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Seven years after bariatric surgery, more than 40% still off insulin
NATIONAL HARBOR, MD – Forty-four percent of insulin-dependent patients with type 2 diabetes mellitus (DM2) were at their glycemic target without insulin a median of seven years after surgery. The data from the largest study to evaluate long-term outcomes in this population were presented at Obesity Week 2017.
“These data confirm that the impressive metabolic effects of bariatric surgery in patients with type 2 diabetes are sustained beyond five years,” reported Ali Aminian, MD, a surgeon who specializes in bariatric procedures at the Cleveland Clinic, Cleveland, Ohio. He said that long-term efficacy has not been well characterized previously.
Reaching the glycemic target, defined as less than 7% HbA1c, without insulin was only one of the primary endpoints. The other was diabetes remission, which was defined as HbA1c less than 6.5%, fasting blood glucose less than 126 mg/dL, and being off all diabetes medications. This was observed in 15% of the patients after a median of 7 years followup.
Contrasting short-term results, defined as outcomes one to two years after bariatric surgery with the long-term followup, Dr. Aminian was able to show that declines were relatively modest over time. For example, 51% were at the glycemic target off insulin at the short-term mark, which translates into an absolute decline of only 7% relative to the 44% observed at the long-term followup assessment.
Similarly, 70% had achieved the American Diabetes Association (ADA) goal of less than 7% within the first two years of surgery, while 59% remained at this goal at the most recent followup. The proportion taking insulin at the short-term mark was 36% rising only to 40% long-term.
When data were stratified by procedure, results favored RYGB over sleeve gastrectomy. For example, 47% of the RYGB patients versus 33% of the sleeve gastrectomy patients were able to reach the ADA goal without insulin at the end of the study. The proportions in diabetes remission were 17% and 10%, respectively. RYGB was also associated with greater improvement in BMI (median -12 vs. - 8 kg/m2) and reduced late weight gain (median 20% vs. 31%).
However, Dr. Aminian, who did not provide statistical calculations for these differences, cautioned that higher risk patients might have been preferentially selected for sleeve gastrectomy. He noted that difference in median HbA1c levels was significantly lower in the RYGB group two years after surgery (P less than .001) but the numerical advantage had lost significance at the last followup (P = .32).
In an evaluation of predictors for glycemic control, a shorter duration of diabetes (less than 10 years) and good glycemic control prior to surgery were both predictors of achieving the primary outcomes on the basis of a multivariate analysis, according to Dr. Aminian. Younger age was a marginal predictor, but Dr. Aminian said that neither type of procedure nor presurgical BMI predicted outcomes from the multivariate analysis.
Relative to baseline, there were significant improvements in median LDL (P = .001). In addition, HDL, triglyceride levels, systolic, and diastolic blood pressure measurements were all significantly improved, both short-term and long-term after bariatric surgery (all P values less than .001), according to Dr. Aminian. When expressed as ADA goals, 82% of participants had blood pressure less than 140/90 mm Hg 7 years after surgery relative to 44% at baseline (P less than .001). The proportion with LDL less 100 mg/dL approached, but did not reach clinical significance (61% vs. 70%; P=0.06).
“When you consider all three parameters [ADA targets for glycemic control, blood pressure control, and lipid control], only 3% of patients met all three targets at baseline but 32% [P< less than .001] were at these targets at long-term followup,” Dr. Aminian reported.
Dr. Aminian reported having no relevant financial relationships.
As the invited discussant on these data, Raul Rosenthal, MD, Director, Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida, reiterated that time with diabetes prior to bariatric surgery may be an important predictor of postsurgical control of metabolic parameters.
“I published a paper about 10 years ago on outcomes in patients with diabetes, and in our experience 5 years was the limit. If you have a history of 5 years or less with diabetes, the chance of going into remission were 80%, and if it was more than 5 years, the likelihood dropped dramatically,” Dr. Rosenthal noted. He indicated duration of diabetes deserves further evaluation for its potential relevance to the optimal timing of bariatric surgery.
NATIONAL HARBOR, MD – Forty-four percent of insulin-dependent patients with type 2 diabetes mellitus (DM2) were at their glycemic target without insulin a median of seven years after surgery. The data from the largest study to evaluate long-term outcomes in this population were presented at Obesity Week 2017.
“These data confirm that the impressive metabolic effects of bariatric surgery in patients with type 2 diabetes are sustained beyond five years,” reported Ali Aminian, MD, a surgeon who specializes in bariatric procedures at the Cleveland Clinic, Cleveland, Ohio. He said that long-term efficacy has not been well characterized previously.
Reaching the glycemic target, defined as less than 7% HbA1c, without insulin was only one of the primary endpoints. The other was diabetes remission, which was defined as HbA1c less than 6.5%, fasting blood glucose less than 126 mg/dL, and being off all diabetes medications. This was observed in 15% of the patients after a median of 7 years followup.
