Archive for February, 2014

Primary Care Guidelines for the Management of Persons Infected With HIV: 2013 Update by the HIV Medicine Association of the Infectious Diseases Society of America

Clinical Infectious Diseases January 1, 2014 V.58 N.1 P.1-10


Judith A. Aberg1, Joel E. Gallant2,3, Khalil G. Ghanem3, Patricia Emmanuel4, Barry S. Zingman5, and Michael A. Horberg6

1Division of Infectious Diseases and Immunology, New York University School of Medicine, Bellevue Hospital Center, New York

2Southwest CARE Center, Santa Fe, New Mexico

3Johns Hopkins University School of Medicine, Baltimore, Maryland

4Department of Pediatrics, University of South Florida Health, Tampa

5Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York

6Mid-Atlantic Permanente Research Institute, Rockville, Maryland

Correspondence: Judith A. Aberg, MD, New York University School of Medicine, 550 First Ave, BCD 5 (Rm 558), New York, NY 10016 (

Evidence-based guidelines for the management of persons infected with human immunodeficiency virus (HIV) were prepared by an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America.

These updated guidelines replace those published in 2009. The guidelines are intended for use by healthcare providers who care for HIV-infected patients. Since 2009, new antiretroviral drugs and classes have become available, and the prognosis of persons with HIV infection continues to improve.

However, with fewer complications and increased survival, HIV-infected persons are increasingly developing common health problems that also affect the general population. Some of these conditions may be related to HIV infection itself or its treatment. HIV-infected persons should be managed and monitored for all relevant age- and sex-specific health problems.

New information based on publications from the period 2009–2013 has been incorporated into this document.


February 28, 2014 at 9:41 pm

Effect of Influenza Vaccination of Healthcare Personnel on Morbidity and Mortality Among Patients: Systematic Review and Grading of Evidence

Clinical Infectious Diseases January 1, 2014 V.58 N.1 P.50-57

Faruque Ahmed1, Megan C. Lindley1, Norma Allred1, Cindy M. Weinbaum2, and Lisa Grohskopf3

1Immunization Services Division, National Center for Immunization and Respiratory Diseases

2Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases

3Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia

Correspondence: Faruque Ahmed, PhD, Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS A-19, Atlanta, GA 30333 (


Influenza vaccination of healthcare personnel (HCP) is recommended in >40 countries. However, there is controversy surrounding the evidence that HCP vaccination reduces morbidity and mortality among patients. Key factors for developing evidence-based recommendations include quality of evidence, balance of benefits and harms, and values and preferences.


We conducted a systematic review of randomized trials, cohort studies, and case-control studies published through June 2012 to evaluate the effect of HCP influenza vaccination on mortality, hospitalization, and influenza cases in patients of healthcare facilities. We pooled trial results using meta-analysis and assessed evidence quality using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.


We identified 4 cluster randomized trials and 4 observational studies conducted in long-term care or hospital settings. Pooled risk ratios across trials for all-cause mortality and influenza-like illness were 0.71 (95% confidence interval [CI], .59–.85) and 0.58 (95% CI, .46–.73), respectively; pooled estimates for all-cause hospitalization and laboratory-confirmed influenza were not statistically significant. The cohort and case-control studies indicated significant protective associations for influenza-like illness and laboratory-confirmed influenza. No studies reported harms to patients. Using GRADE, the quality of the evidence for the effect of HCP vaccination on mortality and influenza cases in patients was moderate and low, respectively. The evidence quality for the effect of HCP vaccination on patient hospitalization was low. The overall evidence quality was moderate.


The quality of evidence is higher for mortality than for other outcomes. HCP influenza vaccination can enhance patient safety.



