Disclosures: Elinor L Baron, MD, DTMH Nothing to disclose. Allyson Bloom, MD Nothing to disclose. Anna R Thorner, MD Nothing to disclose. Jennifer Mitty, MD, MPH Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.
Eosinophilia during prolonged antibiotic therapy (June 2015)
Eosinophilia is not uncommon in patients receiving prolonged intravenous (IV) antibiotics, but the prevalence and significance has not been extensively studied. In a prospective cohort study of 824 patients receiving prolonged intravenous antibiotic therapy, eosinophilia developed in 25 percent, appearing at a median of 15 days of therapy and peaking at a median absolute count of 726/mL (500 to 8610/mL) . Although most patients with eosinophilia completed their courses without complications, one-third developed a hypersensitivity reaction involving rash or hepatic or renal involvement. Medication-associated eosinophilia does not mandate discontinuation of therapy but warrants close monitoring for evidence of hypersensitivity and consideration of alternative medications that could be substituted without compromising care. (See "Approach to the patient with unexplained eosinophilia", section on 'Medications and over the counter remedies'.)
Oral antibiotics added to mechanical bowel prep prior to colorectal surgery (May 2015)
Before colorectal surgery, intravenous antibiotics are commonly used to prevent surgical site infection (SSI). Several studies have suggested a benefit in SSI reduction with the addition of oral antibiotics, typically given with mechanical bowel preparation (MBP), such as polyethylene glycol solutions. As an example, a recent retrospective review evaluated outcomes for 8415 elective colorectal surgeries performed in patients who received no bowel preparation (26 percent), MBP only (45 percent), and oral antibiotics, mainly given with MBP (29 percent) . Intravenous antibiotic prophylaxis was standard. The overall SSI rate was 11 percent, and receipt of oral antibiotics and MBP was associated with lower SSI rates compared with no preparation or MBP alone (6.5 versus 14.9 percent and 12.0 percent, respectively). We generally do not use MBP for elective right and left-sided colectomies because of other adverse effects. However, this study supports our suggestion to use oral antibiotics with MBP when MBP is deemed necessary. (See "Overview of colon resection", section on 'Bowel preparation' and "Control measures to prevent surgical site infection following gastrointestinal procedures in adults", section on 'Colorectal procedures'.)
Enhanced gram-negative activity of novel beta-lactam/beta-lactamase inhibitor combinations (January 2015, MODIFIED March 2015)
The US Food and Drug Administration recently approved two novel cephalosporin-beta-lactamase inhibitor combinations, ceftazidime-avibactam and ceftolazone-tazobactam, which were developed to treat highly resistant gram-negative infections. These agents have broad-spectrum in vitro activity against aerobic gram-negative rods, including Pseudomonas aeruginosa and most extended-spectrum beta-lactamase-producing gram-negative organisms. Ceftazidime-avibactam also has in vitro activity against some carbapenemase-producing organisms. In clinical trials, some of which have not been published yet, clinical cure rates with these new agents alone or in combination with metronidazole were similar to those with comparator antibiotics for complicated urinary tract and intra-abdominal infections [3-6]. (See "Combination beta-lactamase inhibitors, carbapenems, and monobactams", section on 'Ceftolozane-tazobactam' and "Combination beta-lactamase inhibitors, carbapenems, and monobactams", section on 'Ceftazidime-avibactam'.)
IDSA guidelines on vertebral osteomyelitis (August 2015)
Guidelines on diagnosis and treatment of vertebral osteomyelitis in adults have been issued by the Infectious Disease Society of America (IDSA) . These guidelines highlight the use of magnetic resonance imaging as the diagnostic imaging method of choice, withholding empiric antibiotics in patients without sepsis or progressive neurological complications until the microbiological etiology is identified, and the importance of biopsy for microbiologic diagnosis when blood cultures and serology are uninformative. In addition to prolonged antibiotic therapy, they recommend surgical intervention for individuals with progressive neurologic deficits or deformity, spinal instability, or clinical deterioration despite appropriate medical therapy. Our approach to vertebral osteomyelitis is generally consistent with these guidelines. (See "Vertebral osteomyelitis and discitis in adults", section on 'Introduction'.)
Adjunctive glucocorticoids for adults with severe community-acquired pneumonia (August 2015)
For hospitalized patients with community-acquired pneumonia (CAP), glucocorticoids as adjunctive therapy to antibiotics have the potential to reduce the inflammatory response and decrease morbidity. A 2015 meta-analysis of randomized trials that included hospitalized patients with CAP suggested a modest mortality benefit for adjunctive glucocorticoids . A reduction in all-cause mortality was of borderline statistical significance (relative risk [RR] 0.67, 95% CI 0.45-1.01; risk difference 2.8 percent). Rates of mechanical ventilation and acute respiratory distress syndrome were decreased, as were time to clinical stability and duration of hospitalization; rates of hyperglycemia requiring treatment increased.
Clinicians should make the decision whether or not to give glucocorticoids on a case-by-case basis, especially in patients with an elevated risk of adverse effects. Limited evidence suggests that infections caused by certain pathogens (eg, influenza virus, Aspergillus spp) may be associated with worse outcomes in the setting of glucocorticoid use [9,10]; given these concerns, we avoid adjunctive glucocorticoids if one of these pathogens is detected. (See "Treatment of community-acquired pneumonia in adults who require hospitalization", section on 'Glucocorticoids'.)
