Amy Karon

Here are 8 articles in the November issue of Clinician Reviews (accreditation valid until January 1, 2016):

1. Low-risk Prostate Cancer: Immediate Contemplation, Not Immediate Intervention
To take the posttest, go to http://bit.ly/1Vz6Cok

VITALS
Key clinical point: Men with favorable-risk prostate cancer have a low risk for progression to a lethal phenotype and should consider active surveillance.
Major finding: Of 1,298 men with favorable-risk prostate cancer who were enrolled in an active surveillance program, overall, cancer-specific, and metastasis-free survival rates were 69%, 99.9%, and 99.4%, respectively, at 15 years.
Data source: A follow-up of a cohort of men with favorable-risk prostate cancer receiving active surveillance at a single institution that used a clearly defined protocol for enrollment, monitoring, and intervention.
Disclosures: There were no outside funding sources reported. Some coauthors reported consulting or advisory roles with Metamark Genetics, MDxHealth, Dianon Systems, DAKO, Trock, SonaCare Medical, Myriad Genetics, Rochon Genova, Rothwell Figg, and Roche.

2. Diabetes in Seniors Increases Dementia Risk
To take the posttest, go to http://bit.ly/1Q1bITm

VITALS
Key clinical point: Even short-term hyperglycemia in late life can trigger or accelerate cognitive decline, and incident diabetes is a risk factor for dementia after adjustment for differences in cardiovascular disease and other common risk factors.
Major finding: Individuals diagnosed with diabetes later in life have a 16% higher risk for dementia than do those without diabetes.
Data source: A population-based matched cohort study in 225,045 seniors newly diagnosed with diabetes and 668,070 nondiabetic controls.
Disclosures: The Canadian Institutes of Health Research, the Heart and Stroke Foundation of Ontario, the Canadian Institutes of Health Research, the University of Toronto, and the Ontario Ministry of Health and Long-Term Care supported the study. One author reported an unrestricted grant from Amgen, but there were no other conflicts of interest declared.

3. Extremes of Sleep Linked With Early Signs of CVD
To take the posttest, go to http://bit.ly/1FSvLmw

VITALS
Key clinical point: Individuals with very long or short sleep, or poor sleep quality, showed signs of early cardiovascular disease.
Major finding: Extremely short and extremely long sleep duration were associated with significantly increased levels of coronary artery calcification (CAC) and increased brachial-ankle pulse wave velocity (baPWV).
Data source: Cross-sectional study of more than 47,000 healthy adult men and women who reported sleep duration and quality and underwent either measurement of CAC.
Disclosures: The funding source was not reported. The authors reported no disclosures.

4. Sunscreens With DNA Repair Enzymes Might Lessen AK Progression
To take the posttest, go to http://bit.ly/1LdZWFf

VITALS
Key clinical point: Sunscreen containing DNA repair enzymes might prevent malignant progression of actinic keratosis better than sunscreen alone.
Major finding: Field cancerization and cyclobutane pyrimidine dimer levels improved significantly more with sunscreen plus enzymes than with sunscreen only (P < .0001 for each).
Data source: Six-month randomized trial of 28 patients with actinic keratosis.
Disclosures: Biodue S.p.A. provided the methyl aminolevulinate used in the study. Dr. Enzo Emanuele, the study’s senior author, is a major shareholder of Living Research S.A.S., a privately held biomedical research organization that provided funding for the work. The other researchers reported no conflicts of interest.

5. Breastfeeding Protects Against Postpartum MS Relapse
To take the posttest, go to http://bit.ly/1OSYU49

VITALS
Key clinical point: Don’t discourage new mothers with multiple sclerosis from breastfeeding.
Major finding: Among 81 women who did not breastfeed or who supplemented breastfeeding early on, 31 (38.3%) had an MS relapse within the first six postpartum months, compared with 29 women (24.2%) among the 120 who intended to breastfeed their children exclusively for at least two months (adjusted HR, 1.70).
Data source: A prospective study of 201 pregnant women with relapsing-remitting MS who were followed for one year post partum.
Disclosures: The work was funded by the German Research Foundation. The German MS and pregnancy registry was partly supported by Bayer HealthCare, Biogen Idec, Merck Serono, Novartis Pharma, and Genzyme Pharmaceuticals. Five of the researchers reported receiving speaker honoraria or other financial support from pharmaceutical companies.

6. S aureus Seen in 1% of Pediatric CAP Cases
To take the posttest, go to http://bit.ly/1FPJnQ3

VITALS
Key clinical point: About 1% of children presenting to a hospital with community-acquired pneumonia had Staphylococcus aureus infections, which do not respond to recommended firstline narrow-spectrum antibiotics for CAP.
Major finding: In a cohort of 554 children admitted with CAP, seven had S aureus infections, six classified as complicated. All received vancomycin within 24 hours of admission; anemia incidence was significantly higher in S aureus patients than for the rest of the cohort.
Data source: Retrospective cohort study of more than 3,400 children.
Disclosures: The study received no outside funding, and Dr. Hofto disclosed no conflicts of interest.

7. Higher Arrhythmia Risk for Psoriasis Patients
To take the posttest, go to http://bit.ly/1VBdbS6

VITALS
Key clinical point: Patients with psoriasis are at increased risk for arrhythmia compared to those without psoriasis.
Major finding: After researchers adjusted for history and medication use, patients with psoriasis were at increased risk for overall arrhythmia (adjusted hazard ratio, 1.34; 95% confidence interval, 1.29-1.39).
Data source: A retrospective cohort study using data from almost 41,000 psoriasis patients identified from the Taiwan National Health Insurance Research Database, and almost 163,000 age- and sex-matched cohorts from the same database.
Disclosures: The study was institutionally funded. Dr. Chiu, Ms. Chang, and three other authors had no disclosures; one author disclosed having conducted clinical trials or received honoraria from several companies, including Pfizer and Novartis, and having received speaking fees from AbbVie.

8. Hepatitis C Drove Steep Rises in Cirrhosis, HCC, and Related Deaths
To take the posttest, go to http://bit.ly/1jyNrdp

VITALS
Key clinical point: Cirrhosis, hepatocellular carcinoma (HCC), and liver-related mortality rose substantially among Veterans Affairs (VA) patients over the past 12 years, mainly driven by hepatitis C virus infection.
Major finding: The prevalence of cirrhosis nearly doubled between 2001 and 2013, while cirrhosis-related deaths rose by about 50% and the incidence of HCC almost tripled.
Data source: A retrospective cohort study of 129,998 VA patients with cirrhosis and 21,326 VA patients with HCC between 2001 and 2013.
Disclosures: The Department of VA and the Veterans Health Administration funded the study. The investigators declared no competing interests.

