Disclosures: Elinor L Baron, MD, DTMH Employee of UpToDate, Inc. Allyson Bloom, MD Employee of UpToDate, Inc. Anna R Thorner, MD Employee of UpToDate, Inc. Jennifer Mitty, MD, MPH Employee of UpToDate, Inc.
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.
Enhanced gram-negative activity of novel antibiotic ceftolazone-tazobactam (January 2015)
In 2014, the US Food and Drug Administration approved ceftolozane-tazobactam, a novel intravenous cephalosporin-beta-lactamase inhibitor combination. The combination has broad-spectrum in vitro activity against aerobic and aerobic gram-negative rods, including Pseudomonas aeruginosa and most extended-spectrum-beta-lactamase-producing gram negative organisms. In as yet unpublished clinical trials, clinical cure rates with ceftolozane/tazobactam alone or in combination with metronidazole were similar to those with comparator antibiotics for complicated urinary tract and intra-abdominal infections [1,2]. Efficacy of ceftolozane-tazobactam may be attenuated in patients with renal impairment (estimated GFR <50 mL/min). (See "Combination beta-lactamase inhibitors, carbapenems, and monobactams", section on 'Ceftolozane-tazobactam'.)
Trimethoprim-sulfamethoxazole and sudden death (December 2014)
While trimethoprim-sulfamethoxazole (TMP-SMX) has generally been felt to be well tolerated, a case-control study found an association between sudden death, possibly due to hyperkalemia, and prescription of TMP-SMX among older patients who were also receiving an angiotensin converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) .Those who received TMP-SMX had an increased seven-day risk of sudden death compared with those who received amoxicillin (adjusted odds ratio 1.38, 95% CI 1.09-1.76). However, other factors that affected the choice of antibiotic may have confounded these results, and higher quality evidence is needed to determine whether this association is causal. (See "Trimethoprim-sulfamethoxazole: An overview", section on 'Life threatening effects'.)
Prophylactic antibiotics do not benefit patients with acute liver failure (October 2014)
The role of prophylactic antibiotics in the treatment of patients with acute liver failure is controversial. In a retrospective study of 1551 patients with acute liver failure, antimicrobial prophylaxis did not reduce the incidence of bloodstream infection or mortality . Our approach to antibiotic prophylaxis is to not give patients prophylactic antibiotics, but instead give antibiotics only if there is evidence of active infection, positive surveillance culture results, or clinical deterioration. (See "Acute liver failure in adults: Management and prognosis", section on 'Infection surveillance and prevention'.)
Antibiotic decontamination of the digestive tract in the ICU and antimicrobial resistance (October 2014)
The use of prophylactic antibiotics to decontaminate the oropharyngeal and/or digestive tracts of critically ill patients and reduce the risk of infection confers a modest mortality benefit but is not widely used, in part, because of concern that it can promote antimicrobial resistance. A large multicenter cluster-randomized trial in intensive care units in the Netherlands compared resistance rates with selective oropharyngeal decontamination (SOD; antibiotics applied to the oropharynx only) and selective digestive decontamination (SDD; antibiotics applied to the oropharynx and through a nasogastric tube plus a different intravenous antibiotic) . Rates of rectal colonization with highly resistant bacteria were overall lower with SDD than SOD, but colonization with aminoglycoside-resistant gram-negative bacilli increased more over time with SDD than SOD. Given the very low baseline rate of antimicrobial resistance in the Netherlands and the absence of a control group that received no prophylactic antibiotics, these findings do not sufficiently allay concerns about long-term antimicrobial resistance with antibiotic use for decontamination of the gastrointestinal tract. (See "Epidemiology and prevention of infections and antimicrobial resistance in the intensive care unit", section on 'Decontamination of the digestive tract'.)
Multistate outbreak of listeriosis associated with caramel apples (December 2014)
A multistate outbreak of listeriosis associated with commercially produced prepackaged caramel apples was reported in the United States in December 2014 . Updated case counts, a list of states in which cases have been reported, and guidance from the United States Centers for Disease Control and Prevention (CDC) can be found on the CDC’s website. (See "Epidemiology and pathogenesis of Listeria monocytogenes infection", section on 'Food epidemiology and outbreaks'.)
