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'.)
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) [8,9]. 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'.)
Pneumonia and long-term cardiovascular risk (February 2015)
Community-acquired pneumonia has been associated with increased short-term risk of cardiac events. In two cohorts of community-dwelling adults, hospitalization for pneumonia was also associated with increased long-term risk of new-onset cardiovascular disease (myocardial infarction, cerebrovascular accident, or fatal coronary heart disease), even after adjusting for traditional cardiovascular risk factors . In one of the cohorts, the risk of cardiovascular events among patients with pneumonia was highest during the first year after hospitalization and remained higher than among controls through 10 years. In the other cohort, the risk of cardiovascular events was elevated during the first two years following pneumonia hospitalization, but not thereafter. (See "Prognosis of community-acquired pneumonia in adults", section on 'Association with cardiovascular events'.)
Infection associated with contaminated endoscopes (October 2014, MODIFIED February 2015)
In January 2014, the Centers for Disease Control and Prevention (CDC) reported that 69 cases of New Delhi metallo-beta-lactamase (NDM)-producing carbapenem-resistant Enterobacteriaceae (CRE) had been identified in the United States (44 from northeastern Illinois) in the previous year . Further investigation identified 39 cases from one hospital . Sporadic cases have been subsequently reported to the US Food and Drug Administration (FDA) . The source of infection has been 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 [19,21]. 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 and facilities should adhere to reprocessing and surveillance guidelines issued by the Centers for Disease Control and Prevention, the US Food and Drug Administration, and professional societies, such as the American Gastroenterological Association. If a patient is diagnosed with a multidrug-resistant organism following ERCP, the duodenoscope that was used for the procedure should be removed from service until it is verified to be free of pathogens [22,23]. (See "Endoscope disinfection", section on 'Carbapenem-resistant Enterobacteriaceae'.)
Adjunctive glucocorticoids for hospitalized patients with community-acquired pneumonia (January 2015)
There has been interest in using glucocorticoids as adjunctive therapy to antibiotics in hospitalized patients with community-acquired pneumonia (CAP) in an attempt to reduce the inflammatory response, which is likely to contribute to the morbidity of the disease. There are conflicting data on this approach, but the largest randomized trial suggests a modest benefit. In the trial, which included 785 hospitalized adults with CAP, prednisone 50 mg daily for seven days shortened the time to clinical stability by approximately one day compared with placebo, without an increase in complications . In another randomized trial that included 120 patients in Spain with severe CAP and a high inflammatory response, there was less treatment failure among patients who received methylprednisolone 0.5 mg/kg every 12 hours for five days than in those who received placebo, but no difference in the rate of in-hospital mortality . Pending the results of a larger trial evaluating mortality rates in severe CAP, we do not favor the routine use of adjunctive glucocorticoids in adults with CAP. (See "Treatment of community-acquired pneumonia in adults who require hospitalization", section on 'Glucocorticoids'.)
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'.)
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'.)
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 [29-31]. 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 [32,33]. (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'.)
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 53 percent with immediate compared with deferred treatment (41 versus 86 events). Additional information is needed to better understand the benefit of early therapy on the specific, rather than the combined outcomes. Nevertheless, these preliminary 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'.)
Kidney transplantation from HIV-positive deceased donors into HIV-positive recipients (February 2015)
As is the case for most other patients with end stage renal disease (ESRD), kidney transplantation is superior to other forms of renal replacement therapy for HIV-positive patients with ESRD. In countries where dialysis is a limited resource, kidney transplantation is life-saving. However, kidney transplantation is limited by a shortage of available organs. In a case series from South Africa, 27 carefully selected and treated HIV-positive patients underwent transplantation with kidneys from HIV-positive deceased donors . Patient and allograft survival at 1, 3 and 5 years was comparable to reported patient and allograft survival of HIV-positive patients who received kidneys from HIV-negative donors. (See "Solid organ transplantation in HIV-infected individuals", section on 'Renal transplantation'.)
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", section on 'Tenofovir-emtricitabine' and "Overview of kidney disease in HIV-positive patients" and "Primary care of the HIV-infected adult".)
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 . This supports our recommendation to initiate antiretroviral therapy promptly in treatment-naïve pregnant women with advanced HIV disease or CD4 cell count th week of gestation for HIV-infected pregnant women with higher CD4 cell counts. (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'.)