Here are 8 articles in the November issue of Clinician Reviews (accreditation valid until January 1, 2016):

1. Low-risk Prostate Cancer: Immediate Contemplation, Not Immediate Intervention
To take the posttest, go to http://bit.ly/1Vz6Cok

VITALS
Key clinical point: Men with favorable-risk prostate cancer have a low risk for progression to a lethal phenotype and should consider active surveillance.
Major finding: Of 1,298 men with favorable-risk prostate cancer who were enrolled in an active surveillance program, overall, cancer-specific, and metastasis-free survival rates were 69%, 99.9%, and 99.4%, respectively, at 15 years.
Data source: A follow-up of a cohort of men with favorable-risk prostate cancer receiving active surveillance at a single institution that used a clearly defined protocol for enrollment, monitoring, and intervention.
Disclosures: There were no outside funding sources reported. Some coauthors reported consulting or advisory roles with Metamark Genetics, MDxHealth, Dianon Systems, DAKO, Trock, SonaCare Medical, Myriad Genetics, Rochon Genova, Rothwell Figg, and Roche.

2. Diabetes in Seniors Increases Dementia Risk
To take the posttest, go to http://bit.ly/1Q1bITm

VITALS
Key clinical point: Even short-term hyperglycemia in late life can trigger or accelerate cognitive decline, and incident diabetes is a risk factor for dementia after adjustment for differences in cardiovascular disease and other common risk factors.
Major finding: Individuals diagnosed with diabetes later in life have a 16% higher risk for dementia than do those without diabetes.
Data source: A population-based matched cohort study in 225,045 seniors newly diagnosed with diabetes and 668,070 nondiabetic controls.
Disclosures: The Canadian Institutes of Health Research, the Heart and Stroke Foundation of Ontario, the Canadian Institutes of Health Research, the University of Toronto, and the Ontario Ministry of Health and Long-Term Care supported the study. One author reported an unrestricted grant from Amgen, but there were no other conflicts of interest declared.

3. Extremes of Sleep Linked With Early Signs of CVD
To take the posttest, go to http://bit.ly/1FSvLmw

VITALS
Key clinical point: Individuals with very long or short sleep, or poor sleep quality, showed signs of early cardiovascular disease.
Major finding: Extremely short and extremely long sleep duration were associated with significantly increased levels of coronary artery calcification (CAC) and increased brachial-ankle pulse wave velocity (baPWV).
Data source: Cross-sectional study of more than 47,000 healthy adult men and women who reported sleep duration and quality and underwent either measurement of CAC.
Disclosures: The funding source was not reported. The authors reported no disclosures.

4. Sunscreens With DNA Repair Enzymes Might Lessen AK Progression
To take the posttest, go to http://bit.ly/1LdZWFf

VITALS
Key clinical point: Sunscreen containing DNA repair enzymes might prevent malignant progression of actinic keratosis better than sunscreen alone.
Major finding: Field cancerization and cyclobutane pyrimidine dimer levels improved significantly more with sunscreen plus enzymes than with sunscreen only (P < .0001 for each).
Data source: Six-month randomized trial of 28 patients with actinic keratosis.
Disclosures: Biodue S.p.A. provided the methyl aminolevulinate used in the study. Dr. Enzo Emanuele, the study’s senior author, is a major shareholder of Living Research S.A.S., a privately held biomedical research organization that provided funding for the work. The other researchers reported no conflicts of interest.

5. Breastfeeding Protects Against Postpartum MS Relapse
To take the posttest, go to http://bit.ly/1OSYU49

VITALS
Key clinical point: Don’t discourage new mothers with multiple sclerosis from breastfeeding.
Major finding: Among 81 women who did not breastfeed or who supplemented breastfeeding early on, 31 (38.3%) had an MS relapse within the first six postpartum months, compared with 29 women (24.2%) among the 120 who intended to breastfeed their children exclusively for at least two months (adjusted HR, 1.70).
Data source: A prospective study of 201 pregnant women with relapsing-remitting MS who were followed for one year post partum.
Disclosures: The work was funded by the German Research Foundation. The German MS and pregnancy registry was partly supported by Bayer HealthCare, Biogen Idec, Merck Serono, Novartis Pharma, and Genzyme Pharmaceuticals. Five of the researchers reported receiving speaker honoraria or other financial support from pharmaceutical companies.

6. S aureus Seen in 1% of Pediatric CAP Cases
To take the posttest, go to http://bit.ly/1FPJnQ3

VITALS
Key clinical point: About 1% of children presenting to a hospital with community-acquired pneumonia had Staphylococcus aureus infections, which do not respond to recommended firstline narrow-spectrum antibiotics for CAP.
Major finding: In a cohort of 554 children admitted with CAP, seven had S aureus infections, six classified as complicated. All received vancomycin within 24 hours of admission; anemia incidence was significantly higher in S aureus patients than for the rest of the cohort.
Data source: Retrospective cohort study of more than 3,400 children.
Disclosures: The study received no outside funding, and Dr. Hofto disclosed no conflicts of interest.

7. Higher Arrhythmia Risk for Psoriasis Patients
To take the posttest, go to http://bit.ly/1VBdbS6

VITALS
Key clinical point: Patients with psoriasis are at increased risk for arrhythmia compared to those without psoriasis.
Major finding: After researchers adjusted for history and medication use, patients with psoriasis were at increased risk for overall arrhythmia (adjusted hazard ratio, 1.34; 95% confidence interval, 1.29-1.39).
Data source: A retrospective cohort study using data from almost 41,000 psoriasis patients identified from the Taiwan National Health Insurance Research Database, and almost 163,000 age- and sex-matched cohorts from the same database.
Disclosures: The study was institutionally funded. Dr. Chiu, Ms. Chang, and three other authors had no disclosures; one author disclosed having conducted clinical trials or received honoraria from several companies, including Pfizer and Novartis, and having received speaking fees from AbbVie.

8. Hepatitis C Drove Steep Rises in Cirrhosis, HCC, and Related Deaths
To take the posttest, go to http://bit.ly/1jyNrdp

VITALS
Key clinical point: Cirrhosis, hepatocellular carcinoma (HCC), and liver-related mortality rose substantially among Veterans Affairs (VA) patients over the past 12 years, mainly driven by hepatitis C virus infection.
Major finding: The prevalence of cirrhosis nearly doubled between 2001 and 2013, while cirrhosis-related deaths rose by about 50% and the incidence of HCC almost tripled.
Data source: A retrospective cohort study of 129,998 VA patients with cirrhosis and 21,326 VA patients with HCC between 2001 and 2013.
Disclosures: The Department of VA and the Veterans Health Administration funded the study. The investigators declared no competing interests.

Here are 8 articles in the November issue of Clinician Reviews (accreditation valid until January 1, 2016):

1. Low-risk Prostate Cancer: Immediate Contemplation, Not Immediate Intervention
To take the posttest, go to http://bit.ly/1Vz6Cok

VITALS
Key clinical point: Men with favorable-risk prostate cancer have a low risk for progression to a lethal phenotype and should consider active surveillance.
Major finding: Of 1,298 men with favorable-risk prostate cancer who were enrolled in an active surveillance program, overall, cancer-specific, and metastasis-free survival rates were 69%, 99.9%, and 99.4%, respectively, at 15 years.
Data source: A follow-up of a cohort of men with favorable-risk prostate cancer receiving active surveillance at a single institution that used a clearly defined protocol for enrollment, monitoring, and intervention.
Disclosures: There were no outside funding sources reported. Some coauthors reported consulting or advisory roles with Metamark Genetics, MDxHealth, Dianon Systems, DAKO, Trock, SonaCare Medical, Myriad Genetics, Rochon Genova, Rothwell Figg, and Roche.