Infection associated with contaminated endoscopes (October 2014)
In January 2014, the Centers for Disease Control and Prevention (CDC) reported that since January 2013, 69 cases of New Delhi metallo-beta-lactamase (NDM)-producing carbapenem-resistant Enterobacteriaceae (CRE) had been identified in the United States, 44 of which were from northeastern Illinois . Further investigation identified 39 cases from one hospital . The source of infection was subsequently traced to the elevator channel of a single duodenoscope (the endoscopes used for endoscopic retrograde cholangiopancreatography [ERCP]). No lapses in the cleaning protocol were identified. It is theorized that the complex design of the elevator mechanism makes it more difficult to clean than other parts of endoscopes [8,9]. After changing duodenoscope reprocessing from high-level disinfection to gas sterilization with ethylene oxide, no new cases have been identified. Duodenoscopes should be considered as possible sources for CRE outbreaks in healthcare facilities. (See "Endoscope disinfection", section on 'Carbapenem-resistant Enterobacteriaceae'.)
Prophylactic antibiotics before laparoscopic cholecystectomy (September 2014)
Multiple meta-analyses of randomized trials comparing antibiotic prophylaxis with no antibiotic or placebo prior to elective laparoscopic cholecystectomy have found no differences in the incidence of surgical site infection. These trials have generally included 50 to 175 patients in each arm and have used a single dose of antibiotics administered just prior to surgery. A subsequent large trial randomly assigned approximately 1000 low-risk patients undergoing elective laparoscopic cholecystectomy to no antibiotics or intravenous antibiotics given preoperatively and at 12 and 24 hours postoperatively . In this later trial, the incidence of surgical site infection was lower for those who received perioperative antibiotics (0.8 versus 3.7 percent without antibiotics). Despite the added cost of antibiotic administration, overall hospital costs were lower in the prophylaxis group. Further investigation is needed to determine whether the infectious risk reduction of additional antibiotic doses outweighs the risks of toxicity or bacterial drug resistance associated with increased antibiotic usage. (See "Laparoscopic cholecystectomy", section on 'Antibiotics'.)
Perioperative asymptomatic bacteriuria and prosthetic joint infection (August 2014)
Some clinicians screen and treat for asymptomatic bacteriuria prior to joint arthroplasty, but evidence to support this practice is lacking. Although asymptomatic bacteriuria was associated with subsequent prosthetic joint infection in a prospective study of nearly 2500 patients undergoing total hip or knee arthroplasty, treatment of the bacteriuria, which was at the discretion of the clinician, was not associated with a decreased risk of infection . Furthermore, the organisms isolated from the urine were not the same as those from the surgical site infection in any patient. Although asymptomatic bacteriuria may be a marker for individuals at higher risk for subsequent prosthetic joint infection, it appears unlikely to be causative. We do not routinely perform urinalysis or culture in patients without urinary symptoms prior to or following joint arthroplasty. (See "Approach to the adult with asymptomatic bacteriuria", section on 'Patients undergoing joint arthroplasty'.)
Voriconazole plus anidulafungin for invasive aspergillosis (January 2015)
Voriconazole has been the first-line therapy for invasive aspergillosis for several years, but mortality remains substantial. A randomized trial assessed voriconazole with or without a second antifungal agent, anidulafungin (an echinocandin), for the treatment of invasive aspergillosis in patients with hematologic malignancy and/or hematopoietic cell transplant . Results showed a non-significant trend toward improved six-week survival with the combination of voriconazole and anidulafungin compared with voriconazole monotherapy. A post-hoc analysis suggested that the survival benefit was statistically significant among a major subset of patients with probable invasive aspergillosis, defined as radiographic abnormalities and a positive galactomannan antigen. Based on these results, we favor the use of a combination regimen of voriconazole plus an echinocandin for the first one to two weeks of therapy of confirmed invasive aspergillosis. However, some experts remain uncertain about these data and prefer monotherapy with voriconazole. (See "Treatment and prevention of invasive aspergillosis", section on 'Voriconazole and an echinocandin'.)