Uncertain benefit of routine S. aureus decolonization for prevention of surgical site infection (June 2015)
Routine preoperative Staphylococcus aureus screening and decolonization to prevent surgical site infection (SSI) has not been definitively proven to be beneficial or cost-effective. A large multicenter study of patients undergoing cardiac or orthopedic surgical procedures compared the rates of S. aureus SSI prior to and after the implementation of a preventive intervention bundle, which included S. aureus screening, decolonization, and targeted preoperative antimicrobial prophylaxis . The mean rate of deep incisional or organ space S. aureus infection was lower during the intervention compared with the preintervention period (21 versus 36 cases per 100,000 operations). However, the adherence rate to the full bundle was only 39 percent and several patient characteristics (including age and comorbidities) differed between the two periods. Because of these and other limitations, we continue to suggest not using routine preoperative S. aureus screening and decolonization for patients undergoing surgery. (See "Adjunctive measures for prevention of surgical site infection in adults", section on 'S. aureus decolonization'.)
Antimicrobial-resistant Shigella infections in the United States (June 2015)
Antimicrobial resistance in Shigella is an increasing problem in the United States. Fluoroquinolones are typically the antibiotic class of choice in adults, and azithromycin is often used if fluoroquinolone resistance is suspected or documented. Clusters of ciprofloxacin-resistant cases, likely introduced by international travelers with subsequent domestic spread, have been reported throughout the country, and isolates with decreased susceptibility to azithromycin have caused outbreaks and sporadic cases, predominantly among men who have sex with men (MSM) [12,13]. Scattered infections with extremely drug-resistant isolates that are ciprofloxacin-resistant and have decreased susceptibility to azithromycin have also been reported . These reports highlight the importance of obtaining susceptibility testing to ensure adequate efficacy of the chosen antimicrobial when managing shigellosis and emphasizing prevention measures, primarily hygiene practices around food preparation or consumption and oral or anal sex. (See "Shigella infection: Treatment and prevention in adults", section on 'Antimicrobial resistance' and "Shigella infection: Treatment and prevention in children", section on 'Antibiotic resistance'.)
Trends in infective endocarditis incidence in the United States (May 2015)
The epidemiology of infective endocarditis (IE) has changed over time because of changes in the prevalence of risk factors, as well as improved diagnostic tools and management. A study using the Nationwide Inpatient Sample database, which included 457,052 hospitalizations for IE in the United States between 2000 and 2011, found a steady increase in IE incidence over this time . The trends in hospitalization rates overall from 2000 to 2007 and from 2008 to 2011 were not significantly different, but there was a steeper increase in hospitalization rates for streptococcal IE, specifically, after 2007. It has been postulated that this reflects reduced antimicrobial IE prophylaxis after the American College of Cardiology/American Heart Association (ACC/AHA) recommended a narrower range of indications for prophylaxis in 2007. However, in the absence of controlled data, a causal connection is uncertain. Given the available evidence, we continue to recommend an approach to IE prophylaxis consistent with the ACC/AHA guidelines. (See "Epidemiology, risk factors, and microbiology of infective endocarditis", section on 'Epidemiology' and "Antimicrobial prophylaxis for bacterial endocarditis", section on 'Trends in endocarditis incidence'.)
Short-course antibiotic therapy for intraabdominal infection (May 2015)
Short courses of antibiotics have been advocated for patients with intraabdominal infection once source control has been achieved, but many clinicians give longer courses due to concerns about relapsing infection. The efficacy of short-course antimicrobial therapy was demonstrated in a trial in which patients with complicated intraabdominal infection and adequate source control were randomly assigned to receive either a fixed course of antibiotics for 4±1 days or antibiotics until two days after resolution of fever, leukocytosis, and ileus, with a maximum of 10 days of antimicrobial therapy . The median duration of antibiotics was four days in the experimental group versus eight days in the control group. The composite primary outcome of surgical site infection, recurrent intraabdominal infection, or death occurred in a similar percentage of patients in both groups (22 percent). (See "Anaerobic bacterial infections", section on 'Antibiotic treatment'.)
Use of nontoxigenic C. difficile spores for prevention of recurrent infection (May 2015)
Gastrointestinal colonization by nontoxigenic Clostridium difficile strains has been shown to prevent C. difficile infection (CDI) with a toxigenic strain. In a phase 2 study of nontoxigenic C. difficile strain M3 (NTCD-M3) among 168 patients who recovered from CDI following treatment with metronidazole or vancomycin, oral administration of spores of NTCD-M3 led to colonization of the gastrointestinal tract by C. difficile strain M3, reduced CDI recurrence, and appeared to be safe . Recurrence occurred in 11 percent of 125 patients who received NTCD-M3 spores versus 30 percent of 43 patients who received placebo. These results support the feasibility of this approach for prevention of recurrent CDI; further study is needed. (See "Clostridium difficile infection: Prevention and control", section on 'Nontoxigenic C. difficile colonization'.)
Beta-lactam monotherapy for community-acquired pneumonia (April 2015, MODIFIED April 2015)
CAP-START, a large randomized trial performed in the Netherlands, compared empiric therapy for community-acquired pneumonia (CAP) using beta-lactam monotherapy, beta-lactam-macrolide combination therapy, or fluoroquinolone monotherapy in patients admitted to inpatient wards . The risk of death by 90 days was 1.9 percent higher with the beta-lactam-macrolide strategy and 0.6 percent lower with the fluoroquinolone monotherapy strategy than with the beta-lactam strategy. These results reflect noninferiority of the beta-lactam strategy. The median length of hospital stay was similar for all strategies. It is important to note that only 2 percent of patients were found to have infections caused by atypical bacteria, such as Mycoplasma pneumoniae; beta-lactams do not have activity against these pathogens. In other studies from different regions of the world, atypical pathogens have accounted for ≥10 percent of cases of CAP in hospitalized patients, so it is uncertain whether the results of this trial are widely generalizable. (See "Antibiotic studies for the treatment of community-acquired pneumonia in adults", section on 'Combination therapy'.)