Editorial Commentary

Influenza Vaccination of Healthcare Workers: Making the Grade for Action

Marie R. Griffin

Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee

Correspondence: Marie R. Griffin, MD, MPH, Department of Preventive Medicine, Vanderbilt University Medical Center, 1500 21st Ave S, Nashville, TN 37212 (

It is reasonable to ask what type of evidence is needed to recommend or require annual influenza vaccination of healthcare workers to help prevent transmission of influenza to vulnerable hospitalized patients and to residents of long-term care facilities. To make such a recommendation, one would want to know the risks and consequences of influenza in such patients, the safety of the vaccine and its efficacy in preventing influenza in healthcare workers, and the likelihood that vaccinating such workers could prevent the spread of influenza within these facilities in addition to costs and feasibility….


February 28, 2014 at 9:39 pm

Infectious Diseases Specialty Intervention Is Associated With Decreased Mortality and Lower Healthcare Costs

Clinical Infectious Diseases January 1, 2014 V.58 N.1 P.22-28

Steven Schmitt1, Daniel P. McQuillen2, Ronald Nahass3, Lawrence Martinelli4, Michael Rubin5, Kay Schwebke6, Russell Petrak7, J. Trees Ritter8, David Chansolme9, Thomas Slama10, Edward M. Drozd11, Shamonda F. Braithwaite11, Michael Johnsrud12, and Eric Hammelman11

1Department of Infectious Diseases, Medicine Institute, Cleveland Clinic, Ohio

2Center for Infectious Diseases and Prevention, Lahey Hospital & Medical Center, Tufts University School of Medicine, Burlington, Massachusetts

3ID Care, Hillsborough, New Jersey

4Covenant Health, Lubbock, Texas

5Divisions of Clinical Epidemiology and Infectious Diseases, University of Utah School of Medicine, Salt Lake City

6OptumInsight, Eden Prairie, Minnesota

7Metro ID Consultants, LLC, Burr Ridge, Illinois

8French Hospital Medical Center, San Luis Obispo, California

9Infectious Disease Consultants of Oklahoma City, Oklahoma

10Indiana University School of Medicine, Indianapolis, Indiana

11Data Analytics

12Health Economics and Outcomes Research, Avalere Health, Washington, D.C.

Correspondence: Steven Schmitt, MD, 9500 Euclid Ave., Desk G-21, Cleveland, OH 44195, USA (


Previous studies, largely based on chart reviews with small sample sizes, have demonstrated that infectious diseases (ID) specialists positively impact patient outcomes. We investigated how ID specialists impact mortality, utilization, and costs using a large claims dataset.


We used administrative fee-for-service Medicare claims to identify beneficiaries hospitalized from 2008 to 2009 with at least 1 of 11 infections. There were 101 991 stays with and 170 336 stays without ID interventions. Cohorts were propensity score matched for patient demographics, comorbidities, and hospital characteristics. Regression models compared ID versus non-ID intervention and early versus late ID intervention. Risk-adjusted outcomes included hospital and intensive care unit (ICU) length of stay (LOS), mortality, readmissions, hospital charges, and Medicare payments.


The ID intervention cohort demonstrated significantly lower mortality (odds ratio [OR], 0.87; 95% confidence interval [CI], .83 to .91) and readmissions (OR, 0.96; 95% CI, .93 to .99) than the non-ID intervention cohort. Medicare charges and payments were not significantly different; the ID intervention cohort ICU LOS was 3.7% shorter (95% CI, −5.5% to −1.9%). Patients receiving ID intervention within 2 days of admission had significantly lower 30-day mortality and readmission, hospital and ICU length of stay, and Medicare charges and payments compared with patients receiving later ID interventions.


ID interventions are associated with improved patient outcomes. Early ID interventions are also associated with reduced costs for Medicare beneficiaries with select infections.