Fatality due to contaminated probiotic in a preterm infant (November 2014)
In October 2014, a fatal case of mucormycosis caused by Rhizopus oryzae was reported in a premature infant who received the probiotic supplement Solgar ABC Dophilus® Powder for prevention of necrotizing enterocolitis (NEC) . Investigation by the Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), and Connecticut Departments of Public Health and Consumer Protection of the same lot of unopened Solgar ABC Dophilus® Powder revealed contamination with Rhizopus oryzae. As a result, the CDC sent out a Health Alert on November 25, 2014 that recommends Solgar ABC Dophilus not be used in infants, and that any patient who received this product in the last 30 days be evaluated and empiric antifungal therapy be considered in consultation with an infectious disease specialist. This case supports our current practice of NOT routinely using probiotic therapy to prevent NEC until strict criteria are met for manufacturing and regulation of probiotic products, and there are reliable data for optimal administration of these products. (See "Mucormycosis (zygomycosis)", section on 'Healthcare-associated' and "Prevention of necrotizing enterocolitis in newborns", section on 'Probiotics'.)
T2Candida assay for the detection of candidemia (September 2014)
In 2014, the US Food and Drug Administration (FDA) cleared the T2Candida assay for the detection of bloodstream infection caused by C. albicans, C. tropicalis, C. parapsilosis, C. glabrata, and/or C. krusei . The T2Candida test uses magnetic resonance technology to detect these pathogens from a blood specimen within three to five hours, but a specialized instrument is required to perform the assay. It has a sensitivity of 84 to 96 percent and a specificity of nearly 100 percent. The clinical utility of this technique requires further study. (See "Clinical manifestations and diagnosis of candidemia and invasive candidiasis in adults", section on 'T2Candida'.)
Efficacy of the dengue vaccine CYD-TDV (January 2014, MODIFIED November 2014)
No licensed vaccine is available for preventing dengue; thus far CYD-TDV, a live attenuated tetravalent vaccine, is the most promising. Two large trials were published in 2014 evaluating the efficacy of the vaccine. In these randomized, placebo-controlled trials, conducted in over 30,000 children in the Asia-Pacific region, Latin America, and the Caribbean, the vaccine efficacy of three CYD-TDV doses against virologically confirmed dengue was 57 to 61 percent in the intention-to-treat analyses [15,16]. The vaccine efficacy against dengue hemorrhagic fever after three doses was 89 to 95 percent. Therefore, this vaccine is most effective for protection against severe disease. Vaccine efficacy varied by serotype, and was least protective against serotype 2. The epidemiologic threshold of dengue activity upon which national vaccination programs are justified has yet to be determined. (See "Prevention and treatment of dengue virus infection", section on 'Vaccination'.)
Ebola outbreak in 2014 (August 2014, MODIFIED October 2014)
The largest outbreak of Ebola virus infection reported to date is occurring in West Africa. The countries with widespread transmission include Guinea, Liberia, and Sierra Leone . Patients with Ebola virus disease have also been reported in Mali. Cases outside of West Africa have occurred in healthcare workers caring for patients with Ebola virus disease, as well as a returning traveler. The Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) have provided information to help clinicians evaluate and manage patients with suspected Ebola virus disease [18,19]. The decision to test an individual who may have been exposed to Ebola virus depends upon when the potential exposure occurred, the risk of exposure, and whether or not the individual is displaying signs and symptoms consistent with Ebola virus disease (eg, fever, severe headache, myalgias, gastrointestinal symptoms, or unexplained hemorrhage). If testing is indicated, patients should be isolated. Infection control precautions include standard, contact, and droplet precautions, as well as the correct use of appropriate personal protective equipment [20,21]. Clinicians can refer to the CDC and WHO websites for additional information. (See "Clinical manifestations and diagnosis of Ebola virus disease" and "Epidemiology and pathogenesis of Ebola virus disease".)
Timing of antiretroviral initiation during pregnancy (January 2015)
The risk of HIV transmission from an infected mother to her infant is proportional to the level of maternal viremia at delivery. Among women not already taking an antiretroviral regimen, viral suppression at delivery is more likely when a regimen is initiated earlier during gestation. In a large US cohort of antiretroviral-naïve HIV-infected women who initiated a combination antiretroviral regimen during pregnancy, a detectable viral load at delivery was documented in 13 percent overall, but in 24 percent of those who initiated the regimen during the third trimester . See "Use of antiretroviral medications in pregnant HIV-infected patients and their infants in resource-rich settings", section on 'When to initiate antiretroviral medications during pregnancy'.)