Increased mortality with delayed treatment for spontaneous bacterial peritonitis (April 2015)
Patients with spontaneous bacterial peritonitis (SBP) who develop septic shock have high mortality rates, but early initiation of antimicrobial therapy may result in improved outcomes. In a retrospective study of patients with cirrhosis and SBP-associated septic shock, the risk of mortality nearly doubled (1.9-fold increase) with every hour delay in administering antimicrobial therapy . In patients with suspected SBP-associated sepsis, ascitic fluid cultures should be obtained immediately and empiric antimicrobial therapy initiated to maximize the patient's chance of survival. (See "Spontaneous bacterial peritonitis in adults: Treatment and prophylaxis", section on 'Prognosis'.)
Trimethoprim-sulfamethoxazole versus clindamycin for uncomplicated skin infections (March 2015)
The efficacy of various oral antibiotic regimens for soft tissue infections in the era of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is unclear. A randomized trial at four centers in areas where community-acquired MRSA is endemic compared trimethoprim-sulfamethoxazole (TMP-SMX) and clindamycin for empiric treatment of uncomplicated skin infections (including cellulitis and/or abscess) . Among 524 patients (369 adults and 155 children), the efficacy of TMP-SMX and clindamycin were comparable (cure rates 80 versus 78 percent, respectively). For most patients with nonpurulent cellulitis, however, beta-lactam antibiotics with activity against beta-hemolytic streptococci and S. aureus (eg, cephalexin or dicloxacillin) remain the first-line options for empiric treatment. (See "Cellulitis and erysipelas", section on 'Nonpurulent'.)
FDA approval of isavuconazole for invasive aspergillosis and mucormycosis (March 2015)
Isavuconazole was approved by the US Food and Drug Administration in March 2015 for the treatment of invasive aspergillosis and mucormycosis . It is formulated as the prodrug, isavuconazonium sulfate, and it is available as an IV formulation and an oral formulation . For patients with invasive aspergillosis who do not tolerate the first-line antifungal agent, voriconazole, we use either a lipid formulation of amphotericin B or isavuconazole in place of voriconazole. For patients with mucormycosis, isavuconazole can be used as an alternative to posaconazole for step-down therapy or salvage therapy in patients who do not tolerate posaconazole. (See "Pharmacology of azoles", section on 'Isavuconazole' and "Treatment and prevention of invasive aspergillosis" and "Treatment and prevention of invasive aspergillosis", section on 'Initial therapy' and "Mucormycosis (zygomycosis)", section on 'Approach to treatment'.)
Persistence of Ebola virus in bodily fluids (May 2015)
Among survivors of the 2014-2015 Ebola outbreak in West Africa, infectious virus or viral RNA has been detected from several sites (eg, urine, semen, and aqueous humor) even after it is no longer detected in blood [23-25]. Although transmission from persistent virus at these sites is possible, the risk of transmission is not well established. As an example, a patient in West Africa had detectable viral RNA in his semen 199 days after symptom onset. There was apparent transmission of Ebola virus to one, but not another, of his sexual contacts. To prevent sexual transmission of Ebola virus, the Centers for Disease Control and World Health Organization suggest Ebola survivors refrain from all sexual activity (oral, anal, vaginal) until more information on the persistence of infectious virus in convalescent patients becomes available; condoms should be used if abstinence is not possible [26,27]. (See "Epidemiology and pathogenesis of Ebola virus disease", section on 'Risk of transmission through different body fluids'.)
Yaws eradication (February 2015)
Yaws is a treponemal infection that can cause destructive skin and bone lesions and is endemic to rural, equatorial regions in the Eastern Hemisphere. The approach to eradication of yaws consists of a single dose of oral azithromycin (30 mg/kg, maximum 2 g) to be given to the entire population in areas known to harbor yaws . The efficacy of this approach was demonstrated in a study of mass treatment performed in rural villages on Lihir Island, Papua New Guinea . Of 16,092 residents, 83 percent received mass treatment with single dose azithromycin and were monitored for one year; the prevalence of active yaws decreased from 2.4 to 0.3 percent, and the prevalence of latent yaws with high-titer seroreactivity decreased from 18.3 to 6.5 percent. There was a near-absence of high-titer seroreactivity among children 1 to 5 years of age. No evidence of macrolide resistance was observed. (See "Yaws, bejel, and pinta", section on 'Eradication'.)
Benefit of early antiretroviral therapy and isoniazid preventive therapy in endemic areas (July 2015)
In certain resource-limited settings, the epidemics of HIV and tuberculosis (TB) have converged to result in substantial morbidity and mortality, which can be reduced by antiretroviral therapy (ART) and treatment of latent TB infection. In a trial from Ivory Coast, over 2000 HIV-infected patients with a CD4 cell count <800 cells/microL were randomly assigned to receive early ART at the time of enrollment or to defer ART until meeting WHO criteria (which ranged from a CD4 cell threshold of 200 to 500 cells/microL over the course of the trial) . Participants in each group were also randomly assigned to receive six months of isoniazid preventive therapy or not. Early ART and isoniazid each reduced the combined endpoint of all-cause death or severe HIV-related illness by approximately 45 and 35 percent, respectively. The effect of ART was similar among those with baseline CD4 cell counts >500 cells/microL. The benefit of isoniazid was statistically significant among participants who were interferon-gamma release assay (IGRA) test positive at baseline but not in those with a negative IGRA test. These findings demonstrate that the benefit of ART extends to those with CD4 cell counts >500 cells/microL, as seen in resource-rich settings, and reinforce the importance of therapy for the prevention of active TB disease among HIV-infected patients with evidence of latent TB infection. (See "The impact of antiretroviral therapy on morbidity and mortality of HIV infection in resource-limited settings", section on 'Optimal timing of antiretroviral therapy' and "Treatment of latent tuberculosis infection in HIV-infected patients".)