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 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 [51,52]. 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
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. The first cases in South Korea occurred in May 2015; the index case was a man who had recently traveled to Bahrain, the United Arab Emirates, Saudi Arabia, and Qatar . As of early July 2015, >180 secondary and tertiary cases had been reported among household and hospital contacts in South Korea; 36 deaths were reported [64-68]. 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'.)
Preventing hepatitis B virus reactivation in patients receiving chemotherapy (February 2015, MODIFIED June 2015)
Patients with serologic evidence of hepatitis B virus (HBV) infection who receive immunosuppressive therapies are at risk for HBV reactivation. The estimated risk of reactivation is based upon the patient’s serologic status as well as the type of immunosuppressive therapy. Several expert groups, including the American Association for the Study of Liver Diseases, endorse screening all patients for HBV infection prior to receiving most forms of immunosuppressive therapy [70,71]. However, this recommendation is controversial. Updated guidelines from the American Society of Clinical Oncology (ASCO) recommend screening patients only if they are at high risk for HBV infection, are going to undergo hematopoietic cell transplantation, or are going to receive a chemotherapy regimen that includes an anti-CD20 agent (eg, rituximab) . Authors for UpToDate also disagree, with some suggesting universal screening for HBV infection before most forms of immunosuppression and others suggesting the more limited screening of the ASCO guidelines. (See "Hepatitis B virus reactivation associated with immunosuppressive therapy", section on 'Who is at risk for HBV reactivation' and "Hepatitis B virus reactivation associated with immunosuppressive therapy", section on 'Recommendations of others'.)
For patients with serologic evidence of HBV, antiviral therapy may be warranted to decrease the risk of HBV reactivation during immunosuppression. We favor prophylaxis with entecavir or tenofovir over lamivudine in such cases because these agents have more potent antiviral activity and are less likely to select for drug-resistant virus. This preference is supported by results of a trial in which 121 HBV surface antigen (HBsAg)-positive patients were randomly assigned to prophylactic antiviral therapy with entecavir or lamivudine prior to receiving chemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone for diffuse large B-cell lymphoma . The rates of HBV-related hepatitis and HBV reactivation were lower among those who received entecavir. (See "Hepatitis B virus reactivation associated with immunosuppressive therapy", section on 'Which agents to use'.)
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 [74-76]. 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 [77-79]. 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'.)
Measles outbreak in United States (April 2015, MODIFIED April 2015)
The United States has experienced a record number of measles cases during 2014 to 2015. In 2014, 644 cases were reported from 27 states . Between January 1 and May 1, 2015, 169 cases have been reported. Most cases have occurred among individuals who were unvaccinated. Children living in or traveling to areas where there is a measles outbreak (defined as ≥3 cases linked in time and space) and children traveling outside the United States should receive measles-mumps-rubella vaccine earlier than it is routinely recommended. (See "Epidemiology and transmission of measles", section on 'United States' and "Measles, mumps, and rubella immunization in infants, children, and adolescents", section on 'Outbreaks and international travel'.)
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 [84,85]. (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 [87,88]. 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'.)
Oseltamivir for the treatment of influenza in adults (January 2015)
Oseltamivir has been demonstrated to shorten the duration of influenza symptoms and to reduce the duration of viral shedding. However, studies and meta-analyses have provided contradictory results regarding the effect of oseltamivir on influenza-related lower respiratory tract complications in healthy adults. A 2015 meta-analysis evaluated all manufacturer-sponsored randomized trials, published and unpublished, of oseltamivir for the treatment of influenza in adults . Among those with documented influenza, oseltamivir reduced the time to alleviation of all symptoms (median time 98 versus 123 hours), reduced lower respiratory tract complications requiring antibiotics, and reduced hospital admissions for any cause compared with placebo. In contrast to an earlier meta-analysis that aggregated study results and did not demonstrate a benefit with regards to complications, this meta-analysis pooled individual patient data from the trials, which is generally considered a more rigorous method . These results support our recommendations to use an antiviral agent such as oseltamivir in patients with confirmed or suspected influenza and severe illness or at high risk of complications. (See "Treatment of seasonal influenza in adults", section on 'Efficacy of oseltamivir'.)
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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