2. Diabetes in Seniors Increases Dementia Risk
To take the posttest, go to http://bit.ly/1Q1bITm

VITALS
Key clinical point: Even short-term hyperglycemia in late life can trigger or accelerate cognitive decline, and incident diabetes is a risk factor for dementia after adjustment for differences in cardiovascular disease and other common risk factors.
Major finding: Individuals diagnosed with diabetes later in life have a 16% higher risk for dementia than do those without diabetes.
Data source: A population-based matched cohort study in 225,045 seniors newly diagnosed with diabetes and 668,070 nondiabetic controls.
Disclosures: The Canadian Institutes of Health Research, the Heart and Stroke Foundation of Ontario, the Canadian Institutes of Health Research, the University of Toronto, and the Ontario Ministry of Health and Long-Term Care supported the study. One author reported an unrestricted grant from Amgen, but there were no other conflicts of interest declared.

3. Extremes of Sleep Linked With Early Signs of CVD
To take the posttest, go to http://bit.ly/1FSvLmw

VITALS
Key clinical point: Individuals with very long or short sleep, or poor sleep quality, showed signs of early cardiovascular disease.
Major finding: Extremely short and extremely long sleep duration were associated with significantly increased levels of coronary artery calcification (CAC) and increased brachial-ankle pulse wave velocity (baPWV).
Data source: Cross-sectional study of more than 47,000 healthy adult men and women who reported sleep duration and quality and underwent either measurement of CAC.
Disclosures: The funding source was not reported. The authors reported no disclosures.

4. Sunscreens With DNA Repair Enzymes Might Lessen AK Progression
To take the posttest, go to http://bit.ly/1LdZWFf

VITALS
Key clinical point: Sunscreen containing DNA repair enzymes might prevent malignant progression of actinic keratosis better than sunscreen alone.
Major finding: Field cancerization and cyclobutane pyrimidine dimer levels improved significantly more with sunscreen plus enzymes than with sunscreen only (P < .0001 for each).
Data source: Six-month randomized trial of 28 patients with actinic keratosis.
Disclosures: Biodue S.p.A. provided the methyl aminolevulinate used in the study. Dr. Enzo Emanuele, the study’s senior author, is a major shareholder of Living Research S.A.S., a privately held biomedical research organization that provided funding for the work. The other researchers reported no conflicts of interest.

5. Breastfeeding Protects Against Postpartum MS Relapse
To take the posttest, go to http://bit.ly/1OSYU49

VITALS
Key clinical point: Don’t discourage new mothers with multiple sclerosis from breastfeeding.
Major finding: Among 81 women who did not breastfeed or who supplemented breastfeeding early on, 31 (38.3%) had an MS relapse within the first six postpartum months, compared with 29 women (24.2%) among the 120 who intended to breastfeed their children exclusively for at least two months (adjusted HR, 1.70).
Data source: A prospective study of 201 pregnant women with relapsing-remitting MS who were followed for one year post partum.
Disclosures: The work was funded by the German Research Foundation. The German MS and pregnancy registry was partly supported by Bayer HealthCare, Biogen Idec, Merck Serono, Novartis Pharma, and Genzyme Pharmaceuticals. Five of the researchers reported receiving speaker honoraria or other financial support from pharmaceutical companies.

6. S aureus Seen in 1% of Pediatric CAP Cases
To take the posttest, go to http://bit.ly/1FPJnQ3

VITALS
Key clinical point: About 1% of children presenting to a hospital with community-acquired pneumonia had Staphylococcus aureus infections, which do not respond to recommended firstline narrow-spectrum antibiotics for CAP.
Major finding: In a cohort of 554 children admitted with CAP, seven had S aureus infections, six classified as complicated. All received vancomycin within 24 hours of admission; anemia incidence was significantly higher in S aureus patients than for the rest of the cohort.
Data source: Retrospective cohort study of more than 3,400 children.
Disclosures: The study received no outside funding, and Dr. Hofto disclosed no conflicts of interest.

7. Higher Arrhythmia Risk for Psoriasis Patients
To take the posttest, go to http://bit.ly/1VBdbS6

VITALS
Key clinical point: Patients with psoriasis are at increased risk for arrhythmia compared to those without psoriasis.
Major finding: After researchers adjusted for history and medication use, patients with psoriasis were at increased risk for overall arrhythmia (adjusted hazard ratio, 1.34; 95% confidence interval, 1.29-1.39).
Data source: A retrospective cohort study using data from almost 41,000 psoriasis patients identified from the Taiwan National Health Insurance Research Database, and almost 163,000 age- and sex-matched cohorts from the same database.
Disclosures: The study was institutionally funded. Dr. Chiu, Ms. Chang, and three other authors had no disclosures; one author disclosed having conducted clinical trials or received honoraria from several companies, including Pfizer and Novartis, and having received speaking fees from AbbVie.

8. Hepatitis C Drove Steep Rises in Cirrhosis, HCC, and Related Deaths
To take the posttest, go to http://bit.ly/1jyNrdp

VITALS
Key clinical point: Cirrhosis, hepatocellular carcinoma (HCC), and liver-related mortality rose substantially among Veterans Affairs (VA) patients over the past 12 years, mainly driven by hepatitis C virus infection.
Major finding: The prevalence of cirrhosis nearly doubled between 2001 and 2013, while cirrhosis-related deaths rose by about 50% and the incidence of HCC almost tripled.
Data source: A retrospective cohort study of 129,998 VA patients with cirrhosis and 21,326 VA patients with HCC between 2001 and 2013.
Disclosures: The Department of VA and the Veterans Health Administration funded the study. The investigators declared no competing interests.

SAN DIEGO – Fecal microbiota transplantation (FMT) is now first-line therapy for Clostridium difficile infection (CDI) in much of Scandinavia. At an annual conference on infectious diseases, two specialists debated whether that should be the case in the United States, too.

The epidemiology of CDI has changed greatly in the past decade, as other researchers have noted (Infect Drug Resist. 2014;7:63-72). Incidence, severity, and case-fatality rates have risen substantially, and individuals who lack the usual risk factors for CDI are now acquiring it in community settings. Moreover, CDI adds about 5-6 days to a patient’s average hospital stay, and almost one in three affected patients is rehospitalized (Am J Infect Control. 2015 Apr 1;43[4]:314-7.) – most often within a week of discharge, said Dr. Thomas Moore, who is at the University of Kansas, Wichita.

“Should FMT be used as first-line therapy? Not just yes, but hell, yes! It has superior efficacy,” Dr. Moore said.

Courtesy CDC/Dr. Gilda Jones

He pointed to the recent landmark study (N Engl J Med. 2013;368:407-15) of CDI in which duodenal infusions of donor feces more than tripled the rates of relapse-free cure, compared with vancomycin monotherapy or vancomycin with bowel lavage (P less than .001 for both comparisons). Moreover, diarrhea resolved for 81% of patients after the first fecal infusion, and the observed superiority over the vancomycin regimens was so marked that investigators stopped the study after the interim analysis.