Direct-acting antiviral therapy for HCV in HIV-infected patients (July 2015)
Although HIV-infected patients had lower response rates to chronic hepatitis C virus (HCV) treatment with peginterferon and ribavirin compared with HIV-uninfected patients, a growing number of studies have demonstrated that HIV/HCV coinfection is not associated with worse response to direct-acting antiviral-based regimens. Most recently, the regimen of ledpasvir-sofosbuvir for 12 weeks and the regimen of the investigational NS5A inhibitor daclatasvir with sofosbuvir for 12 weeks were each reported to result in sustained virologic response (SVR) rates exceeding 90 percent among HIV/HCV coinfected patients, including those who had failed prior HCV treatment and those with cirrhosis [31,32]. The efficacy and safety in these studies are comparable to those observed among HCV monoinfected patients. Potential drug interactions with antiretroviral agents remain a major consideration when selecting HCV treatment regimens in HIV-infected patients. (See "Treatment of hepatitis C virus infection in the HIV-infected patient", section on 'Genotype 1 infection'.)
Early versus deferred antiretroviral therapy in treatment-naive HIV-infected individuals (May 2015)
Trials have demonstrated that antiretroviral therapy (ART) improves morbidity and mortality in HIV-infected individuals with CD4 cell counts <350 cells/microL. The benefit of ART for those with higher CD4 cell counts had been suggested by observational data but had not previously been demonstrated in a randomized trial. In the START trial, 4685 HIV-infected adults who had not previously received ART and had a CD4 cell count >500 cells/microL were randomly assigned to initiate ART immediately or when the CD4 cell count declined to <350 cells/microL . After approximately three years of follow-up, an interim analysis found that the risk of the combined outcome of AIDS-related events, serious non-AIDS events (eg, major cardiovascular, renal and liver disease, and cancer), or death was reduced by 57 percent with immediate compared with deferred treatment (42 versus 96 events). These data support guidelines in the United States that recommend ART initiation in all HIV-infected patients, regardless of CD4 cell count. (See "When to initiate antiretroviral therapy in HIV-infected patients", section on 'The START trial'.)
HIV infection and chronic kidney disease (February 2015)
The HIV Medicine Association of the Infectious Diseases Society of America has updated its guidelines for the management of chronic kidney disease in patients infected with HIV . They recommend screening for kidney disease with serum creatinine measurement and urinalysis at baseline and during use of antiretroviral therapy. The guidelines also discuss indications for nephrology referral and selection of antiretroviral regimens in the setting of renal impairment. The discussion in UpToDate is generally consistent with these guidelines. (See "Selecting antiretroviral regimens for the treatment-naïve HIV-infected patient" and "Overview of kidney disease in HIV-positive patients" and "Primary care of the HIV-infected adult".)
Outcomes with viral respiratory illness before allogeneic hematopoietic cell transplantation (July 2015)
Hematopoietic cell transplant (HCT) candidates with upper respiratory tract symptoms at the time that the conditioning regimen is due to begin should postpone transplantation until the illness has resolved, when feasible. This recommendation is supported by a prospective study that showed that patients with a respiratory virus detected prior to allogeneic HCT had fewer days alive and out of the hospital and lower survival at day 100 compared with patients with negative samples . Among symptomatic patients, those with respiratory viruses detected had increased overall mortality compared with patients without viruses detected; among asymptomatic patients, detection of respiratory viruses was not associated with increased mortality. (See "Evaluation for infection before hematopoietic cell transplantation", section on 'Community respiratory viruses'.)
Updated ASCO guidelines for use of WBC growth factors (July 2015)
Updated guidelines from the American Society of Clinical Oncology (ASCO) are available for the use of white blood cell growth factors (colony stimulating factors, CSFs) . The new guidelines specify several clinical situations in which primary prophylaxis with CSFs is appropriate to prevent febrile neutropenia during chemotherapy: Patients receiving a drug regimen that carries a baseline risk of febrile neutropenia of ≥20 percent, patients 65 years and older with diffuse aggressive lymphoma who are being treated with curative chemotherapy (particularly in the presence of comorbidities), and patients receiving dose-dense chemotherapy regimens that are supported by convincing efficacy data (eg, adjuvant treatment of high-risk breast cancer and high-dose intensity methotrexate, vinblastine, doxorubicin, and cisplatin for urothelial cancer). (See "Use of granulocyte colony stimulating factors in adult patients with chemotherapy-induced neutropenia and conditions other than acute leukemia, myelodysplastic syndrome, and hematopoietic cell transplantation".)
Risk of serious infections with biologic drugs for rheumatoid arthritis (May 2015)
Postmarketing surveillance and observational studies provided the first indications that the tumor necrosis factor (TNF)-alpha inhibitors are associated with an increased risk of serious infections. Data from individual randomized trials and large observational studies have been inconsistent on this issue. A meta-analysis of randomized trials of patients with rheumatoid arthritis who received biologic drugs including TNF-alpha inhibitors found that standard-dose biologic drugs and high-dose biologic drugs were associated with an increased risk of serious infections compared with traditional disease-modifying antirheumatic drugs (DMARDs), but low-dose biologic drugs were not . The risk was lower in patients who were methotrexate-naive compared with those who had previously received a traditional DMARD or a TNF-alpha inhibitor. (See "Tumor necrosis factor-alpha inhibitors: Bacterial, viral, and fungal infections", section on 'Assessing the risk of serious infection'.)