Editorial Commentary

Infectious Diseases: A Friend in Need

Emilio Bouza

Department of Microbiology and Infectious Diseases, Hospital General Gregorio Marañón

Department of Medicine, Universidad Complutense, Madrid, Spain

Correspondence: Emilio Bouza, MD, PhD, Servicio de Microbiología y E. Infecciosas, Hospital General Universitario Gregorio Marañón, Dr Esquerdo 46, 28007 Madrid (

Schmitt et al must be congratulated for their effort to provide evidence to third-party payers on the convenience and advantages to consult infectious diseases specialists early, at least for patients with severe, nosocomially acquired infectious complications [1]. In a very interesting article published in this issue of the journal, they demonstrated that “ID interventions are associated with improved patient outcomes … and reduced costs” [1]. Their article has the added value of raising old and new issues that are not always approached similarly in different countries and in different situations.

The first issue that I would consider is the need for infectious diseases specialists at the present time. We are far from the years in which, in the pages of this very journal, prestigious physicians such as Petersdorf and Beeson bitterly discussed the need for more infectious diseases specialists [2–4]. In 1980, Beeson [5] claimed that our specialty lacks every attribute needed for successful practice: special technology, chronicity of disease, and balanced remuneration. Petersdorf, at that same time, suggested, “It is my conclusion that infectious disease is destined to function best as an academic specialty whose trainees should pursue careers …


February 28, 2014 at 9:38 pm

Community-acquired staphylococcal pneumonia.

J Bras Pneumol. 2008 Sep;34(9):683-9.

Santos JW1, Nascimento DZ, Guerra VA, Rigo Vda S, Michel GT, Dalcin TC.

Pulmonology Department, Santa Maria University Hospital of the Federal University of Santa Maria, Santa Maria, Brazil.



Staphylococcal pneumonia typically presents high rates of morbidity and mortality. It typically occurs in cases of influenza (airborne transmission) or during episodes of bacteremia (blood-borne transmission).


A retrospective and descriptive study was conducted in patients admitted to our hospital between January of 1992 and December of 2003. All of he patients included had been diagnosed with community-acquired pneumonia caused by Staphylococcus aureus. All were older than 14 years of age, and none were intravenous drug users.


Community-acquired pneumonia was identified in 332 cases, of which 24 (7.3%) were identified as cases of staphylococcal pneumonia. Age ranged from 14 to 89 years. Fifteen patients were male, and nine were female. Twelve patients met the criteria for severe pneumonia. Chest X-rays showed unilateral consolidation in 14 cases, bilateral consolidation in 10, pleural effusion in 15, rapid radiological progression of pulmonary lesions in 14, cavitation in 6 and pneumothorax in 1. Most of the patients presented comorbidities, of which diabetes mellitus was the most common. Twelve patients presented complications such as empyema and septic shock. Four patients died, translating to a mortality rate of 16.6% in our sample.


The clinical presentation of pneumonia caused by S. aureus is similar to that of pneumonia caused by other etiological agents. Radiological findings, epidemiological data and risk factors provide important clues to the diagnosis. These factors are important for clinical suspicion, since S. aureus is not typically addressed in empirical treatment.


February 25, 2014 at 8:20 am

Empyema thoracis.

Clin Med Insights Circ Respir Pulm Med. 2010 Jun 17;4:1-8.

Ahmed AE1, Yacoub TE.

Department of Medicine, Faculty of Medicine, University of Khartoum, Khartoum, Sudan.


Epmyema thoracis is associated with high mortality ranging between 6% to 24%. The incidence of empyema is increasing in both children and adults; the cause of this surge is unknown.

Most cases of empyema complicate community- or hospital-acquired pneumonia but a proportion results from iatrogenic causes or develops without pneumonia.

Parapneumonic effusions (PPE) develop in about one half of the patients hospitalized with pneumonia and their presence cause a four-fold increase in mortality.

Three stages in the natural course of empyema have long been described: the exudative, fibrinopurulent, and organizing phases.

Clinically, PPE are classified as simple PPE, complicated PPE, and frank empyema. Simple PPE are transudates with a pH > 7.20 whereas complicated PPE are exudates with glucose level <2.2 mmol/l and pH < 7.20.

Two guidelines statements on the management of PPE in adults have been published by the American College of Chest Physicians (ACCP) and the British Thoracic Society (BTS). Although they differ in their approach on how to manage PPE, they agree on drainage of the pleural space in complicated PPE and frank empyema.