Efficacy of second-line antiretroviral regimens in resource-limited settings (September 2014)
In resource-limited settings, the choice of an antiretroviral regimen for HIV infection following virologic failure with an initial regimen must often be made without knowledge of the presence of resistance mutations. There has been concern that drug resistance following failure of a nucleoside reverse transcriptase inhibitor (NRTI) based regimen would render subsequent NRTI-based regimens less effective. However, in a trial from sub-Saharan Africa that included 1277 HIV-infected individuals who had failed treatment with a non-nucleoside reverse transcriptase inhibitor (NNRTI) plus two NRTIs, rates of virologic suppression were similar with a boosted protease inhibitor plus two to three NRTIs or plus an integrase inhibitor (88 and 87 percent, respectively) . Virologic suppression rates with boosted protease inhibitor monotherapy were lower. These data support the World Health Organization recommendations to use a boosted protease inhibitor with at least two NRTIs as a second line regimen in resource limited settings. (See "The impact of antiretroviral therapy on morbidity and mortality of HIV infection in resource-limited settings", section on 'Drug resistance'.)
Treatment guidelines for adults with HIV infection (July 2014)
The 2014 International Antiviral Society-USA panel (IAS-USA) has published antiretroviral treatment guidelines for adults with HIV infection . These guidelines are generally in agreement with the 2014 Department of Health and Human Services panel recommendations . ART should be initiated for virtually all treatment-naïve HIV-infected individuals. Recommended regimens contain a backbone of two different nucleoside/nucleotide reverse transcriptase inhibitors, and a third drug, which may be an integrase inhibitor, a non-nucleoside reverse transcriptase inhibitor, or a boosted protease inhibitor. (See "Selecting antiretroviral regimens for the treatment-naïve HIV-infected patient", section on 'Recommendations of others'.)
Effectiveness of prior zoster vaccination in patients receiving chemotherapy (October 2014)
Live vaccines are contraindicated in patients receiving myelosuppressive chemotherapy. It is therefore ideal to give indicated vaccines prior to the initiation of chemotherapy, when feasible. However, there has been some concern that chemotherapy might reduce the protective effect of vaccinations. A cohort study has demonstrated that zoster vaccine administered prior to the oncologic diagnosis remains effective in patients ≥60 years of age who are receiving chemotherapy for a solid tumor . The incidence rate of herpes zoster among the unvaccinated group was almost twice that of the vaccinated group. (See "Immunizations in patients with cancer", section on 'Zoster vaccine'.)
No association between HPV vaccination and multiple sclerosis (January 2015)
Although anecdotal and sporadic case reports had fueled concerns about a potential causal relationship between human papillomavirus (HPV) vaccination and development of multiple sclerosis and other demyelinating disorders, larger studies have refuted this. In a study of nearly four million Swedish and Danish females aged 10 to 44 years, receipt of the quadrivalent HPV vaccine was not associated with demyelinating diseases, including multiple sclerosis, optic neuritis, transverse myelitis, and acute disseminated encephalomyelitis . This study adds to the abundance of data demonstrating the overall safety of HPV vaccination. (See "Recommendations for the use of human papillomavirus vaccines", section on 'Postlicensure data'.)
New human papillomavirus (HPV) vaccine targets nine HPV types (December 2014)
Infection with human papillomavirus (HPV) types 16, 18, 31, 33, 45, 52, and 58 is implicated in approximately 90 percent of invasive cervical cancers. The US Food and Drug Administration has approved Gardasil 9, a 9-valent HPV vaccine that targets those seven HPV types in addition to the two types associated with genital warts (6 and 11), for the prevention of HPV-related disease . In an as-yet-unpublished trial that included approximately 14,000 females randomly assigned to receive the 9-valent or quadrivalent HPV vaccine, immune responses with the two vaccines were comparable for the HPV types targeted by both (6, 11, 16, and 18). Additionally, the 9-valent HPV vaccine was 97 percent effective for preventing precancerous and cancerous lesions of the cervix, vagina, and vulva associated with the other targeted HPV types (31, 33, 45, 52, and 58). Safety profiles were overall similar. The 9-valent vaccine is expected to be available in the US in early 2015. (See "Recommendations for the use of human papillomavirus vaccines", section on 'Available vaccines'.)