Yellow fever vaccine booster doses (June 2015)
Immunity after a single dose of yellow fever vaccine is long lasting. In June 2015, the United States Advisory Committee on Immunization Practices (ACIP) issued recommendations stating that a single primary dose of yellow fever vaccine is adequate for most travelers, with additional doses reserved for certain at-risk individuals . However, the World Health Organization (WHO) international certificate of yellow fever immunization for international travel is valid for only 10 years; a booster dose is required every 10 years for the certificate to be reissued. The World Health Assembly adopted the recommendation to remove the 10-year booster dose requirement from the International Health Regulations by June 2016; until this time, travelers to countries with a yellow fever vaccination entry requirement must have received a dose of yellow fever vaccine within the past 10 years. (See "Yellow fever", section on 'Whom to vaccinate'.)
US ACIP recommendations for serogroup B meningococcal vaccination (June 2015)
In late 2014 and early 2015, the US Food and Drug Administration approved two serogroup B meningococcal vaccines (Trumenba, MenB-FHbp and Bexsero, MenB-4C). In June 2015, the Advisory Committee on Immunization Practices (ACIP) issued recommendations for serogroup B meningococcal vaccine for high-risk individuals aged 10 years or older; these include individuals with persistent complement component deficiencies, individuals with anatomic or functional asplenia, microbiologists routinely exposed to N. meningitidis isolates, and individuals at increased risk because of a serogroup B meningococcal disease outbreak . These indications overlap with those for the quadrivalent meningococcal conjugate vaccine and are summarized in the table (table 1). Among patients with none of the above risk factors, the ACIP advises discussion between doctors and patients regarding vaccination against serogroup B meningococcus; routine vaccination has not been recommended . (See "Meningococcal vaccines", section on 'Use in United States'.)
Effectiveness of pertussis vaccine in infants (May 2015)
Infants younger than 12 months have the highest incidence of pertussis and pertussis-related complications, including death. In a large case-control study, having received ≥1 dose of pertussis vaccine was associated with a 72 percent reduction in the risk of death and a 31 percent reduction in the risk of hospitalization in infants ≥6 weeks of age (the minimum age for the first dose of pertussis vaccine) . However, 64 percent of the deaths occurred in infants younger than six weeks. These findings highlight the importance of timely pertussis immunization for infants, as well as maternal immunization during pregnancy and immunization of the infant’s close contacts, as recommended by the Global Pertussis Initiative . (See "Diphtheria, tetanus, and pertussis immunization in infants and children 0 through 6 years of age", section on 'Efficacy and effectiveness' and "Immunizations during pregnancy", section on 'Tetanus, diphtheria, and pertussis vaccination' and "Bordetella pertussis infection in adolescents and adults: Treatment and prevention", section on 'Tdap booster'.)
The efficacy of an inactivated vaccine to prevent zoster (April 2015)
The live attenuated zoster vaccine reduces the risk of herpes zoster with a reported vaccine efficacy of 60 to 70 percent in adults 50 years and older, but it cannot be used in immunocompromised individuals and may have decreased efficacy in adults 70 years and older. A randomized, placebo-controlled trial evaluated the efficacy of HZ/su, an experimental recombinant inactivated zoster vaccine administered in two doses two months apart, among 15,411 adults 50 years and older . After three years of follow-up, the overall vaccine efficacy against herpes zoster was 97.2 percent (95% CI 93.7-99.0), and efficacy among adults 70 years and older was similar to that seen in adults between 50 and 69 years of age. (See "Prevention of varicella-zoster virus infection: Herpes zoster", section on 'Inactivated vaccines'.)
Aerosolized measles vaccine inferior to subcutaneous vaccine with respect to seropositivity rate (April 2015)
Measles vaccine is usually given by subcutaneous injection; an aerosolized vaccine could be administered by individuals with less training and would not require sterile needles or syringes. In a study including 2004 infants aged 9.0 to 11.9 months in India randomized to receive measles vaccine either by aerosol inhalation or subcutaneous injection, aerosolized vaccine was found to be immunogenic but inferior to the subcutaneous vaccine with respect to seropositivity rate . Follow-up was completed for 1560 children (775 children in the aerosolized vaccine group and 785 children in the subcutaneous vaccine group); seropositivity rates at day 91 were 85.4 and 94.6 percent, respectively. Subcutaneous administration of the measles vaccine remains the standard of care. (See "Prevention and treatment of measles", section on 'Types of vaccines'.)
Pneumococcal conjugate vaccine in adults ≥65 years of age (September 2014, MODIFIED March 2015)
The CAPiTA trial, which is the largest trial to assess the efficacy of the 13-valent pneumococcal conjugate vaccine (PCV13, Prevnar 13) in adults, compared PCV13 to placebo in approximately 85,000 immunocompetent adults ≥65 years of age in the Netherlands who had not received a pneumococcal vaccine previously . The trial demonstrated 46 percent efficacy of PCV13 against vaccine-type pneumococcal pneumonia, 45 percent efficacy against vaccine-type nonbacteremic pneumococcal pneumonia, and 75 percent efficacy against vaccine-type invasive pneumococcal disease. Efficacy persisted for the duration of the trial (mean follow-up four years). However, some concern has been raised that since this trial began before PCV13 was used routinely in infants in the Netherlands, it might not answer the question of whether its use in adults is efficacious in countries that routinely vaccinate infants. (See "Pneumococcal vaccination in adults", section on 'Efficacy'.)
