November 1, 2007

Hot Topics in Infectious Diseases 2007

Here’s this year’s list of the must-read papers as chosen by leaders in the fields of infectious diseases and HIV and presented at IDSA 2007 during the always popular “What’s Hot” session. Each presenter also describes why the articles made his list.

Bennet Lorber, MD, FIDSA, Temple University Health Sciences Center:

Pronovost et al. “An intervention to decrease catheter-related bloodstream infections in the ICU.” N Engl J Med 2006;355:2725-32.

Each year almost 50,000 patients in the United States develop catheter-related blood stream infections resulting in at least 17,000 attributable deaths. In this study, a few simple infection control interventions were instituted, namely a) handwashing, b) full-barrier precautions during catheter insertion, c) using chlorhexidine to clean skin, d) avoiding the femoral site, and e) removing unnecessary catheters. These simple, low-tech, low-cost interventions reduced the rate of catheter-related bloodstream infections by 66 percent, and the impact was sustained over a long period.

Johnson et al. “Sharing of virulent Escherichia coli clones among household members of a woman with acute cystitis.” Clin Infect Dis 2006;43:e101-8.

E. coli sharingA longitudinal study in the household of woman with cystitis showed extensive sharing of E. coli clones among family members and a pet dog. Patterns of sharing suggest host-to-host transmission and are not consistent with sexual transmission or a food source.  It is suggested that household members could serve as reservoirs for later recolonization and explain observation of widely separated same-strain recurrent urinary tract infections in women without evidence of sustained colonization with the causative strain.  

Scott et al. “An outbreak of multidrug-resistant Acinetobacter baumannii-calcoaceticus complex infection in the US military health care system associated with military operations in Iraq.” Clin Infect Dis 2007;44:1577-84.

This study reports on an epidemic of highly resistant Acinetobacter infections in U.S. military personnel in Iraq who were critically ill following severe trauma.  The infection source appears to be nosocomial and related to the field hospital environment. Infection control in field hospitals is tough; new approaches are needed.

Högenauer et al. “Klebsiella oxytoca as a causative organism of antibiotic-associated hemorrhagic colitis.” N Engl J Med 2006;355:2418-26.

K. oxytoca can cause antibiotic-associated hemorrhagic colitis.  Look for it (culture for K. oxytoca) in younger patients with right-sided or transverse colon hemorrhagic colitis.  While looking, stop antibiotics and NSAIDs.

Dr. Lorber’s other hot articles:

Wilson et al. “Prevention of infective endocarditis. Guidelines from the American Heart Association.” Circulation 2007;116:1736-54.

Gupta et al. “Statin use and hospitalization for sepsis in patients with chronic kidney disease.” JAMA 2007;297:1455-64.

Barry M. “The tail end of guinea worm: global eradication without a drug or a vaccine.” N Engl J Med 2007;356:2561-64.

John G. Bartlett, MD, FIDSA, Johns Hopkins University School of Medicine, past president of IDSA:

Lindenauer et al. “Public reporting and pay for performance in hospital quality improvement.” N Engl J Med 2007;356:486-96.

Metersky et al. “Antibiotic timing and diagnostic uncertainty in Medicare patients with pneumonia.” Chest 2006;130:16-21.

Polgreen et al. “An outbreak of severe Clostridium difficile-associated disease possibly related to inappropriate antimicrobial therapy for community-acquired pneumonia.” Infect Control Hosp Epidemiol 2007;28:212-14.

Lindenauer et al. show that a Medicare trial run of “pay-for-performance” achieved a 12 percent increase in compliance with the “4 hour” rule for administering antibiotics for community-acquired pneumonia (CAP).  But Metersky et al. and Polgreen et al. wrote about the downside: abuse of antibiotics, including some deaths due to Clostridium difficile in patients treated for CAP but in retrospect did not have it.  The Centers for Medicare and Medicaid Services has decided to drop the “4 hour rule” for “pay-for-performance” due to unintended consequences.

Zar et al. “A comparison of vancomycin and metroniazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity.” Clin Infect Dis 2007;45:302-7.

These authors report a prospective study of 150 patients with C. difficile infection who were randomized to oral vancomycin or metronidazole.  Vancomycin proved superior but only in those classified as having serious disease, with cure rates of 97 percent for vancomycin vs. 76 percent for metronidazole.

Wang et al. “Increased vancomycin MICs for Staphylococcus aureus clinical isolates from a university hospital during a 5-year period.” J Clin Microbiol 2006;44:3883-6.

Hidayat et al. “High-dose vancomycin therapy for methicillin-resistant Staphylococcus aureus infections.” Arch Intern Med 2006;166:2138-44.

Tenover and Moellering. “The rationale for revising the Clinical And Laboratory Standards Institute vancomycin minimal inhibitory concentration interpretive criteria for Staphylococcus aureus.” Clin Infect Dis 2007;44:1208-15.

These studies provide the rationale for the Clinical And Laboratory Standards Institute (CLSI) recommendation to reduce the minimal inhibitory concentration (MIC) threshold for S. aureus sensitivity to vancomycin from 4 mcg/mL to 2 mcg/mL.  The concern was based on a number of associated observations including 16 anecdotal cases of patients with S. aureus isolates with MICs of 4 mcg/mL who had persistent bacteremia for more than a week despite standard doses of vancomycin.  There were many concerns, including MIC creep, heteroresistance, and nephrotoxicity of vancomycin with increased doses. In addition, there was the calculation that an MIC of 4 requires a dose of 8 gm/day to achieve the desired AUC/MIC ratio!

Labandeira-Rey et al. “Staphylococcus aureus Panton-Valentine leukocidin causes necrotizing pneumonia.” Science 315:1130-3.

Voyich et al. “Is Panton-Valentine Leukocidin the major virulence determinant in community-associated methicillin-resistant Staphylococcus aureus disease?” J Infect Dis 2006;194:1761-70.

Labandeira-Rey et al. examine the virulence of USA 300 strains of MRSA and show that Panton-Valentine leukocidin (PVL) causes lung necrosis and death with nasal challenge in mice.  BUT Voyich et al. tested the same hypothesis using intramuscular and intravenous challenge, and concluded that PVL is nothing more than a marker for the USA 300 strain.  The truth may be someplace in the middle.

Gandhi et al. “Extensively drug-resistant tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural area of South Africa.” Lancet 2006;368:1575-80.

Extensively drug-resistant tuberculosis (XDR TB) is a new term used for multidrug-resistant TB that is also resistant to fluoroquinolones and at least one injectable drug.  This paper reviews 53 cases in rural South Africa.  There appeared to be a strain that was commonly hospital-acquired; all 44 patients tested for HIV were positive and 52 (98 percent) died, with a median survival time of 16 days.  The author emphasized the need for surveillance, hospital infection control, and better microbiology.

Escombe et al. “Natural ventilation for the prevention of airborne contagion.” PLoS Med 2007;4:e68.

The authors examine airflow as an indicator of TB control in hospitalized patients in Lima, Peru.  The best (safest) airflow was in old hospitals with high ceilings and big open windows.  The worst airflow was in rooms constructed with (expensive) mechanical ventilation to assure negative pressure.

Dr. Bartlett’s other hot articles:

“Severe methicillin-resistant Staphylococcus aureus community acquired pneumonia associated with influenza—Louisiana and Georgia, December 2006-January 2007.” MMWR 2007;56:325-329.

Yang et al. “Immunization by avian H5 influenza hemagglutinin mutants with altered receptor binding specificity.” Science 2007;317:825-8.

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