire others to become champions for public health throughout the world.

Other changes have been made in the Society Awards to reflect the diversity of career paths within ID. The Oswald Avery Award and the Society Citation awards will now allow nominations in three tracks–Clinical Practice, Research (Clinical Investigation or Basic Science), and Public Health—to allow the Awards Committee to better evaluate the nominees.

IDSA offers awards to honor lifetime achievement, early career success, and exemplary contributions throughout the field. For details on all the awards, see http://www.idsociety.org/Society_Awards/.

In Memoriam: Leon G. Smith, MD, FIDSA

Leon G. Smith, MD, FIDSA (1929-2016)

Leon Smith, MD, FIDSA, chairman of medicine and chief of infectious diseases at St. Michael's Medical Center in Newark, New Jersey, passed away on December 19, 2016 at age 87.

During his career, Dr. Smith received multiple awards, including IDSA's Walter E. Stamm Mentor Award, the Mastership Award from the American College of Physicians, the Knight of Saint Gregory honor, and Castle Connolly's Top Doctors Award for more than 15 years.

Dr. Smith earned his medical degree from Georgetown University School of Medicine and completed his residency and fellowship in infectious diseases at the National Institutes of Health and Yale-Grace New Haven Hospital. He went on to St. Michael's Medical Center in Newark and became one of the first infectious diseases specialists in New Jersey, consulting at hospitals across the state. As chairman of medicine and chief of infectious diseases, he founded St. Michael's medical education program. During his time at St. Michael's, Dr. Smith trained hundreds of doctors in internal medicine and dozens more in infectious disease. Those who were fortunate enough to have trained under him were forever changed by the inspiration he provided.

"He was a true mentor to many of us, a real role model, someone who spent his entire life giving to those in need locally, regionally, nationally and internationally," said IDSA Past President Thomas Slama, MD, FIDSA. "He was a persistent and inspirational leader to hundreds if not thousands of physicians and someone whose smile could melt an iceberg. He treated me as if I were one of his sons and if I am fortunate, some of his valued traits will have been passed on to me."

During the early stages of the AIDS epidemic, Dr. Smith was aware of the lack of understanding that led to fear and discrimination and reluctance on the part of hospitals to admit and care for patients with HIV. Realizing that the epidemic would reach Newark, Dr. Smith worked with Archbishop Theodore Edgar McCarrick to ensure that St. Michael's Medical Center would open its doors to these patients. The facility was the first in New Jersey to establish an AIDS inpatient unit and clinic.

Dr. Smith is survived by his five children, Leon, Michele Blackwood, Stephan, Ann Denehy, and Marshall, his sister, Marion Kuhlemann, and his 15 grandchildren. Four of his children have followed in his footsteps and gone on to become doctors, and two of his grandchildren attend medical school (thus far).

Journal Club

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.

Integrase Inhibitor Regimen Superior in Antiretroviral-Naive Women with HIV?

Reviewed by Lauren Richey, MD, MPH

Worldwide, half of HIV infections occur in women, but women are routinely under-represented in clinical trials assessing antiretroviral therapy (ART). Current guidelines are derived from studies that include predominately men and do not address potential sex biases in efficacy, tolerability, and safety of different ART regimens.

The Women AntiretroViral Efficacy and Safety (WAVES) Study, a randomized, double-blind, phase 3 study recently published in Lancet HIV, included only women. The study assessed safety and efficacy of two ART regimens: an integrase inhibitor regimen (elvitegravir, cobicistat, emtricitabine, and tenofovir disoproxil fumarate) versus a protease inhibitor regimen (ritonavir boosted atazanavir, emtricitabine, and tenofovir disoproxil fumarate) in treatment-naive women living with HIV. Gilead Sciences provided funding and participated in data analysis and manuscript preparation.