The 23-valent pneumococcal polysaccharide vaccine (PPSV23) has been recommended for many years in the United States for all adults ≥65 years of age. In September 2014, the United States Advisory Committee on Immunization Practices (ACIP) began also recommending PCV13 for all adults ≥65 years of age . The ACIP revision was prompted by results from the CAPiTA trial. Current recommendations for individuals ≥65 years of age who have not previously received either PCV13 or PPSV23 are to administer PCV13 followed 6 to 12 months later by PPSV23 (algorithm 1). In June 2015, the ACIP voted to recommend that the interval between administration of PCV13 and PPSV23 for adults ≥65 years of age be changed to one year. Formal recommendations have not yet been released. In patients who have already received PPSV23, at least one year should elapse before they are given PCV13. (See "Pneumococcal vaccination in adults", section on 'Indications'.)
Sputum Xpert MTB/RIF for discontinuation of TB airborne isolation (February 2015)
Serial acid-fast bacilli (AFB) sputum smears are traditionally used to assess the need for continued airborne infection isolation for patients with suspected tuberculosis, and airborne precautions can generally be discontinued if three serial AFB smear are negative. In February 2015, the US FDA approved the use of the Xpert MTB/RIF assay, a nucleic acid amplification test that detects Mycobacterium tuberculosis (MTB), as an alternative to serial AFB smears for this purpose [47,48]. This approval was based on a study demonstrating that sputum Xpert MTB/RIF results are highly predictive of AFB smear results and may require fewer sputum samples . Xpert MTB/RIF assay testing on a single sputum sample detected MTB in approximately 97 percent of patients who had at least one positive result on two or three serial fluorescent-stained AFB sputum smears and were subsequently culture-confirmed as infected with MTB. Xpert MTB/RIF assay testing on two serial sputum samples detected 100 percent of AFB smear–positive/MTB culture-positive patients. (See "Diagnosis of pulmonary tuberculosis in HIV-uninfected patients", section on 'Xpert MTB/RIF assay' and "Tuberculosis transmission and control".)
Isoniazid and rifapentine for treatment of latent tuberculosis infection in children (February 2015)
Isoniazid (INH) is the regimen of choice for the treatment of latent tuberculosis infection in children, but full adherence throughout the nine-month course can be challenging. A study among 1058 children ages 2 to 17 years demonstrated that directly observed treatment with three months of INH and rifapentine (RPT) was as effective as nine months of unsupervised INH alone for prevention of tuberculosis . Treatment related adverse events were uncommon and similar with the two regimens. Directly observed treatment with INH-RPT is a reasonable regimen for children aged 2 to 17 years when the circumstances make completion of nine months of daily INH difficult. (See "Latent tuberculosis infection in children", section on 'Isoniazid and rifapentine'.)
RTS,S/AS01 malaria vaccine in children (April 2015)
A successful malaria vaccine used in conjunction with other control interventions could reduce the global disease burden of malaria. Phase 3 trial results of RTS,S/AS01 vaccine demonstrated that the vaccine induced partial protection against clinical malaria among children ages 5 to 17 months over the follow-up period of the trial (median 48 months), and showed benefit of the 18-month booster . In the intention-to-treat population, vaccine efficacy among children ages 5 to 17 months who received three doses plus a booster (months 0, 1, 2 and 20) was 36 percent. Formal recommendations from advisory groups for clinical use of this vaccine are forthcoming. (See "Epidemiology, prevention, and control of malaria in endemic areas", section on 'Vaccine development'.)
Cerebral malaria and elevated intracranial pressure (March 2015)
Cerebral malaria is an encephalopathy that presents with impaired consciousness, delirium, and/or seizures. Cerebral edema and elevated intracranial pressure may contribute to a fatal outcome. In one study that included 168 children with cerebral malaria, approximately 84 percent of deaths occurred among individuals with evidence of severe brain swelling on MRI at admission; such swelling was noted among 27 percent of survivors . (See "Clinical manifestations of malaria", section on 'Cerebral malaria'.)
SEXUALLY TRANSMITTED DISEASES
Repeat testing for women treated for trichomoniasis (July 2015)
The risk of repeat infection following treatment for a sexually transmitted infection (STI) is high. In the United States, reinfection with Trichomonas vaginalis has been reported to occur in up to 17 percent of women following treatment for an initial infection. The 2015 Centers for Disease Control and Prevention (CDC) guidelines on the management of STIs recommend that women treated for confirmed T. vaginalis infection undergo repeat testing within three months of treatment, regardless of partner treatment status . Prior guidelines had only listed retesting as a consideration. The preferred diagnostic test for repeat testing is a nucleic acid amplification test (NAAT) on a vaginal swab, which can be performed as soon as two weeks after treatment. Data are insufficient to support retesting men. (See "Trichomoniasis", section on 'Follow-up'.)
Updated CDC guidelines on the management of sexually transmitted infections (June 2015)
The US Centers for Disease Control and Prevention (CDC) updated its guidelines on the management of sexually transmitted infections in June 2015 . Major revisions include a lower threshold for the diagnosis of urethritis based on microscopy of a urethral specimen, a new emphasis on the role of Mycoplasma genitalium in persistent urethritis and cervicitis, preference for nucleic acid amplification-based testing for the diagnosis of Trichomonas vaginalis, and a recommendation to retest women after treatment for T. vaginalis to evaluate for reinfection. New screening recommendations include annual hepatitis C virus (HCV) testing for HIV-infected men who have sex with men and T. vaginalis testing for HIV-infected women annually and when pregnant. (See "Urethritis in adult men", section on 'Diagnostic criteria' and "Mycoplasma genitalium infection in men and women", section on 'Nongonococcal urethritis' and "Trichomoniasis", section on 'Follow-up' and "Primary care of the HIV-infected adult", section on 'Sexually transmitted infections'.)