Circulating influenza A H3N2 viruses in the United States (December 2014)
In December 2014, the CDC released a health advisory stating that more than half of influenza A H3N2 viruses collected and analyzed in the United States in October and November 2014 were antigenically different (drifted) from the H3N2 antigen included in this season's influenza vaccines . Most isolated influenza viruses to date have been H3N2 strains. During previous seasons in which influenza A H3N2 viruses have predominated, higher hospitalization and mortality rates have been reported among older people, very young children, and individuals with certain medical conditions. Influenza vaccination is still strongly recommended because it usually provides some cross-protection against drifted viruses and because influenza vaccines protect against other strains. The CDC health advisory was issued to reemphasize the importance of the use of neuraminidase inhibitors (eg, oseltamivir, zanamivir) when indicated for the treatment and prevention of influenza infection as an adjunct to vaccination. (See "Seasonal influenza vaccination in adults", section on 'Drifted H3N2 viruses during the 2014 to 2015 influenza season' and "Seasonal influenza in children: Prevention with vaccines", section on 'Drifted H3N2 viruses during the 2014 to 2015 influenza season'.)
FDA approval of meningococcal serogroup B vaccines (October 2014)
Neisseria meningitidis serogroup B is responsible for approximately one-third of cases of meningococcal disease in the United States and has caused outbreaks on college campuses in the recent past. Previously licensed meningococcal vaccines in the United States do not protect against serogroup B. In October 2014, the US Food and Drug Administration approved a serogroup B meningococcal vaccine (Trumenba) for use in individuals 10 through 25 years of age . In January 2015, the FDA approved another serogroup B meningococcal vaccine (Bexsero) for use in individuals 10 through 25 years of age . The United States Advisory Committee on Immunization Practices has not yet released recommendations for their use. (See "Meningococcal vaccines", section on 'In children and adolescents' and "Meningococcal vaccines", section on 'Group B meningococcus vaccines'.)
Pneumococcal conjugate vaccine in adults ≥65 years of age (September 2014)
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 the pneumococcal conjugate vaccine (PCV13) for all adults ≥65 years of age . 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 patients who have already received PPSV23, at least one year should elapse before they are given PCV13.
The ACIP revision was prompted by results from the CAPiTA trial. This randomized placebo-controlled trial, including approximately 85,000 adults ≥65 years of age in the Netherlands, demonstrated the efficacy of PCV13 against vaccine-type pneumococcal pneumonia, vaccine-type nonbacteremic pneumococcal pneumonia, and vaccine-type invasive pneumococcal disease . 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 'Indications'.)
ACIP recommendations for the 2014-2015 influenza season (August 2014)
In August 2014 the United States Advisory Committee on Immunization Practices (ACIP) released updated recommendations for the prevention of seasonal influenza with vaccines . Important changes from previous recommendations include:
●A preferential recommendation for the nasal spray vaccine (live attenuated influenza vaccine, LAIV) over the intramuscular injection (inactivated influenza vaccine, IIV) for children two through eight years of age who do not have specific contraindications to the nasal vaccine (eg, asthma, egg allergy, diabetes, immunosuppression). UpToDate agrees with this recommendation, but also prefers LAIV for children older than eight years. If LAIV is not immediately available, IIV should be administered to avoid missing an opportunity for influenza immunization. (See "Seasonal influenza in children: Prevention with vaccines", section on 'LAIV compared with IIV'.)
●Changes to the dosing schedule for children six months through eight years of age (algorithm 2). (See "Seasonal influenza in children: Prevention with vaccines", section on 'Schedule'.)
Recommendations for adults are largely unchanged. (See "Seasonal influenza vaccination in adults", section on 'Overview'.)
Shortened TB treatment with fluoroquinolone-containing regimen not effective (September 2014, MODIFIED October 2014)
Because of their highly bactericidal activity against Mycobacterium tuberculosis, the use of fluoroquinolones in an antituberculous regimen has been hypothesized to allow a shorter duration of treatment. However, shortening treatment with a moxifloxacin-containing regimen to four months was not effective in a phase III trial that included 1931 patients with uncomplicated, smear-positive pulmonary tuberculosis. The study demonstrated that each of two moxifloxacin-containing regimens (isoniazid, rifampin, pyrazinamide, and moxifloxacin; or rifampin, pyrazinamide, ethambutol, and moxifloxacin) given for 17 weeks resulted in greater treatment failure and relapse compared with the standard control regimen of two months of isoniazid, rifampin, pyrazinamide, and ethambutol followed by four months of isoniazid and rifampin . This was despite shorter times to negative sputum cultures with the moxifloxacin regimens than the control regimen. Subsequent studies using gatifloxacin as the fluoroquinolone or moxifloxacin in combination with other antituberculous agents similarly demonstrated worse outcomes with a shorter four-month regimen [36,37]. (See "Treatment of pulmonary tuberculosis in HIV-negative patients", section on 'Fluoroquinolones'.)
