User login
It is time for the 2010 ID Consult predictions. Instead of starting with my usual Yogi Berra quote, this year I thought I'd tap “Dilbert” creator Scott Adams: “There are many methods for predicting the future. For example, you can read horoscopes, tea leaves, tarot cards, or crystal balls. Collectively, these methods are known as nutty methods. Or you can put well-researched facts into sophisticated computer 'models, more commonly referred to as a complete waste of time.'” Maybe this explains why pandemic influenza was not on my list last year!
Indeed, although I have almost always had something to say about influenza for the last several years in my January “predictions” column, I did not correctly predict the emergence of pandemic influenza, which came on like a sledge hammer in April 2009. One major lesson learned from this unprecedented experience was the importance of collaboration.
In our institution, our emergency department and urgent care volume peaked at levels never seen before. Finding additional space to see patients, scheduling additional providers, and streamlining documentation were major problems that required innovative solutions. The mix of the high volume of worried well with the occasional very sick patient required vigilance on everyone's part.
Subspecialty and community providers also rose to the challenge, and for now, everyone is relieved that disease rates have decreased steadily over the last 4 weeks. Still, we are seeing admissions that exceed what we would usually see for this time of year and expect this to continue through April.
Here are my predictions, with the first two based on our influenza experience:
1. All lessons learned will benefit us, if and when the next outbreak occurs (and it will not necessarily be influenza).
2. Influenza vaccine will be nationally mandated for all health care workers (HCWs). Our institution utilized a mandated policy that required that all HCWs had to have vaccine or a declination signed by Dec. 1. We were able to get 91% of our HCWs immunized, compared with 82% in the last couple years, which is great. Yet, there were still gaps in coverage in certain high-risk units and in individual physicians and nurses. Among those who declined vaccination, some said they would not get vaccine unless it was mandated. Protecting the vulnerable child within our hospitals while also keeping our colleagues well is a major motivation to utilize a mandated policy. I think next year will be the year.
3. More data will focus on the use of palivizumab. Major changes in the American Academy of Pediatrics' Red Book included standardization of a start date and maximum number of doses, as well as changes in eligibility criteria focusing on gestation and age at the start of the season. There is no question we will be revisiting some of these issues in the future.
4. Meningococcal disease will continue to decline in the United States. Meningococcal infections have steadily decreased in the United States over the last 12 years, although the reasons for this are not entirely clear. In 1997, the incidence was 1.1/100,000 population, decreasing to 0.8/100,000 in 2000 and down to 0.3/100,000 in 2008. The implementation of vaccine in and of itself does not explain this decline, because no vaccine is effective against serogroup B and its population-based rates also decreased.
5. Rotavirus cases will continue to decrease. Simpler guidelines for dosing the rotavirus vaccines will result in better coverage and a continued decrease in disease. It is still amazing to me that residents in this era may not care for a single hospitalized child with rotavirus gastroenteritis.
6. Practitioners will more proactively utilize hepatitis A vaccine for the close contacts of adopted infants arriving from high-risk countries. Several reported cases of adults who had not traveled internationally but became infected with hepatitis A within 60 days after the arrival of an international adoptee have prompted new recommendations. Practitioners should identify all who will provide care for the new arrival (including grandparents and babysitters) and ensure they receive hepatitis A immunization before the child arrives, preferably referring them as soon as the plan for adoption is made.
7. The 13-valent pneumococcal conjugate vaccine (PCV13/Prevnar 13) will be here by spring. The emergence of pneumococcus serotype 19A with its typical pattern of multidrug resistance fast-tracked this vaccine, and it looks like it will be ready for implementation soon. Straightforward recommendations from the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices will be available, and we hope to see the impact of this strategy within the next couple of years. Will new serotypes emerge once again?