Evidence suggests FMT is safe as well as effective, said Dr. Moore. Centers in Norway, Sweden, Denmark, Finland, and Holland have treated at least 900 patients with no reported adverse effects and with cure rates of about 90%, he noted. Of more than 1,000 published FMT studies worldwide, there has been one only report of peritonitis after colonoscopy, one case of irritable bowel syndrome, three reports of mild enteritis, one case of upper gastrointestinal bleeding, one death from sepsis from a dislodged gastrostomy tube, and one case of new-onset obesity, which occurred after a patient received fecal microbiota donated by an obese relative, he added (Open Forum Infect Dis. 2015 Feb 1. doi: 10.1093/ofid/ofv004). Patients now receive fecal microbiota donations from normal-weight individuals, he noted (http://www.openbiome.org/stool-donation/).

“Fecal microbiota transplantation could save lives,” Dr. Moore concluded. Donor material is “cheap and unlimited, the procedure is cost-effective, easy to perform, can even be done at home, and patient satisfaction is very high.”

But Dr. Johan S. Bakken, an infectious disease specialist at St. Luke’s Hospital in Duluth, Minn., argued that FMT is not ready for first-line use for CDI in the United States. “There are no published FMT practice guidelines for initial therapy, even in Scandinavia, and no randomized controlled trials of FMT conducted anywhere,” said Dr. Bakken. He noted that because the Food and Drug Administration has not approved FMT for first-line use in CDI, utilization could require an approved Investigational New Drug application, leading to “unavoidable” treatment delays.

Clinicians also should not gloss over concerns about adverse effects with FMT, Dr. Bakken said. In addition to the case of new-onset obesity, there are risks of aspirating fecal material or perforating hollow viscera. Furthermore, the potential long-term adverse consequences of FMT are unknown, he said.

In contrast, the rate of resolution of initial CDI with per oral vancomycin or fidaxomicin is more than 80%, Dr. Bakken said. Moreover, liquid vancomycin at an appropriate dose and frequency for CDI costs about $4.25 per day in Duluth, he added. “No comparative outcomes data are available for FMT, but it is more costly than vancomycin, may not be locally available, and requires several days or weeks of planning,” he emphasized.

Cost-reimbursement issues with third-party payers are also likely with FMT, according to Dr. Bakken. “There also are potential or perceived medicolegal issues with FMT,” he said. “Keep in mind that about 80% of the world’s lawyers work and practice in the U.S.A.”

Dr. Moore had no disclosures. Dr. Bakken reported being an advisory board member of Rebiotix, which is developing a biologic drug to treat recurrent CDI.

SAN DIEGO – Fecal microbiota transplantation (FMT) is now first-line therapy for Clostridium difficile infection (CDI) in much of Scandinavia. At an annual conference on infectious diseases, two specialists debated whether that should be the case in the United States, too.

The epidemiology of CDI has changed greatly in the past decade, as other researchers have noted (Infect Drug Resist. 2014;7:63-72). Incidence, severity, and case-fatality rates have risen substantially, and individuals who lack the usual risk factors for CDI are now acquiring it in community settings. Moreover, CDI adds about 5-6 days to a patient’s average hospital stay, and almost one in three affected patients is rehospitalized (Am J Infect Control. 2015 Apr 1;43[4]:314-7.) – most often within a week of discharge, said Dr. Thomas Moore, who is at the University of Kansas, Wichita.

“Should FMT be used as first-line therapy? Not just yes, but hell, yes! It has superior efficacy,” Dr. Moore said.

Courtesy CDC/Dr. Gilda Jones

He pointed to the recent landmark study (N Engl J Med. 2013;368:407-15) of CDI in which duodenal infusions of donor feces more than tripled the rates of relapse-free cure, compared with vancomycin monotherapy or vancomycin with bowel lavage (P less than .001 for both comparisons). Moreover, diarrhea resolved for 81% of patients after the first fecal infusion, and the observed superiority over the vancomycin regimens was so marked that investigators stopped the study after the interim analysis.

Evidence suggests FMT is safe as well as effective, said Dr. Moore. Centers in Norway, Sweden, Denmark, Finland, and Holland have treated at least 900 patients with no reported adverse effects and with cure rates of about 90%, he noted. Of more than 1,000 published FMT studies worldwide, there has been one only report of peritonitis after colonoscopy, one case of irritable bowel syndrome, three reports of mild enteritis, one case of upper gastrointestinal bleeding, one death from sepsis from a dislodged gastrostomy tube, and one case of new-onset obesity, which occurred after a patient received fecal microbiota donated by an obese relative, he added (Open Forum Infect Dis. 2015 Feb 1. doi: 10.1093/ofid/ofv004). Patients now receive fecal microbiota donations from normal-weight individuals, he noted (http://www.openbiome.org/stool-donation/).

“Fecal microbiota transplantation could save lives,” Dr. Moore concluded. Donor material is “cheap and unlimited, the procedure is cost-effective, easy to perform, can even be done at home, and patient satisfaction is very high.”

But Dr. Johan S. Bakken, an infectious disease specialist at St. Luke’s Hospital in Duluth, Minn., argued that FMT is not ready for first-line use for CDI in the United States. “There are no published FMT practice guidelines for initial therapy, even in Scandinavia, and no randomized controlled trials of FMT conducted anywhere,” said Dr. Bakken. He noted that because the Food and Drug Administration has not approved FMT for first-line use in CDI, utilization could require an approved Investigational New Drug application, leading to “unavoidable” treatment delays.

Clinicians also should not gloss over concerns about adverse effects with FMT, Dr. Bakken said. In addition to the case of new-onset obesity, there are risks of aspirating fecal material or perforating hollow viscera. Furthermore, the potential long-term adverse consequences of FMT are unknown, he said.

In contrast, the rate of resolution of initial CDI with per oral vancomycin or fidaxomicin is more than 80%, Dr. Bakken said. Moreover, liquid vancomycin at an appropriate dose and frequency for CDI costs about $4.25 per day in Duluth, he added. “No comparative outcomes data are available for FMT, but it is more costly than vancomycin, may not be locally available, and requires several days or weeks of planning,” he emphasized.

Cost-reimbursement issues with third-party payers are also likely with FMT, according to Dr. Bakken. “There also are potential or perceived medicolegal issues with FMT,” he said. “Keep in mind that about 80% of the world’s lawyers work and practice in the U.S.A.”

Dr. Moore had no disclosures. Dr. Bakken reported being an advisory board member of Rebiotix, which is developing a biologic drug to treat recurrent CDI.

SAN DIEGO – Fecal microbiota transplantation (FMT) is now first-line therapy for Clostridium difficile infection (CDI) in much of Scandinavia. At an annual conference on infectious diseases, two specialists debated whether that should be the case in the United States, too.

The epidemiology of CDI has changed greatly in the past decade, as other researchers have noted (Infect Drug Resist. 2014;7:63-72). Incidence, severity, and case-fatality rates have risen substantially, and individuals who lack the usual risk factors for CDI are now acquiring it in community settings. Moreover, CDI adds about 5-6 days to a patient’s average hospital stay, and almost one in three affected patients is rehospitalized (Am J Infect Control. 2015 Apr 1;43[4]:314-7.) – most often within a week of discharge, said Dr. Thomas Moore, who is at the University of Kansas, Wichita.