Corticosteroids of limited benefit in tuberculous pericarditis (September 2014)
Whether corticosteroids are beneficial for patients with tuberculous pericarditis has been controversial. A randomized trial including 1400 adults initiating antimicrobial treatment for definite or probable tuberculous pericarditis in South Africa (approximately two-thirds of patients had concomitant HIV infection) demonstrated no effect of adjunctive corticosteroids on the primary composite efficacy outcome of death, cardiac tamponade requiring pericardiocentesis, or development of constrictive pericarditis . Corticosteroid use did reduce the incidence of constrictive pericarditis alone (4.4 versus 7.8 percent). The overall lack of benefit may have reflected harm from corticosteroid treatment in patients with HIV, and it remains possible that patients without HIV could benefit from corticosteroids. Based on the totality of the evidence, we do not routinely use adjunctive corticosteroids in the absence of constrictive disease or high risk for constrictive disease. This approach is in disagreement with prior guidelines favoring routine use of corticosteroids for all patients with tuberculous pericarditis.
We continue to suggest administration of corticosteroids for patients with constrictive tuberculous pericarditis and for those felt to be at high risk of developing the condition (ie, large effusion, high level of pericardial fluid inflammatory cells, or early signs of constriction). (See "Tuberculous pericarditis", section on 'Role of corticosteroids'.)
VIRAL INFECTIONS, NON-HIV
Rapid nucleic acid amplification test for seasonal influenza (January 2015)
A rapid nucleic acid amplification test for influenza, the Alere i influenza A & B test, is available in several countries in Europe. In January 2015, the US Food and Drug Administration allowed use of the test in non-traditional laboratory sites, including physicians' offices, emergency rooms, health department clinics, and other healthcare facilities . This test uses a nasal swab sample and provides results (reports influenza A or B, but not subtypes) in as few as 15 minutes. It is performed on a small proprietary machine. Nucleic acid amplification tests are generally more sensitive than antigen and immunofluorescence techniques, which most other rapid influenza tests utilize. (See "Diagnosis of seasonal influenza in adults", section on 'Nucleic acid tests'.)
Late cytomegalovirus prophylaxis versus preemptive therapy following hematopoietic cell transplantation (January 2015)
During the early postengraftment period following allogeneic hematopoietic cell transplantation (HCT), preemptive strategies are employed more commonly than prophylactic strategies to prevent cytomegalovirus (CMV) disease. Optimal preventive strategies during the late postengraftment period (days 100 to 270) have been uncertain. In a multicenter trial, allogeneic HCT recipients at high risk for late CMV disease were randomly assigned to receive six months of valganciclovir prophylaxis or placebo at a median of approximately 97 days after HCT . Plasma CMV levels were monitored weekly and the study drug was replaced by preemptive antiviral therapy if the CMV viral load increased above a certain threshold. Although fewer patients receiving valganciclovir prophylaxis warranted preemptive therapy (11 versus 36 percent of placebo recipients), the primary composite endpoint (death, CMV disease, or other invasive bacterial or fungal infections by 270 days after HCT) occurred at similar frequencies in both groups (20 and 21 percent). These results suggest that routine prophylaxis during the late postengraftment period is not warranted; however, it is prudent to monitor the CMV load in the blood in high-risk patients and initiate preemptive therapy if it becomes positive. (See "Prevention of viral infections in hematopoietic cell transplant recipients", section on 'Late postengraftment'.)
Interferon-free regimens for chronic genotype 1 HCV infection (December 2013, MODIFIED January 2015)
Several highly effective and well tolerated interferon-free options are now available for chronic genotype 1 hepatitis C virus (HCV) infection. Ledipasvir-sofosbuvir, ombitasvir-paritaprevir-ritonavir plus dasabuvir, and simeprevir plus sofosbuvir all achieve sustained virologic response (SVR) rates, and thus effective cure, in excess of 90 percent in genotype 1 infected patients [41-49]. The duration of the regimen and the decision of whether to add weight-based ribavirin depend on the treatment history, presence of cirrhosis, and, for the ombitasvir-paritaprevir-ritonavir plus dasabuvir regimen, the infecting subtype (1a or 1b) (algorithm 3). The choice between the regimens depends primarily on the potential for drug interactions and drug toxicity. Additionally, in the United States, options will be limited by the individual's insurance provider. If cost or insurance coverage is not an issue, we generally favor the regimen of ledipasvir-sofosbuvir for its favorable adverse effect profile, its minimal drug interactions, and its ease of administration (a single pill once daily). (See "Treatment regimens for chronic hepatitis C virus genotype 1", section on 'Selection of treatment regimens'.)