8. Clindamycin resistance rates for Staphylococcus aureus will continue to rise. In our institution, 25% of pneumococcal strains and 12% of S. aureus are resistant. My colleague Dr. Christopher Harrison believes that if pneumococcal serotype 19A decreases with PCV 13, clindamycin resistance rates for pneumococcus in general may decrease. The level of resistance at which recommendations for treatment of staphylococcal infection will need to be changed is not clear. Some think alternative treatment should be considered at above 10%.
9. Speaking of resistance, vancomycin may no longer be the cornerstone of therapy for methicillin-resistant S. aureus (MRSA) infection by year's end. In the past, a typical S. aureus minimum inhibitory concentration (MIC) for vancomycin was 0.25–0.5 μg/mL. More recently, MICs of 1 (now 60% or so of isolates) or higher (still just 1%) have been seen, a phenomenon that has been termed “MIC creep.” Data in the adult population suggest that even if dosing is pushed to 60 mg/kg per day—the dosing typically used for CNS infections—clinical failures may occur at higher MICs.
10. We will need better evidence to support the utility of newer antistaphylococcal drugs including linezolid, daptomycin, telavancin, and ceftobiprole. Linezolid remains a very expensive drug choice with predictable adverse reactions, particularly neutropenia. Dosing for daptomycin (a lipopeptide), telavancin (a lipoglycopeptide), and ceftobiprole (our first fifth generation cephalosporin) are still not set.
Lastly, I predict—or at least hope for—a happy, healthy, and productive 2010 for all
It is time for the 2010 ID Consult predictions. Instead of starting with my usual Yogi Berra quote, this year I thought I'd tap “Dilbert” creator Scott Adams: “There are many methods for predicting the future. For example, you can read horoscopes, tea leaves, tarot cards, or crystal balls. Collectively, these methods are known as nutty methods. Or you can put well-researched facts into sophisticated computer 'models, more commonly referred to as a complete waste of time.'” Maybe this explains why pandemic influenza was not on my list last year!
Indeed, although I have almost always had something to say about influenza for the last several years in my January “predictions” column, I did not correctly predict the emergence of pandemic influenza, which came on like a sledge hammer in April 2009. One major lesson learned from this unprecedented experience was the importance of collaboration.
In our institution, our emergency department and urgent care volume peaked at levels never seen before. Finding additional space to see patients, scheduling additional providers, and streamlining documentation were major problems that required innovative solutions. The mix of the high volume of worried well with the occasional very sick patient required vigilance on everyone's part.
Subspecialty and community providers also rose to the challenge, and for now, everyone is relieved that disease rates have decreased steadily over the last 4 weeks. Still, we are seeing admissions that exceed what we would usually see for this time of year and expect this to continue through April.
Here are my predictions, with the first two based on our influenza experience:
1. All lessons learned will benefit us, if and when the next outbreak occurs (and it will not necessarily be influenza).
2. Influenza vaccine will be nationally mandated for all health care workers (HCWs). Our institution utilized a mandated policy that required that all HCWs had to have vaccine or a declination signed by Dec. 1. We were able to get 91% of our HCWs immunized, compared with 82% in the last couple years, which is great. Yet, there were still gaps in coverage in certain high-risk units and in individual physicians and nurses. Among those who declined vaccination, some said they would not get vaccine unless it was mandated. Protecting the vulnerable child within our hospitals while also keeping our colleagues well is a major motivation to utilize a mandated policy. I think next year will be the year.
3. More data will focus on the use of palivizumab. Major changes in the American Academy of Pediatrics' Red Book included standardization of a start date and maximum number of doses, as well as changes in eligibility criteria focusing on gestation and age at the start of the season. There is no question we will be revisiting some of these issues in the future.
4. Meningococcal disease will continue to decline in the United States. Meningococcal infections have steadily decreased in the United States over the last 12 years, although the reasons for this are not entirely clear. In 1997, the incidence was 1.1/100,000 population, decreasing to 0.8/100,000 in 2000 and down to 0.3/100,000 in 2008. The implementation of vaccine in and of itself does not explain this decline, because no vaccine is effective against serogroup B and its population-based rates also decreased.