Contrasting short-term results, defined as outcomes one to two years after bariatric surgery with the long-term followup, Dr. Aminian was able to show that declines were relatively modest over time. For example, 51% were at the glycemic target off insulin at the short-term mark, which translates into an absolute decline of only 7% relative to the 44% observed at the long-term followup assessment.
Similarly, 70% had achieved the American Diabetes Association (ADA) goal of less than 7% within the first two years of surgery, while 59% remained at this goal at the most recent followup. The proportion taking insulin at the short-term mark was 36% rising only to 40% long-term.
When data were stratified by procedure, results favored RYGB over sleeve gastrectomy. For example, 47% of the RYGB patients versus 33% of the sleeve gastrectomy patients were able to reach the ADA goal without insulin at the end of the study. The proportions in diabetes remission were 17% and 10%, respectively. RYGB was also associated with greater improvement in BMI (median -12 vs. - 8 kg/m2) and reduced late weight gain (median 20% vs. 31%).
However, Dr. Aminian, who did not provide statistical calculations for these differences, cautioned that higher risk patients might have been preferentially selected for sleeve gastrectomy. He noted that difference in median HbA1c levels was significantly lower in the RYGB group two years after surgery (P less than .001) but the numerical advantage had lost significance at the last followup (P = .32).
In an evaluation of predictors for glycemic control, a shorter duration of diabetes (less than 10 years) and good glycemic control prior to surgery were both predictors of achieving the primary outcomes on the basis of a multivariate analysis, according to Dr. Aminian. Younger age was a marginal predictor, but Dr. Aminian said that neither type of procedure nor presurgical BMI predicted outcomes from the multivariate analysis.
Relative to baseline, there were significant improvements in median LDL (P = .001). In addition, HDL, triglyceride levels, systolic, and diastolic blood pressure measurements were all significantly improved, both short-term and long-term after bariatric surgery (all P values less than .001), according to Dr. Aminian. When expressed as ADA goals, 82% of participants had blood pressure less than 140/90 mm Hg 7 years after surgery relative to 44% at baseline (P less than .001). The proportion with LDL less 100 mg/dL approached, but did not reach clinical significance (61% vs. 70%; P=0.06).
“When you consider all three parameters [ADA targets for glycemic control, blood pressure control, and lipid control], only 3% of patients met all three targets at baseline but 32% [P< less than .001] were at these targets at long-term followup,” Dr. Aminian reported.
Dr. Aminian reported having no relevant financial relationships.
As the invited discussant on these data, Raul Rosenthal, MD, Director, Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida, reiterated that time with diabetes prior to bariatric surgery may be an important predictor of postsurgical control of metabolic parameters.
“I published a paper about 10 years ago on outcomes in patients with diabetes, and in our experience 5 years was the limit. If you have a history of 5 years or less with diabetes, the chance of going into remission were 80%, and if it was more than 5 years, the likelihood dropped dramatically,” Dr. Rosenthal noted. He indicated duration of diabetes deserves further evaluation for its potential relevance to the optimal timing of bariatric surgery.
NATIONAL HARBOR, MD – Forty-four percent of insulin-dependent patients with type 2 diabetes mellitus (DM2) were at their glycemic target without insulin a median of seven years after surgery. The data from the largest study to evaluate long-term outcomes in this population were presented at Obesity Week 2017.
“These data confirm that the impressive metabolic effects of bariatric surgery in patients with type 2 diabetes are sustained beyond five years,” reported Ali Aminian, MD, a surgeon who specializes in bariatric procedures at the Cleveland Clinic, Cleveland, Ohio. He said that long-term efficacy has not been well characterized previously.
Reaching the glycemic target, defined as less than 7% HbA1c, without insulin was only one of the primary endpoints. The other was diabetes remission, which was defined as HbA1c less than 6.5%, fasting blood glucose less than 126 mg/dL, and being off all diabetes medications. This was observed in 15% of the patients after a median of 7 years followup.
Contrasting short-term results, defined as outcomes one to two years after bariatric surgery with the long-term followup, Dr. Aminian was able to show that declines were relatively modest over time. For example, 51% were at the glycemic target off insulin at the short-term mark, which translates into an absolute decline of only 7% relative to the 44% observed at the long-term followup assessment.
Similarly, 70% had achieved the American Diabetes Association (ADA) goal of less than 7% within the first two years of surgery, while 59% remained at this goal at the most recent followup. The proportion taking insulin at the short-term mark was 36% rising only to 40% long-term.