Ocular syphilis in the United States (April 2015)
Ocular syphilis, a potentially sight-threatening form of neurosyphilis, has been reported more frequently among HIV-infected patients compared with those without HIV. It can occur at any time after initial infection and may be associated with rash. Ocular findings typically include uveitis or optic neuritis, and the diagnosis is supported by a reactive serologic test. In the United States, an outbreak of ocular syphilis has been reported in California and Washington since December 2014; the majority of cases were among HIV-infected men who have sex with men, and several cases resulted in blindness . (See "Epidemiology, clinical presentation, and diagnosis of syphilis in the HIV-infected patient", section on 'Neurosyphilis'.)
Prevalence and clinical presentation of Borrelia miyamotoi infection (June 2015)
Borrelia miyamotoi is an emerging zoonotic pathogen that is transmitted by the same genus of ticks (eg, Ixodes scapularis, Ixodes pacificus) that transmits Borrelia burgdorferi (the agent of Lyme disease), Anaplasma phagocytophilum, and Babesia species. In one case series, B. miyamotoi was identified using polymerase chain reaction (PCR) in approximately 1 percent of specimens from 11,515 patients in the northeastern United States who presented with an acute febrile episode from April through November in 2013 and 2014 . Clinical information was available for 51 patients with B. miyamotoi infection; the majority had marked headache, myalgia, arthralgia, malaise, and/or fatigue, and 24 percent were hospitalized. Diagnostic testing is not widely available, but doxycycline, which is used to treat many other tick-borne infections, is also effective against B. miyamotoi. (See "Borrelia miyamotoi infection", section on 'Clinical manifestations'.)
VIRAL INFECTIONS, NON-HIV
Topical microbicides to reduce genital herpes acquisition (August 2015)
Preventive measures to reduce the transmission of genital herpes virus infections include the use of barrier protection and chronic suppressive antiviral therapy in infected individuals. The use of novel approaches, such as topical microbicides, is under investigation. The effect of vaginally administered tenofovir gel on herpes simplex virus type 2 (HSV-2) acquisition was evaluated in a study of seronegative women from South Africa who participated in a clinical trial designed to assess the efficacy of this agent in reducing HIV acquisition . The incidence of HSV-2 infection was lower among those who received tenofovir gel (10 versus 21 cases per 100 person-years with placebo). In contrast, vaginal tenofovir did not reduce viral shedding among HSV-2-infected women in a separate study . Topical tenofovir is not clinically available, and further longer-term study is warranted to clarify its overall effect on HSV-2 transmission. (See "Prevention of genital herpes virus infections", section on 'Topical microbicides'.)
Daclatasvir-based regimens for genotype 3 HCV infection (August 2015)
In the era of direct-acting antiviral agents for chronic hepatitis C virus (HCV) infection, patients with genotype 3 infection have emerged as a difficult-to-treat population, with suboptimal sustained virologic response (SVR) rates with short courses of previously available regimens. In July 2015, the US Food and Drug Administration approved the use of the novel NS5A inhibitor daclatasvir in combination with sofosbuvir for genotype 3 HCV infection. This agent has been available in Europe and elsewhere. Daclatasvir plus sofosbuvir for 12 weeks is now our preferred regimen for genotype 3-infected patients without cirrhosis. In an open-label study that included 120 such patients, SVR rates were 96 percent with that regimen . SVR rates were only 63 percent in the 32 patients with cirrhosis included in the study, although limited evidence suggests that efficacy is enhanced with the addition of ribavirin to the regimen [60,61]. Thus, daclatasvir plus sofosbuvir plus weight-based ribavirin is our preferred regimen for genotype 3-infected patients with cirrhosis; the regimen is given for 12 to 24 weeks, although the optimal duration is uncertain. Sofosbuvir plus peginterferon plus ribavirin for 12 weeks is an effective alternative for patients willing to take interferon and has more established efficacy data. (See "Treatment regimens for chronic hepatitis C virus genotypes 2 and 3", section on 'Genotype 3'.)
Hospitalization risk in children <9 years old with dengue vaccine CYD-TDV (July 2015)
No licensed vaccine is available for preventing dengue. The vaccine that is most advanced in development is CYD-TDV, a formulation of four chimeric yellow fever 17D vaccine viruses, each engineered to express the surface envelope and membrane proteins from one of the four dengue virus serotypes. The safety and efficacy of CYD-TDV after the administration of three doses over a 12-month period has been studied in three large pediatric trials. In an analysis of the long-term results from those trials, the pooled efficacy for preventing symptomatic dengue infection in the first 25 months was 60 percent for all ages . However, the vaccine was associated with an elevated risk of hospitalization for dengue among children younger than nine years in the setting of natural infection in the third year after vaccination. Further follow-up of participants in these trials will be important to assess the durability of vaccine-induced protective immunity. (See "Prevention and treatment of dengue virus infection", section on 'Vaccination'.)
Causes of community-acquired pneumonia in adults in the United States (July 2015)
As molecular tests have become more widely available, viruses are being detected with increasing frequency in patients with community-acquired pneumonia (CAP). In the Etiology of Pneumonia in the Community (EPIC) study, an active Centers for Disease Control and Prevention (CDC) surveillance study of adults requiring hospitalization for CAP, one or more viruses were detected in 23 percent of cases, bacteria in 11 percent, bacteria and viruses in 3 percent, and fungi or mycobacteria in 1 percent; an etiology was not identified in 62 percent of cases . The most commonly identified organisms were rhinovirus (in 9 percent), influenza virus (in 6 percent), and S. pneumoniae (in 5 percent). In a related study, detection of rhinovirus was associated with CAP in adults, but not in children . These results add to accumulating evidence that rhinovirus is likely to play a role in CAP in adults. (See "Epidemiology, pathogenesis, and microbiology of community-acquired pneumonia in adults", section on 'Rhinovirus' and "Epidemiology, pathogenesis, and microbiology of community-acquired pneumonia in adults", section on 'Microbiologic diagnosis'.)