5. Rotavirus cases will continue to decrease. Simpler guidelines for dosing the rotavirus vaccines will result in better coverage and a continued decrease in disease. It is still amazing to me that residents in this era may not care for a single hospitalized child with rotavirus gastroenteritis.
6. Practitioners will more proactively utilize hepatitis A vaccine for the close contacts of adopted infants arriving from high-risk countries. Several reported cases of adults who had not traveled internationally but became infected with hepatitis A within 60 days after the arrival of an international adoptee have prompted new recommendations. Practitioners should identify all who will provide care for the new arrival (including grandparents and babysitters) and ensure they receive hepatitis A immunization before the child arrives, preferably referring them as soon as the plan for adoption is made.
7. The 13-valent pneumococcal conjugate vaccine (PCV13/Prevnar 13) will be here by spring. The emergence of pneumococcus serotype 19A with its typical pattern of multidrug resistance fast-tracked this vaccine, and it looks like it will be ready for implementation soon. Straightforward recommendations from the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices will be available, and we hope to see the impact of this strategy within the next couple of years. Will new serotypes emerge once again?
8. Clindamycin resistance rates for Staphylococcus aureus will continue to rise. In our institution, 25% of pneumococcal strains and 12% of S. aureus are resistant. My colleague Dr. Christopher Harrison believes that if pneumococcal serotype 19A decreases with PCV 13, clindamycin resistance rates for pneumococcus in general may decrease. The level of resistance at which recommendations for treatment of staphylococcal infection will need to be changed is not clear. Some think alternative treatment should be considered at above 10%.
9. Speaking of resistance, vancomycin may no longer be the cornerstone of therapy for methicillin-resistant S. aureus (MRSA) infection by year's end. In the past, a typical S. aureus minimum inhibitory concentration (MIC) for vancomycin was 0.25–0.5 μg/mL. More recently, MICs of 1 (now 60% or so of isolates) or higher (still just 1%) have been seen, a phenomenon that has been termed “MIC creep.” Data in the adult population suggest that even if dosing is pushed to 60 mg/kg per day—the dosing typically used for CNS infections—clinical failures may occur at higher MICs.
10. We will need better evidence to support the utility of newer antistaphylococcal drugs including linezolid, daptomycin, telavancin, and ceftobiprole. Linezolid remains a very expensive drug choice with predictable adverse reactions, particularly neutropenia. Dosing for daptomycin (a lipopeptide), telavancin (a lipoglycopeptide), and ceftobiprole (our first fifth generation cephalosporin) are still not set.
Lastly, I predict—or at least hope for—a happy, healthy, and productive 2010 for all
It is time for the 2010 ID Consult predictions. Instead of starting with my usual Yogi Berra quote, this year I thought I'd tap “Dilbert” creator Scott Adams: “There are many methods for predicting the future. For example, you can read horoscopes, tea leaves, tarot cards, or crystal balls. Collectively, these methods are known as nutty methods. Or you can put well-researched facts into sophisticated computer 'models, more commonly referred to as a complete waste of time.'” Maybe this explains why pandemic influenza was not on my list last year!
Indeed, although I have almost always had something to say about influenza for the last several years in my January “predictions” column, I did not correctly predict the emergence of pandemic influenza, which came on like a sledge hammer in April 2009. One major lesson learned from this unprecedented experience was the importance of collaboration.
In our institution, our emergency department and urgent care volume peaked at levels never seen before. Finding additional space to see patients, scheduling additional providers, and streamlining documentation were major problems that required innovative solutions. The mix of the high volume of worried well with the occasional very sick patient required vigilance on everyone's part.
Subspecialty and community providers also rose to the challenge, and for now, everyone is relieved that disease rates have decreased steadily over the last 4 weeks. Still, we are seeing admissions that exceed what we would usually see for this time of year and expect this to continue through April.