“Should FMT be used as first-line therapy? Not just yes, but hell, yes! It has superior efficacy,” Dr. Moore said.

Courtesy CDC/Dr. Gilda Jones

He pointed to the recent landmark study (N Engl J Med. 2013;368:407-15) of CDI in which duodenal infusions of donor feces more than tripled the rates of relapse-free cure, compared with vancomycin monotherapy or vancomycin with bowel lavage (P less than .001 for both comparisons). Moreover, diarrhea resolved for 81% of patients after the first fecal infusion, and the observed superiority over the vancomycin regimens was so marked that investigators stopped the study after the interim analysis.

Evidence suggests FMT is safe as well as effective, said Dr. Moore. Centers in Norway, Sweden, Denmark, Finland, and Holland have treated at least 900 patients with no reported adverse effects and with cure rates of about 90%, he noted. Of more than 1,000 published FMT studies worldwide, there has been one only report of peritonitis after colonoscopy, one case of irritable bowel syndrome, three reports of mild enteritis, one case of upper gastrointestinal bleeding, one death from sepsis from a dislodged gastrostomy tube, and one case of new-onset obesity, which occurred after a patient received fecal microbiota donated by an obese relative, he added (Open Forum Infect Dis. 2015 Feb 1. doi: 10.1093/ofid/ofv004). Patients now receive fecal microbiota donations from normal-weight individuals, he noted (http://www.openbiome.org/stool-donation/).

“Fecal microbiota transplantation could save lives,” Dr. Moore concluded. Donor material is “cheap and unlimited, the procedure is cost-effective, easy to perform, can even be done at home, and patient satisfaction is very high.”

But Dr. Johan S. Bakken, an infectious disease specialist at St. Luke’s Hospital in Duluth, Minn., argued that FMT is not ready for first-line use for CDI in the United States. “There are no published FMT practice guidelines for initial therapy, even in Scandinavia, and no randomized controlled trials of FMT conducted anywhere,” said Dr. Bakken. He noted that because the Food and Drug Administration has not approved FMT for first-line use in CDI, utilization could require an approved Investigational New Drug application, leading to “unavoidable” treatment delays.

Clinicians also should not gloss over concerns about adverse effects with FMT, Dr. Bakken said. In addition to the case of new-onset obesity, there are risks of aspirating fecal material or perforating hollow viscera. Furthermore, the potential long-term adverse consequences of FMT are unknown, he said.

In contrast, the rate of resolution of initial CDI with per oral vancomycin or fidaxomicin is more than 80%, Dr. Bakken said. Moreover, liquid vancomycin at an appropriate dose and frequency for CDI costs about $4.25 per day in Duluth, he added. “No comparative outcomes data are available for FMT, but it is more costly than vancomycin, may not be locally available, and requires several days or weeks of planning,” he emphasized.

Cost-reimbursement issues with third-party payers are also likely with FMT, according to Dr. Bakken. “There also are potential or perceived medicolegal issues with FMT,” he said. “Keep in mind that about 80% of the world’s lawyers work and practice in the U.S.A.”

Dr. Moore had no disclosures. Dr. Bakken reported being an advisory board member of Rebiotix, which is developing a biologic drug to treat recurrent CDI.

SAN DIEGO – Enterovirus D68 appeared more virulent – but not more lethal – than rhinovirus and other strains of enterovirus among children, said the authors of a single-center study.

The pulmonary pathogen was linked to higher rates of respiratory distress, hospital admission, and magnesium sulfate therapy, but patients were no more likely to die or require critical care unit admission than were those infected with other EV genotypes or rhinovirus, said Dr. Dominik Mertz of the division of infectious diseases at McMaster University, in Hamilton, Ont.

Amy Karon/Frontline Medical News

The study also uncovered no evidence of EV-68 transmission at the hospital, Dr. Mertz and his associates said at an annual scientific meeting on infectious diseases.

In 2014, an outbreak of EV-D68 in the United States included more than 1,000 confirmed cases, almost all among children, and many of whom had comorbid asthma or a history of wheezing. Fourteen patients died, and the Centers for Disease Control and Prevention noted that millions more individuals probably had milder EV-D68 infections for which they were never tested.

Dr. Mertz and his associates studied children who presented consecutively to the hospital during the 3 months between Aug. 1 and Oct. 31, 2014. During that time, nasopharyngeal swabs that were positive for EV or rhinovirus were automatically tested for EV-D68. The researchers matched EV-D68–positive patients with children who were positive for rhinovirus or other EVs on the basis of sex, age, and date of presentation to the hospital.

Almost a third (93 of 297; 31%) of rhinovirus or EV samples were positive for EV-D68. Among 87 matched pairs, EV-D68 infection was associated with a threefold greater odds of respiratory distress (95% confidence interval, 1.47-6.14), and a more than twofold rise in the odds of needing magnesium sulfate therapy (odds ratio, 2.62; 95% CI, 1.06-6.47). There was a trend toward greater risk of hospital admission with EV-D68, although it was not statistically significant (OR, 2.29; 95% CI, 0.96-5.46; P = .06).

Notably, EV-68 did not increase the likelihood of death or CCU admission, while, influenza causes dozens of deaths among children in the United States every year, Dr. Mertz and his coinvestigator Dr. Jeffrey Pernica noted in an interview (MMWR. 2014 Jun 6:63[22];483-90). Studies have yet to compare the morbidity and mortality burdens of influenza, respiratory syncytial virus, and EV-D68, and they would like to do so, they said.

“There was a lot of fuss made about EV-D68,” said Dr. Mertz. “But we have flu every year, and many more kids get the flu and die of flu than EV-D68.”

Patients with EV-D68 infection were more likely than others to have a family history of atopy (OR, 2.25) and a personal history of asthma or wheezing (OR, 1.77), hay fever (1.22), and eosinophilia (4.5), although none of these associations reached statistical significance, the investigators reported. “It seems reasonable to hypothesize that EV-D68 is a more virulent pulmonary pathogen to those with preexisting atopic disease than other rhinoviruses and enteroviruses,” Dr. Mertz and his associates wrote in an associated article (CMAJ. 2015 Oct. 13. doi: 10.1503/cmaj.150619). “We can hypothesize that these children are more likely to have respiratory distress because of the combination of allergy and EV-D68, but why the same doesn’t hold true for rhinovirus or other enterovirus strains, we don’t know,” Dr. Mertz said.

The investigators received no funding for the study and reported no conflicts of interest.

SAN DIEGO – Enterovirus D68 appeared more virulent – but not more lethal – than rhinovirus and other strains of enterovirus among children, said the authors of a single-center study.

The pulmonary pathogen was linked to higher rates of respiratory distress, hospital admission, and magnesium sulfate therapy, but patients were no more likely to die or require critical care unit admission than were those infected with other EV genotypes or rhinovirus, said Dr. Dominik Mertz of the division of infectious diseases at McMaster University, in Hamilton, Ont.

Amy Karon/Frontline Medical News

The study also uncovered no evidence of EV-68 transmission at the hospital, Dr. Mertz and his associates said at an annual scientific meeting on infectious diseases.