In 11 different countries, 575 adult women were randomly assigned to either the integrase or protease regimen. Pregnancy, breast feeding, and creatinine clearance of less than 70 ml/minute at enrollment were exclusion criteria. Participants had an average age of 35 and were racially diverse. The primary endpoint, 48 week viral loads of less than 50 copies, was met by 87 percent of the women in the integrase inhibitor group and 81 percent of the women in the protease inhibitor group, meeting the predefined criteria for superiority. The difference was more striking in Russia for integrase inhibitor versus protease inhibitor regimen (89 percent versus 74 percent, respectively) and in the non-black subgroup (89 percent versus 78 percent, respectively). In the U.S., the results for the primary endpoint were much lower and slightly better for the protease inhibitor regimen versus the integrase inhibitor regimen (70 percent versus 68 percent, respectively). Discontinuation was higher in the protease inhibitor group (45 versus 29 women, respectively) driven predominately by adverse events (19 versus 5, respectively) related to rash and bilirubin-associated complications.

Geographically and ethnically diverse ART trials among women living with HIV are feasible. Previous trials among men showed protease inhibitor regimens to be non-inferior, with lower discontinuation rates for adverse events; this study shows integrase inhibitor regimens may be superior for women due to increased tolerability. Further studies to delineate sex-based differences in ART safety and efficacy are needed.

( Squires et al.Lancet HIV.2016 Sep;3(9):e410-20.)


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Early Removal of Central Venous Catheters and Mortality Impact in Children with Candidemia

Reviewed by Terri Stillwell, MD

Bloodstream infections due to Candida species remain a common health care-associated infection in hospitalized children, leading to significant morbidity and mortality. Oftentimes risk factors for candidemia are inherent to being severely ill and less likely modifiable. However, early central venous catheter (CVC) removal may be an impactful intervention. A recent Journal of the Pediatric Infectious Diseases Society article evaluated the association between CVC retention and 30-day all-cause inpatient mortality.

This retrospective, observational study assessed 285 pediatric patients (<19 years of age) with candidemia from 2000 through 2012. Patients had to have at least one CVC in place at the time the blood culture was drawn and survive for at least one day after the blood culture became positive with a CVC present. The number of days from the blood culture turning positive for yeast to the day of line removal was evaluated in relation to all-cause inpatient mortality within 30 days of the blood culture turning positive for yeast. Potential confounders also assessed included: parenteral nutrition, immunosuppressive medications, recent surgery, dialysis, intensive care unit (ICU) admission, and time to initiation of antifungal therapy. In the final analysis, a composite variable for clinical complexity, incorporating immunosuppressive medications, parenteral nutrition, and ICU admission, was used. Patients were followed until 30 days from positive culture result, hospital discharge, or death.

In this study, the most frequently isolated Candida species was C. albicans (50 percent), followed by C. parapsilosis (25 percent), with various other Candida species compromising the remainder of the cohort. Thirty-day all-cause inpatient mortality was 10.5 percent. CVC retention had a statistically significant association with an increased risk of death on any given day (OR: 3.59). This association remained significant even when adjusting for age and clinical complexity (OR: 2.50).

Despite limitations of potential confounders, this study provides additional data that early removal of CVCs impacts overall mortality in candidemic pediatric patients.

( Fisher et al.J Ped Infect Dis. 2016;5(4):403-408.)


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Procalcitonin as an Early Marker in Severe Community-Acquired Pneumonia

Reviewed by Kelly Cawcutt, MD

Patients with community-acquired pneumonia (CAP) who require invasive ventilation or vasopressor use have improved outcomes when admitted to the intensive care unit (ICU). Existing guidelines and predictive scoring systems, however, are fraught with inaccuracy in identifying those who need ICU admission. The authors of a recent article published in Chest evaluated the association of procalcitonin (PCT) as a marker for invasive respiratory support or vasopressor support (IRVS) and whether PCT added predictive value to existing pneumonia severity scoring systems.