Here are my predictions, with the first two based on our influenza experience:
1. All lessons learned will benefit us, if and when the next outbreak occurs (and it will not necessarily be influenza).
2. Influenza vaccine will be nationally mandated for all health care workers (HCWs). Our institution utilized a mandated policy that required that all HCWs had to have vaccine or a declination signed by Dec. 1. We were able to get 91% of our HCWs immunized, compared with 82% in the last couple years, which is great. Yet, there were still gaps in coverage in certain high-risk units and in individual physicians and nurses. Among those who declined vaccination, some said they would not get vaccine unless it was mandated. Protecting the vulnerable child within our hospitals while also keeping our colleagues well is a major motivation to utilize a mandated policy. I think next year will be the year.
3. More data will focus on the use of palivizumab. Major changes in the American Academy of Pediatrics' Red Book included standardization of a start date and maximum number of doses, as well as changes in eligibility criteria focusing on gestation and age at the start of the season. There is no question we will be revisiting some of these issues in the future.
4. Meningococcal disease will continue to decline in the United States. Meningococcal infections have steadily decreased in the United States over the last 12 years, although the reasons for this are not entirely clear. In 1997, the incidence was 1.1/100,000 population, decreasing to 0.8/100,000 in 2000 and down to 0.3/100,000 in 2008. The implementation of vaccine in and of itself does not explain this decline, because no vaccine is effective against serogroup B and its population-based rates also decreased.
5. Rotavirus cases will continue to decrease. Simpler guidelines for dosing the rotavirus vaccines will result in better coverage and a continued decrease in disease. It is still amazing to me that residents in this era may not care for a single hospitalized child with rotavirus gastroenteritis.
6. Practitioners will more proactively utilize hepatitis A vaccine for the close contacts of adopted infants arriving from high-risk countries. Several reported cases of adults who had not traveled internationally but became infected with hepatitis A within 60 days after the arrival of an international adoptee have prompted new recommendations. Practitioners should identify all who will provide care for the new arrival (including grandparents and babysitters) and ensure they receive hepatitis A immunization before the child arrives, preferably referring them as soon as the plan for adoption is made.
7. The 13-valent pneumococcal conjugate vaccine (PCV13/Prevnar 13) will be here by spring. The emergence of pneumococcus serotype 19A with its typical pattern of multidrug resistance fast-tracked this vaccine, and it looks like it will be ready for implementation soon. Straightforward recommendations from the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices will be available, and we hope to see the impact of this strategy within the next couple of years. Will new serotypes emerge once again?
8. Clindamycin resistance rates for Staphylococcus aureus will continue to rise. In our institution, 25% of pneumococcal strains and 12% of S. aureus are resistant. My colleague Dr. Christopher Harrison believes that if pneumococcal serotype 19A decreases with PCV 13, clindamycin resistance rates for pneumococcus in general may decrease. The level of resistance at which recommendations for treatment of staphylococcal infection will need to be changed is not clear. Some think alternative treatment should be considered at above 10%.
9. Speaking of resistance, vancomycin may no longer be the cornerstone of therapy for methicillin-resistant S. aureus (MRSA) infection by year's end. In the past, a typical S. aureus minimum inhibitory concentration (MIC) for vancomycin was 0.25–0.5 μg/mL. More recently, MICs of 1 (now 60% or so of isolates) or higher (still just 1%) have been seen, a phenomenon that has been termed “MIC creep.” Data in the adult population suggest that even if dosing is pushed to 60 mg/kg per day—the dosing typically used for CNS infections—clinical failures may occur at higher MICs.
10. We will need better evidence to support the utility of newer antistaphylococcal drugs including linezolid, daptomycin, telavancin, and ceftobiprole. Linezolid remains a very expensive drug choice with predictable adverse reactions, particularly neutropenia. Dosing for daptomycin (a lipopeptide), telavancin (a lipoglycopeptide), and ceftobiprole (our first fifth generation cephalosporin) are still not set.
Lastly, I predict—or at least hope for—a happy, healthy, and productive 2010 for all