In 2014, an outbreak of EV-D68 in the United States included more than 1,000 confirmed cases, almost all among children, and many of whom had comorbid asthma or a history of wheezing. Fourteen patients died, and the Centers for Disease Control and Prevention noted that millions more individuals probably had milder EV-D68 infections for which they were never tested.

Dr. Mertz and his associates studied children who presented consecutively to the hospital during the 3 months between Aug. 1 and Oct. 31, 2014. During that time, nasopharyngeal swabs that were positive for EV or rhinovirus were automatically tested for EV-D68. The researchers matched EV-D68–positive patients with children who were positive for rhinovirus or other EVs on the basis of sex, age, and date of presentation to the hospital.

Almost a third (93 of 297; 31%) of rhinovirus or EV samples were positive for EV-D68. Among 87 matched pairs, EV-D68 infection was associated with a threefold greater odds of respiratory distress (95% confidence interval, 1.47-6.14), and a more than twofold rise in the odds of needing magnesium sulfate therapy (odds ratio, 2.62; 95% CI, 1.06-6.47). There was a trend toward greater risk of hospital admission with EV-D68, although it was not statistically significant (OR, 2.29; 95% CI, 0.96-5.46; P = .06).

Notably, EV-68 did not increase the likelihood of death or CCU admission, while, influenza causes dozens of deaths among children in the United States every year, Dr. Mertz and his coinvestigator Dr. Jeffrey Pernica noted in an interview (MMWR. 2014 Jun 6:63[22];483-90). Studies have yet to compare the morbidity and mortality burdens of influenza, respiratory syncytial virus, and EV-D68, and they would like to do so, they said.

“There was a lot of fuss made about EV-D68,” said Dr. Mertz. “But we have flu every year, and many more kids get the flu and die of flu than EV-D68.”

Patients with EV-D68 infection were more likely than others to have a family history of atopy (OR, 2.25) and a personal history of asthma or wheezing (OR, 1.77), hay fever (1.22), and eosinophilia (4.5), although none of these associations reached statistical significance, the investigators reported. “It seems reasonable to hypothesize that EV-D68 is a more virulent pulmonary pathogen to those with preexisting atopic disease than other rhinoviruses and enteroviruses,” Dr. Mertz and his associates wrote in an associated article (CMAJ. 2015 Oct. 13. doi: 10.1503/cmaj.150619). “We can hypothesize that these children are more likely to have respiratory distress because of the combination of allergy and EV-D68, but why the same doesn’t hold true for rhinovirus or other enterovirus strains, we don’t know,” Dr. Mertz said.

The investigators received no funding for the study and reported no conflicts of interest.

SAN DIEGO – Enterovirus D68 appeared more virulent – but not more lethal – than rhinovirus and other strains of enterovirus among children, said the authors of a single-center study.

The pulmonary pathogen was linked to higher rates of respiratory distress, hospital admission, and magnesium sulfate therapy, but patients were no more likely to die or require critical care unit admission than were those infected with other EV genotypes or rhinovirus, said Dr. Dominik Mertz of the division of infectious diseases at McMaster University, in Hamilton, Ont.

Amy Karon/Frontline Medical News

The study also uncovered no evidence of EV-68 transmission at the hospital, Dr. Mertz and his associates said at an annual scientific meeting on infectious diseases.

In 2014, an outbreak of EV-D68 in the United States included more than 1,000 confirmed cases, almost all among children, and many of whom had comorbid asthma or a history of wheezing. Fourteen patients died, and the Centers for Disease Control and Prevention noted that millions more individuals probably had milder EV-D68 infections for which they were never tested.

Dr. Mertz and his associates studied children who presented consecutively to the hospital during the 3 months between Aug. 1 and Oct. 31, 2014. During that time, nasopharyngeal swabs that were positive for EV or rhinovirus were automatically tested for EV-D68. The researchers matched EV-D68–positive patients with children who were positive for rhinovirus or other EVs on the basis of sex, age, and date of presentation to the hospital.

Almost a third (93 of 297; 31%) of rhinovirus or EV samples were positive for EV-D68. Among 87 matched pairs, EV-D68 infection was associated with a threefold greater odds of respiratory distress (95% confidence interval, 1.47-6.14), and a more than twofold rise in the odds of needing magnesium sulfate therapy (odds ratio, 2.62; 95% CI, 1.06-6.47). There was a trend toward greater risk of hospital admission with EV-D68, although it was not statistically significant (OR, 2.29; 95% CI, 0.96-5.46; P = .06).

Notably, EV-68 did not increase the likelihood of death or CCU admission, while, influenza causes dozens of deaths among children in the United States every year, Dr. Mertz and his coinvestigator Dr. Jeffrey Pernica noted in an interview (MMWR. 2014 Jun 6:63[22];483-90). Studies have yet to compare the morbidity and mortality burdens of influenza, respiratory syncytial virus, and EV-D68, and they would like to do so, they said.

“There was a lot of fuss made about EV-D68,” said Dr. Mertz. “But we have flu every year, and many more kids get the flu and die of flu than EV-D68.”

Patients with EV-D68 infection were more likely than others to have a family history of atopy (OR, 2.25) and a personal history of asthma or wheezing (OR, 1.77), hay fever (1.22), and eosinophilia (4.5), although none of these associations reached statistical significance, the investigators reported. “It seems reasonable to hypothesize that EV-D68 is a more virulent pulmonary pathogen to those with preexisting atopic disease than other rhinoviruses and enteroviruses,” Dr. Mertz and his associates wrote in an associated article (CMAJ. 2015 Oct. 13. doi: 10.1503/cmaj.150619). “We can hypothesize that these children are more likely to have respiratory distress because of the combination of allergy and EV-D68, but why the same doesn’t hold true for rhinovirus or other enterovirus strains, we don’t know,” Dr. Mertz said.

The investigators received no funding for the study and reported no conflicts of interest.

SAN DIEGO – Going tieless and “bare beneath the elbows” has been touted for infection control. But while some clinicians endorse the practice, others call it inconvenient, unprofessional, and distracting. At an annual conference on infectious diseases, two specialists in the field debated going “BBE” and its evidence base.

Widespread practice of BBE dates to at least 2008, when the National Health Service in the United Kingdom mandated it as part of a set of measures to decrease nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Clinicians at NHS were directed to leave jewelry, neckties, and wrist watches at home, hang up their lab coats, and wear short sleeves. The policy aims not only to reduce points of physical contact between providers and patients, but also to improve hand and wrist washing, said Dr. Michael Edmond, who is at the University of Iowa Hospitals and Clinics in Iowa City.

© iChip/iStockphoto

Some evidence supports going BBE, said Dr. Edmond. Pathogenic gram-negative rods have been cultured from neckties, scrubs, uniforms, and white coats in multiple studies, he added. Inadequate laundering is part of the problem – clinical faculty in one study reported washing their coats about once every 2 weeks, even less often than medical students did.

“So when is biological plausibility enough to support a change in practice?” Dr. Edmond asked. “There is a potential for benefit in going BBE. There is no risk for harm. And there is minimal cost. On the basis of the same evidence and assumptions, we are willing to wrap ourselves in plastic and confine patients to their hospital rooms – that is, to use contact precautions. And yet, we are not willing to eliminate white coats and ties.”