They also recommend the use of intrapleural fibrinolysis and surgical intervention in those who do not show improvement, but the level of evidence for the use of intrapleural fibrinolysis is not high highlighting the need for more research in this area.

A recently published large randomized trial has shown no survival advantage with the use of intrapleural streptokinase in patients with pleural infection. However, streptokinase enhances drainage of infected pleural fluid and may still be used in patients with large collection of infected pleural fluid causing breathlessness or ventilatory failure.

There is emerging evidence that the combination of intrapleural tPA/DNase is significantly superior to tPA or DNase alone, or placebo in improving pleural fluid drainage in patients with pleural space infection. A guideline statement on the management of PPE in children has been published by the BTS.

It recommends the use of antibiotics in all patients with PPE in addition to either video-assisted thoracoscopic surgery (VATS) or tube thoracostomy and intrapleural fibrinolysis. Prospective randomized trials have shown that intrapleural fibrinolysis is as effective as VATS for the treatment of childhood empyema and is a more economic treatment and therefore, should be the primary treatment of choice.


February 25, 2014 at 8:18 am

Community-acquired methicillin-resistant Staphylococcus aureus pneumonia: a clinical audit.

Respirology. 2011 Aug;16(6):926-31.

Thomas R1, Ferguson J, Coombs G, Gibson PG.



Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) strains are primarily associated with skin and soft tissue infections; however, they are increasingly causing more invasive infections including severe community-acquired pneumonia. The objective of this study was to describe the clinico-pathological characteristics of community-acquired MRSA pneumonia.


A retrospective analysis of case records from January 2002 to August 2008 was performed on patients admitted with community-acquired MRSA pneumonia to two large teaching hospitals.


Sixteen patients with community-acquired MRSA pneumonia were identified. Their age ranged from 11 months to 86 years (median age; 30 years). Duration of symptoms before hospital presentation ranged from one to 21 days. Most patients had productive cough, fever and dyspnoea. The most common radiological presentation included multilobar consolidation (8/16), necrotizing consolidation (7/16) and empyema (5/16). Seven patients required intensive care support; four required ionotropic support and five required mechanical ventilation for a mean duration of 53 h and 6.6 days, respectively. Six patients underwent surgery (VATS or open thoracotomy). There was a mean delay of approximately 69 h (range; 18 h to 11 days) after presentation before appropriate MRSA antimicrobial treatment was initiated. Three patients died of complications from pneumonia, all within 72 h of presentation. Among survivors, the average length of hospital stay was 23.8 days (range; 10-49 days). Majority of survivors were left with mild residual radiological changes.


Community-acquired MRSA pneumonia is increasing and should be suspected in patients with severe community-acquired pneumonia. There was a delay in initiation of appropriate antimicrobial treatment that could have lead to increased morbidity.


February 24, 2014 at 3:13 pm

Predictive factors, microbiology and outcome of patients with parapneumonic effusion.

Eur Respir J. 2011 Nov;38(5):1173-9.

Falguera M1, Carratalà J, Bielsa S, García-Vidal C, Ruiz-González A, Chica I, Gudiol F, Porcel JM.


We aimed to determine the incidence, clinical consequences and microbiological findings related to the presence of pleural effusion in community-acquired pneumonia, and to identify predictive factors for empyema/complicated parapneumonic effusion.

We analysed 4,715 consecutive patients with community-acquired pneumonia from two acute care hospitals. Patients were classified into three groups: no pleural effusion, uncomplicated parapneumonic effusion and empyema/complicated parapneumonic effusion.

A total of 882 (19%) patients had radiological evidence of pleural fluid, of whom 261 (30%) met criteria for empyema/complicated parapneumonic effusion. The most important event related to the presence of uncomplicated parapneumonic effusion was a longer hospital stay.