Intravenous peramivir for influenza (December 2014)
Peramivir was approved by the US Food and Drug Administration (FDA) in December 2014 for treating uncomplicated influenza infection in adults who have been ill for ≤2 days [50,51]. Peramivir is the first IV neuraminidase inhibitor to be approved by the FDA, although it has been in use in Japan and South Korea for several years. It is administered as a single intravenous dose of 600 mg. In a randomized trial, those who received peramivir had their influenza symptoms alleviated an average of 21 hours sooner and became afebrile approximately 12 hours sooner than those who received placebo. Patients who cannot receive zanamivir or oseltamivir (eg, those who cannot tolerate inhaled or enteral agents) should receive IV peramivir. Although the FDA has only approved IV peramivir for patients with uncomplicated influenza, we think it is also reasonable to use it for patients with severe influenza who cannot receive oral oseltamivir or inhaled zanamivir; in such patients, we would use either oseltamivir by a nasogastric tube or IV peramivir. (See "Treatment of seasonal influenza in adults", section on 'Efficacy of peramivir' and "Treatment of seasonal influenza in adults", section on 'Choice of antiviral drug'.)
Direct-acting antiviral agents for post-transplantation hepatitis C recurrence (November 2014)
Recurrence of hepatitis C virus (HCV) following liver transplantation occurs in more than 95 percent of patients who fail to have the virus eradicated prior to transplantation. Current treatment regimens using direct-acting antiviral agents such as sofosbuvir and simeprevir are based largely on studies in patients with HCV who have not undergone liver transplantation. Treatment of patients with HCV recurrence after liver transplantation with direct-acting antiviral agents was recently examined in a study with 34 patients . The patients were given ombitasvir (an NS5A inhibitor), ritonavir-boosted paritaprevir (a protease inhibitor), dasabuvir (a nonnucleoside NS5B polymerase inhibitor), and ribavirin for 24 weeks. A sustained virologic response at 24 weeks was achieved by 97 percent of patients, with no episodes of graft rejection. This study supports the use of direct-acting antiviral agents in patients with HCV recurrence following liver transplantation. (See "Liver transplantation for hepatitis C virus infection", section on 'Other regimens'.)
Clusters of enterovirus D68 infections in the United States (September 2014)
Since August 2014, clusters of severe respiratory infections due to enterovirus D68 have been reported across the continental United States [53,54]. These have occurred predominantly in children with a prior history of asthma and have been generally characterized by low grade or absent fever with wheezing, dyspnea, hypoxia, and perihilar infiltrates. Infection has also been associated with rare cases of limb weakness with spinal cord lesions on imaging. The possibility of enterovirus D68 should thus be suspected in cases of severe respiratory illnesses without alternative explanation, particularly in young children. Treatment is supportive and prevention relies on basic hygienic measures, including handwashing with soap and water. Alcohol-based sanitizers may be ineffective against enteroviruses. Enterovirus D68 had previously been implicated in smaller clusters of respiratory infections but was otherwise rarely reported. Additional surveillance information can be found on the CDC website. (See "Virus-induced wheezing and asthma: An overview", section on 'Enterovirus D68 infection' and "Clinical manifestations and diagnosis of enterovirus and parechovirus infections", section on 'Respiratory disease' and "Epidemiology, pathogenesis, treatment, and prevention of enterovirus and parechovirus infections", section on 'Serotypes and disease'.)
Chikungunya fever in the Caribbean and the Americas (July 2014)
Chikungunya is an arthropod-borne virus (arbovirus) endemic to West Africa that causes acute febrile polyarthralgia and arthritis. In December 2013, the first cases of chikungunya fever in the western hemisphere were reported in the Caribbean Island of Saint Martin [55,56]. Since then, local transmission has been confirmed in many countries and territories in the Caribbean, North America, Central America, and South America [55,57-60]. The first two cases of local transmission in the continental United States were reported in Florida in mid-July 2014 [59,60]; local transmission has been reported more widely in Puerto Rico . (See "Chikungunya fever", section on 'Americas'.)
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