Patient perception is not at issue, Dr. Edmond argued. Only about half of patients at one British hospital said they wanted physicians to wear traditional white coats, and that proportion dropped to 22% after patients received educational materials on clothing contamination, he noted. In another study, patients ranked their physician’s appearance behind knowledge, compassion, and politeness when asked which characteristics they valued most.

“Without strong evidence for benefit, we should recommend – not mandate – this new practice,” Dr. Edmond concluded.

But Dr. Neil O. Fishman disagreed, calling BBE “an evidence-free zone.” Dr. Fishman, who is at the University of Pennsylvania in Philadelphia, noted a total lack of randomized, controlled trials or well-performed observational studies supporting BBE. “No clinical studies have demonstrated cross-transmission of health care–associated pathogens from a health care provider to a patient,” he said.

Moreover, BBE does not prevent contamination, Dr. Fishman said. Bacterial cultures of the hands of BBE clinicians and controls revealed no differences in total bacteria counts or numbers of clinically significant pathogens, he said. Cultures of white coats and the undersides of wrists also were similar in terms of total bacteria and MRSA counts, he added.

Despite the lack of evidence, BBE has been implemented at NHS “mainly as a political gesture and has had unintended consequences,” Dr. Fishman said. Informal attire has promoted a less-robust view of infection control, junior doctors have adopted scruffy attire and “slovenly” personal hygiene, and all the focus on clothing has distracted from hand washing, he added.

Furthermore, less than 12% of clinicians have complied with BBE, according to Dr. Fishman. Abstainers report feeling cold and not knowing what time it is. Women, in particular, say they have no pockets to carry work essentials. “This is a gender equity issue,” Dr. Fishman said. “Can we afford to promote practices based on limited evidence, a theoretical rationale, or individual opinions? This is a lack of focus on what really matters.”

Dr. Edmond and Dr. Fishman reported no disclosures.

SAN DIEGO – Going tieless and “bare beneath the elbows” has been touted for infection control. But while some clinicians endorse the practice, others call it inconvenient, unprofessional, and distracting. At an annual conference on infectious diseases, two specialists in the field debated going “BBE” and its evidence base.

Widespread practice of BBE dates to at least 2008, when the National Health Service in the United Kingdom mandated it as part of a set of measures to decrease nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Clinicians at NHS were directed to leave jewelry, neckties, and wrist watches at home, hang up their lab coats, and wear short sleeves. The policy aims not only to reduce points of physical contact between providers and patients, but also to improve hand and wrist washing, said Dr. Michael Edmond, who is at the University of Iowa Hospitals and Clinics in Iowa City.

© iChip/iStockphoto

Some evidence supports going BBE, said Dr. Edmond. Pathogenic gram-negative rods have been cultured from neckties, scrubs, uniforms, and white coats in multiple studies, he added. Inadequate laundering is part of the problem – clinical faculty in one study reported washing their coats about once every 2 weeks, even less often than medical students did.

“So when is biological plausibility enough to support a change in practice?” Dr. Edmond asked. “There is a potential for benefit in going BBE. There is no risk for harm. And there is minimal cost. On the basis of the same evidence and assumptions, we are willing to wrap ourselves in plastic and confine patients to their hospital rooms – that is, to use contact precautions. And yet, we are not willing to eliminate white coats and ties.”

Patient perception is not at issue, Dr. Edmond argued. Only about half of patients at one British hospital said they wanted physicians to wear traditional white coats, and that proportion dropped to 22% after patients received educational materials on clothing contamination, he noted. In another study, patients ranked their physician’s appearance behind knowledge, compassion, and politeness when asked which characteristics they valued most.

“Without strong evidence for benefit, we should recommend – not mandate – this new practice,” Dr. Edmond concluded.

But Dr. Neil O. Fishman disagreed, calling BBE “an evidence-free zone.” Dr. Fishman, who is at the University of Pennsylvania in Philadelphia, noted a total lack of randomized, controlled trials or well-performed observational studies supporting BBE. “No clinical studies have demonstrated cross-transmission of health care–associated pathogens from a health care provider to a patient,” he said.

Moreover, BBE does not prevent contamination, Dr. Fishman said. Bacterial cultures of the hands of BBE clinicians and controls revealed no differences in total bacteria counts or numbers of clinically significant pathogens, he said. Cultures of white coats and the undersides of wrists also were similar in terms of total bacteria and MRSA counts, he added.

Despite the lack of evidence, BBE has been implemented at NHS “mainly as a political gesture and has had unintended consequences,” Dr. Fishman said. Informal attire has promoted a less-robust view of infection control, junior doctors have adopted scruffy attire and “slovenly” personal hygiene, and all the focus on clothing has distracted from hand washing, he added.

Furthermore, less than 12% of clinicians have complied with BBE, according to Dr. Fishman. Abstainers report feeling cold and not knowing what time it is. Women, in particular, say they have no pockets to carry work essentials. “This is a gender equity issue,” Dr. Fishman said. “Can we afford to promote practices based on limited evidence, a theoretical rationale, or individual opinions? This is a lack of focus on what really matters.”

Dr. Edmond and Dr. Fishman reported no disclosures.

SAN DIEGO – Going tieless and “bare beneath the elbows” has been touted for infection control. But while some clinicians endorse the practice, others call it inconvenient, unprofessional, and distracting. At an annual conference on infectious diseases, two specialists in the field debated going “BBE” and its evidence base.

Widespread practice of BBE dates to at least 2008, when the National Health Service in the United Kingdom mandated it as part of a set of measures to decrease nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. Clinicians at NHS were directed to leave jewelry, neckties, and wrist watches at home, hang up their lab coats, and wear short sleeves. The policy aims not only to reduce points of physical contact between providers and patients, but also to improve hand and wrist washing, said Dr. Michael Edmond, who is at the University of Iowa Hospitals and Clinics in Iowa City.

© iChip/iStockphoto

Some evidence supports going BBE, said Dr. Edmond. Pathogenic gram-negative rods have been cultured from neckties, scrubs, uniforms, and white coats in multiple studies, he added. Inadequate laundering is part of the problem – clinical faculty in one study reported washing their coats about once every 2 weeks, even less often than medical students did.

“So when is biological plausibility enough to support a change in practice?” Dr. Edmond asked. “There is a potential for benefit in going BBE. There is no risk for harm. And there is minimal cost. On the basis of the same evidence and assumptions, we are willing to wrap ourselves in plastic and confine patients to their hospital rooms – that is, to use contact precautions. And yet, we are not willing to eliminate white coats and ties.”

Patient perception is not at issue, Dr. Edmond argued. Only about half of patients at one British hospital said they wanted physicians to wear traditional white coats, and that proportion dropped to 22% after patients received educational materials on clothing contamination, he noted. In another study, patients ranked their physician’s appearance behind knowledge, compassion, and politeness when asked which characteristics they valued most.

“Without strong evidence for benefit, we should recommend – not mandate – this new practice,” Dr. Edmond concluded.