Relevant clinical and microbiological consequences were associated with empyema/complicated parapneumonic effusion. Five independent baseline characteristics could predict the development of empyema/complicated parapneumonic effusion: age < 60 yrs (p = 0.012), alcoholism (p = 0.002), pleuritic pain (p = 0.002), tachycardia >100 beats·min⁻¹ (p = 0.006) and leukocytosis >15,000 mm⁻³ (p < 0.001).

A higher incidence of anaerobes and Gram-positive cocci was found in this subgroup of patients.

We conclude that only the development of empyema/complicated parapneumonic effusion carried relevant consequences; this condition should be suspected in the presence of some baseline characteristics and managed by using antimicrobials active against Gram-positive cocci and anaerobes.


February 24, 2014 at 3:11 pm

The spectrum of pneumococcal empyema in adults in the early 21st century.

Clin Infect Dis 2011 Aug 1; 53(3) :254-61.

Burgos J, Lujan M, Falcó V, et al.


Infectious Diseases Department, Universitat Autònoma de Barcelona, Barcelona, Spain.


Increased rates of empyema have been reported in children after the introduction of the pneumococcal conjugate vaccine (PCV7). Our objective was to describe the risk factors for pneumococcal empyema in adults and to analyze the differences in the incidence, disease characteristics, and serotype distribution between the pre- and post-PCV7 eras.


An observational study of all adults hospitalized with invasive pneumococcal disease (IPD) who presented with empyema in 2 Spanish hospitals was conducted during the periods 1996-2001 (prevaccine period) and 2005-2009 (postvaccine period). Incidences of empyema were calculated. A multivariate analysis was performed to identify variables associated with pneumococcal empyema.


Empyema was diagnosed in 128 of 1080 patients with invasive pneumococcal disease. Among patients aged 18-50 years, the rates of pneumococcal pneumonia with empyema increased from 7.6% to 14.9% (P = .04) and the incidence of pneumococcal empyema increased from 0.5 to 1.6 cases per 100,000 person-years (198% [95% confidence interval {CI}, 49%-494%]). The incidence of empyema due to serotype 1 increased significantly from 0.2 to 0.8 cases per 100,000 person-years (253% [95% CI, 67%-646%]). Serotype 1 caused 43.3% of cases of empyema during the postvaccine period. Serotypes 1 (odds ratio [OR], 5.88; [95% CI, 2.66-13]) and 3 (OR, 5.49 [95% CI, 1.93-15.62]) were independently associated with development of empyema.


The incidence of pneumococcal empyema in young adults has increased during the postvaccine period, mainly as a result of the emergence of serotype 1. Serotypes 1 and 3 are the main determinants of development of this suppurative complication.


February 23, 2014 at 3:57 pm

Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010.

Thorax 2010 Aug.:ii41-53.

Davies HE, Davies RJ, Davies CW, et al.


Oxford Centre for Respiratory Medicine, Churchill Hospital Site, Oxford Radcliffe Hospital, Oxford, UK.



February 23, 2014 at 3:55 pm

Pleural infection – Changing bacteriology and its implications.

Respirology 2011 May; 16(4) :598-603.

Lisboa T, Waterer GW, Lee YC

Critical Care Department and Infection Control Committee, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul and Intensive Care Unit, Hospital Santa Rita, Complexo Hospitalar Santa Casa, Porto Alegre, Brazil.

The incidence of pleural infection continues to rise worldwide. Identifying the causative organism(s) is important to guide antimicrobial therapy.

The bacteriology of pleural infection is complex and has changed over time.

Recent data suggest that the bacterial causes of empyema are significantly different between adult and paediatric patients, between community-acquired and nosocomial empyemas and can vary among geographical regions of the world.

Since the introduction of pneumococcal vaccines, a change has been observed in the distribution of the serotypes of Streptococcus pneumoniae in empyema. These observations have implications on therapy and vaccine strategies.

Clinicians need to be aware of the local bacteriology of empyema in order to guide antibiotic treatment.



February 23, 2014 at 3:54 pm

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