Middle East respiratory syndrome coronavirus in South Korea and other Asian countries (June 2015)
Middle East respiratory syndrome coronavirus (MERS-CoV) first emerged in 2012 to cause severe pneumonia in patients in the Arabian Peninsula. Cases continue to occur. A large outbreak occurred in South Korea between May and early July 2015; the index case was a man who had recently traveled to Bahrain, the United Arab Emirates, Saudi Arabia, and Qatar . By early July 2015, 185 secondary and tertiary cases had been reported among household and hospital contacts in South Korea; 36 deaths were reported [66-70]. One case occurred in a man who traveled to China following exposure to two relatives with MERS-CoV infection; this patient is the first reported case in China . The first case of MERS-CoV in Thailand was reported in June 2015 in a man who traveled from Oman to Bangkok . (See "Middle East respiratory syndrome coronavirus", section on 'Cases and clusters'.)
Investigational fixed-dose combination therapies for chronic HCV infection (May 2015)
Drug development for chronic hepatitis C virus (HCV) infection continues at a rapid pace and is yielding new, simple, and highly effective regimens that are both interferon- and ribavirin-free. Recent studies of such regimens have demonstrated the following:
●A once-daily, single-pill combination of the NS3/4A protease inhibitor grazoprevir and the NS5A inhibitor elbasvir given for 12 weeks resulted in sustained virological response (SVR) rates greater than 90 percent among treatment-naïve and experienced genotype 1-infected patients with and without cirrhosis [72-74]. The addition of ribavirin to the regimen did not appear to substantially improve outcomes. Data on this regimen in patients with HIV coinfection, Child-Pugh Class B cirrhosis, severe renal impairment, and genotype 4 or 6 infection are also very promising [75-77]. This regimen is not expected to be available until 2016. (See "Investigational therapies for hepatitis C virus infection", section on 'Grazoprevir and elbasvir'.)
●A single-pill combination of the NS5A inhibitor daclatasvir, the NS3/4A protease inhibitor asunaprevir, and the non-nucleoside NS5B inhibitor beclabuvir given twice daily for 12 weeks resulted in SVR rates of 92 and 89 percent among treatment-naïve and experienced genotype 1-infected patients without cirrhosis . A trial among patients with cirrhosis suggested that response rates are even higher when this regimen is combined with ribavirin . (See "Investigational therapies for hepatitis C virus infection", section on 'Daclatasvir and asunaprevir combinations'.)
Avian H5N1 outbreak in Egypt (March 2015)
Highly pathogenic avian H5N1 influenza viruses have caused disease in >780 people since 2003 . The largest outbreak of H5N1 influenza in humans to date began in Egypt in late 2014 and has continued into 2015; 116 cases and 36 deaths were reported between January and late March 2015 [81,82]. (See "Epidemiology, transmission, and pathogenesis of avian influenza", section on 'Avian influenza H5N1'.)
Possible association of giant cell arteritis with varicella zoster virus (March 2015)
The etiology of giant cell arteritis (GCA) remains unknown, although various infectious causes have been considered as triggering events. One of the largest studies to evaluate the relationship between varicella zoster virus (VZV) and GCA included temporal artery (TA) biopsies from 82 pathologically-confirmed GCA patients and 13 TA biopsies from healthy controls . VZV antigen was found in 74 percent of pathologically-confirmed GCA TAs versus 8 percent of normal TAs. The majority of biopsies showing GCA contained VZV antigen in skip areas that correlated with adjacent GCA pathology. However, direct pathogenetic evidence of a causal role of VZV in GCA is lacking. (See "Pathogenesis of giant cell (temporal) arteritis", section on 'Etiology and pathogenesis'.)
Interferon-free regimens to treat HCV in HIV/HCV coinfected patients (February 2015)
Patients coinfected with HIV and hepatitis C virus (HCV) traditionally had lower response rates to HCV treatment with peginterferon and ribavirin compared with individuals without HIV infection. However, with the use of direct-acting antiviral (DAA) agents in HCV treatment, HIV infection is no longer a negative predictor of response. In two studies of HIV/HCV genotype 1 coinfected individuals, sustained virological response rates to two interferon-free DAA regimens (ledipasvir-sofosbuvir or ombitasvir-paritaprevir-ritonavir and dasabuvir plus ribavirin) were greater than 90 percent, comparable to rates in populations infected with HCV alone [84,85]. The major consideration in HCV antiviral regimen selection for HIV/HCV coinfected patients is the potential for drug interactions between antiretroviral and HCV antiviral agents. (See "Treatment of hepatitis C virus infection in the HIV-infected patient", section on 'Genotype 1 infection'.)
OTHER INFECTIOUS DISEASES
Revised name and diagnostic criteria for chronic fatigue syndrome (February 2015)
Diagnostic criteria for chronic fatigue syndrome have been revised (table 2) by the Institute of Medicine (IOM), which has also suggested renaming the condition as systemic exertion intolerance disease (SEID) . The IOM diagnostic criteria focus on the most specific features of the disease. Symptoms should be present for at least six months and have moderate, substantial, or severe intensity at least one-half of the time. Other criteria include post-exertional malaise, sleep problems, cognitive impairment, and orthostatic-related symptoms. (See "Clinical features and diagnosis of chronic fatigue syndrome (systemic exertion intolerance disease)", section on 'Definition'.)
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