But Dr. Neil O. Fishman disagreed, calling BBE “an evidence-free zone.” Dr. Fishman, who is at the University of Pennsylvania in Philadelphia, noted a total lack of randomized, controlled trials or well-performed observational studies supporting BBE. “No clinical studies have demonstrated cross-transmission of health care–associated pathogens from a health care provider to a patient,” he said.

Moreover, BBE does not prevent contamination, Dr. Fishman said. Bacterial cultures of the hands of BBE clinicians and controls revealed no differences in total bacteria counts or numbers of clinically significant pathogens, he said. Cultures of white coats and the undersides of wrists also were similar in terms of total bacteria and MRSA counts, he added.

Despite the lack of evidence, BBE has been implemented at NHS “mainly as a political gesture and has had unintended consequences,” Dr. Fishman said. Informal attire has promoted a less-robust view of infection control, junior doctors have adopted scruffy attire and “slovenly” personal hygiene, and all the focus on clothing has distracted from hand washing, he added.

Furthermore, less than 12% of clinicians have complied with BBE, according to Dr. Fishman. Abstainers report feeling cold and not knowing what time it is. Women, in particular, say they have no pockets to carry work essentials. “This is a gender equity issue,” Dr. Fishman said. “Can we afford to promote practices based on limited evidence, a theoretical rationale, or individual opinions? This is a lack of focus on what really matters.”

Dr. Edmond and Dr. Fishman reported no disclosures.

SAN DIEGO – Identifying a botfly infestation can be the toughest part of treating it. It’s not uncommon for travelers to return from Costa Rica, Belize, and other Central and South American countries with Dermatobia hominis infestations, but clinicians in North America are not necessarily comfortable diagnosing them or removing the larvae,, said Dr. Susan McLellan, who explained how to do so at an annual scientific meeting on infectious diseases.

Clinicians here may confuse botfly infestations with infected sebaceous cysts, staphylococcal infections, cellulitis, or even cutaneous leismaniasis. To make the diagnosis, ask about travel history in patients who present with painful furuncular lesions, said Dr. McLellan, associate professor of clinical medicine at Tulane University, New Orleans.

Closer inspection of these lesions may reveal the two dark spiracles, or breathing holes, of the larvae, which are key to removing them, Dr. Mclellan added. “The larvae have to stick their little spiracles out to breathe,” she said. “You can get them to come further out by covering up these breathing holes with anything occlusive. It can be peanut butter. It can be petroleum jelly. Just cover them up until they stick themselves out more, and then you can grab them and pull them out.”

The “first smother, then pull” approach does not always work with botfly larvae because they have spines on their bodies that can hook into subepidermal tissue, Dr. McLellan noted. “Sometimes you have to make a very, very careful incision,” she said. “Do not incise the larva at all, though. Just pop it out. These lesions do not get superinfected unless you chop up the larva while they are still inside.”

Also do not bother asking patients if they were bitten by the black adult botfly, said Dr. McLellan. Adult D. hominis do not bite, but instead lay their eggs on mosquitos. “Any biting insect that flies could potentially be a carrier,” Dr. McLellan noted. “The mother botfly catches the other flying insect, dumps her eggs on it, and that other insect starts delivering them.” A single mosquito bite can transfer several botfly eggs to a human host. When the larvae hatch and burrow into the skin, they cause pain, redness, and swelling until removed.

Dr. McLellan spoke at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. She reported having no conflicts of interest.

SAN DIEGO – Identifying a botfly infestation can be the toughest part of treating it. It’s not uncommon for travelers to return from Costa Rica, Belize, and other Central and South American countries with Dermatobia hominis infestations, but clinicians in North America are not necessarily comfortable diagnosing them or removing the larvae,, said Dr. Susan McLellan, who explained how to do so at an annual scientific meeting on infectious diseases.

Clinicians here may confuse botfly infestations with infected sebaceous cysts, staphylococcal infections, cellulitis, or even cutaneous leismaniasis. To make the diagnosis, ask about travel history in patients who present with painful furuncular lesions, said Dr. McLellan, associate professor of clinical medicine at Tulane University, New Orleans.

Closer inspection of these lesions may reveal the two dark spiracles, or breathing holes, of the larvae, which are key to removing them, Dr. Mclellan added. “The larvae have to stick their little spiracles out to breathe,” she said. “You can get them to come further out by covering up these breathing holes with anything occlusive. It can be peanut butter. It can be petroleum jelly. Just cover them up until they stick themselves out more, and then you can grab them and pull them out.”

The “first smother, then pull” approach does not always work with botfly larvae because they have spines on their bodies that can hook into subepidermal tissue, Dr. McLellan noted. “Sometimes you have to make a very, very careful incision,” she said. “Do not incise the larva at all, though. Just pop it out. These lesions do not get superinfected unless you chop up the larva while they are still inside.”

Also do not bother asking patients if they were bitten by the black adult botfly, said Dr. McLellan. Adult D. hominis do not bite, but instead lay their eggs on mosquitos. “Any biting insect that flies could potentially be a carrier,” Dr. McLellan noted. “The mother botfly catches the other flying insect, dumps her eggs on it, and that other insect starts delivering them.” A single mosquito bite can transfer several botfly eggs to a human host. When the larvae hatch and burrow into the skin, they cause pain, redness, and swelling until removed.

Dr. McLellan spoke at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. She reported having no conflicts of interest.

SAN DIEGO – Identifying a botfly infestation can be the toughest part of treating it. It’s not uncommon for travelers to return from Costa Rica, Belize, and other Central and South American countries with Dermatobia hominis infestations, but clinicians in North America are not necessarily comfortable diagnosing them or removing the larvae,, said Dr. Susan McLellan, who explained how to do so at an annual scientific meeting on infectious diseases.

Clinicians here may confuse botfly infestations with infected sebaceous cysts, staphylococcal infections, cellulitis, or even cutaneous leismaniasis. To make the diagnosis, ask about travel history in patients who present with painful furuncular lesions, said Dr. McLellan, associate professor of clinical medicine at Tulane University, New Orleans.

Closer inspection of these lesions may reveal the two dark spiracles, or breathing holes, of the larvae, which are key to removing them, Dr. Mclellan added. “The larvae have to stick their little spiracles out to breathe,” she said. “You can get them to come further out by covering up these breathing holes with anything occlusive. It can be peanut butter. It can be petroleum jelly. Just cover them up until they stick themselves out more, and then you can grab them and pull them out.”

The “first smother, then pull” approach does not always work with botfly larvae because they have spines on their bodies that can hook into subepidermal tissue, Dr. McLellan noted. “Sometimes you have to make a very, very careful incision,” she said. “Do not incise the larva at all, though. Just pop it out. These lesions do not get superinfected unless you chop up the larva while they are still inside.”

Also do not bother asking patients if they were bitten by the black adult botfly, said Dr. McLellan. Adult D. hominis do not bite, but instead lay their eggs on mosquitos. “Any biting insect that flies could potentially be a carrier,” Dr. McLellan noted. “The mother botfly catches the other flying insect, dumps her eggs on it, and that other insect starts delivering them.” A single mosquito bite can transfer several botfly eggs to a human host. When the larvae hatch and burrow into the skin, they cause pain, redness, and swelling until removed.

Dr. McLellan spoke at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. She reported having no conflicts of interest.