The nested, prospective cohort study included adult patients hospitalized with CAP in Illinois and Tennessee between January 2010 and June 2012. All patients had sera stored and those with a remaining adequate serum volume for PCT measurement were included. The primary outcome was IRVS within 72 hours of hospital admission. Pneumonia severity scores assessed included the American Thoracic Society minor criteria for severe CAP, Pneumonia Severity Index, and SMART-COP. Each severity score was evaluated with and without PCT inclusion to assess whether PCT rendered a significant additive effect.

Of the 1,770 included patients, 115 (6.5 percent) required IRVS in the first 72 hours. The serum PCT was statistically significantly higher among patients with IRVS than those without. PCT was evaluated as a continuous variable, and between 0.05 ng/mL and 10 ng/mL, there was a 1 to 2 percent increase in risk of IRVS for every ng/mL the PCT increased. The IRVS risk plateaued at PCT concentrations > 10 ng/mL.

This association was then translated into an assessment of the additive value of PCT to the severity scores. PCT increased the area under the ROC curve for all scoring systems. Subgroup analysis between low and high risk groups based on the scoring systems continued to show improved predictive value in statistical models.

PCT alone may not render enough predictive value to determine clinical need for ICU admission based on IRVS. However, further studies incorporating PCT into augmented scoring systems may yield improved patient outcomes via increased accuracy in predicting severity of illness and resultant ICU admissions.

( Self et al.Chest. 2016 Oct;150(4):819-828.)


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Clostridium difficile Risk Increased by Antibiotic Use by Prior Inpatient Bed Occupants

Reviewed by Michael T. Melia, MD

Antibiotic use is associated with increased risk of Clostridium difficile infection (CDI) at individual patient, hospital, and regional levels. Within hospital rooms, a current roommate or prior occupant with CDI also increases CDI risk. Does antibiotic use by a hospital bed's previous occupant - regardless of whether that occupant had CDI - result in increased CDI risk?

A recent article in JAMA Internal Medicine describes a retrospective cohort study of adults who spent at least 48 hours in the bed they initially occupied upon admission to four hospitals in the New York City area. Patients were excluded if they had had CDI within 90 days prior to or 48 hours of admission. Only admissions in which the prior bed occupant had been in the bed for at least 24 hours were included; the duration of bed vacancy was less than one week. The primary exposure was receipt of at least one dose of antibiotics (other than those specifically used to treat CDI) by the prior bed occupant.

Of 100,615 pairs of sequentially-admitted patients, 576 subsequent patients developed CDI within 2-14 days of bed arrival. Subsequent patients diagnosed with CDI were more likely to have traditional CDI risk factors, as were their prior bed occupants. On multivariable analysis, receipt of antibiotics was the prior bed occupants' only characteristic associated with increased CDI risk for subsequent patients.

While traditional CDI risk factors related to the subsequent patient were the most important CDI risk factors in this study, receipt of antibiotics by the prior bed occupant was associated with a 22 percent relative increase in subsequent patients' CDI risk. Although there are limitations of retrospective, observational studies, and while the observed effect size was small, the findings highlight another possible environmental contributor to CDI risk, as well as another possible peril of antibiotic use.

( Freedberg et al.JAMA Intern Med. 2016 Dec 1;176(12):1801-1808.)


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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:

December 15

  • Paradoxical Reactions in Meningitis due to Mycobacterium Tuberculosis
  • Early Source Control, Together With Antifungal Therapy, Is the Key to Management of Intra-abdominal Candida Infection

December 1

  • Vancomycin Minimum Inhibitory Concentration Revisited
  • How to Avoid Human Pentastomiasis: Cook Your Snake Well
  • Case Vignette: Conidiobolomycosis

November 15

  • Neurological Findings in Acute HIV Infection: Frequent, Mild, and Reversible
  • Why Antibiotic Allergy De-labeling Is Important
  • Case Vignette: Lagochilascariasis

November 1

  • Rifampin for Surgically Treated Staphylococcal Endocarditis?
  • Ceftaroline and Neutropenia
  • Case Vignette: Colonic Anisakiasis