When data were stratified by procedure, results favored RYGB over sleeve gastrectomy. For example, 47% of the RYGB patients versus 33% of the sleeve gastrectomy patients were able to reach the ADA goal without insulin at the end of the study. The proportions in diabetes remission were 17% and 10%, respectively. RYGB was also associated with greater improvement in BMI (median -12 vs. - 8 kg/m2) and reduced late weight gain (median 20% vs. 31%).
However, Dr. Aminian, who did not provide statistical calculations for these differences, cautioned that higher risk patients might have been preferentially selected for sleeve gastrectomy. He noted that difference in median HbA1c levels was significantly lower in the RYGB group two years after surgery (P less than .001) but the numerical advantage had lost significance at the last followup (P = .32).
In an evaluation of predictors for glycemic control, a shorter duration of diabetes (less than 10 years) and good glycemic control prior to surgery were both predictors of achieving the primary outcomes on the basis of a multivariate analysis, according to Dr. Aminian. Younger age was a marginal predictor, but Dr. Aminian said that neither type of procedure nor presurgical BMI predicted outcomes from the multivariate analysis.
Relative to baseline, there were significant improvements in median LDL (P = .001). In addition, HDL, triglyceride levels, systolic, and diastolic blood pressure measurements were all significantly improved, both short-term and long-term after bariatric surgery (all P values less than .001), according to Dr. Aminian. When expressed as ADA goals, 82% of participants had blood pressure less than 140/90 mm Hg 7 years after surgery relative to 44% at baseline (P less than .001). The proportion with LDL less 100 mg/dL approached, but did not reach clinical significance (61% vs. 70%; P=0.06).
“When you consider all three parameters [ADA targets for glycemic control, blood pressure control, and lipid control], only 3% of patients met all three targets at baseline but 32% [P< less than .001] were at these targets at long-term followup,” Dr. Aminian reported.
Dr. Aminian reported having no relevant financial relationships.
As the invited discussant on these data, Raul Rosenthal, MD, Director, Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida, reiterated that time with diabetes prior to bariatric surgery may be an important predictor of postsurgical control of metabolic parameters.
“I published a paper about 10 years ago on outcomes in patients with diabetes, and in our experience 5 years was the limit. If you have a history of 5 years or less with diabetes, the chance of going into remission were 80%, and if it was more than 5 years, the likelihood dropped dramatically,” Dr. Rosenthal noted. He indicated duration of diabetes deserves further evaluation for its potential relevance to the optimal timing of bariatric surgery.
AT OBESITY WEEK 2017
Key clinical point: In the largest study to follow insulin-dependent patients after bariatric surgery, substantial benefits persist after median 7 years of followup.
Major finding: Among 252 insulin-dependent patients followed for a minimum of 5 years, 44% remain off insulin and 15% are off all anti-diabetic medications.
Data source: Retrospective single-center analysis.
Disclosures: Dr. Aminian reported having no relevant financial relationships.
Weight recidivism after bariatric surgery: What constitutes failure?
NATIONAL HARBOR, MD. – A standard definition of bariatric surgery failure based on weight regain is needed to assess long-term outcomes in place of the seemingly arbitrary thresholds now in use, according to discussion generated by long-term outcome studies presented at Obesity Week 2017.
In another study, presented by Colin Martyn, MD, a general surgery resident at Texas Tech University Health Sciences Center, El Paso, the bariatric surgery failure rate at 11 years was characterized as an “alarming” 33.9%. In this study, bariatric surgery was considered a failure if the patient did not maintain excess weight loss (EWL) of 50% or greater.
The problem with this definition, like many others, is that “it fails to recognize that there could be significant health benefits and improvements in quality of life with less weight loss,” according to Philip Schauer, MD, director of the Cleveland Clinic Bariatric and Metabolic Institute. As the invited discussant for the data presented by Dr. Martyn, Dr. Schauer acknowledged that 50% EWL has been used by others as the dividing line between success and failure, but he called it “obsolete.”
This definition was one of several applied to weight recidivism in the study presented by Dr. Morell. Others included weight regain of more than 25% EWL over the postoperative nadir, an increase in body mass index to more than 35 kg/m2 after achieving a lower BMI, and a postsurgical BMI increase of more than 5 mg/m2. Not surprisingly, weight recidivism “varied widely with regard to the definitions used,” Dr. Morell reported.
Dr. Morell’s study involved evaluation of 1,766 patients with at least 1 year of follow-up after bariatric procedure. Most (1,490 patients) underwent laparoscopic Roux-en-y gastric bypass. After 2 years of follow-up, 93% achieved at least the 50% EWL threshold of treatment success, but Dr. Morell reported that the proportion above this or any threshold progressively diminished over time. For a definition of treatment success, Dr. Morell favors maintenance of at least 20% total weight loss as a threshold of long-term clinical success, a threshold met by 75% of patients at 5 years, in his analysis.
As has been shown in these studies and reported previously, the regaining of weight over time after bariatric surgery is common and progressive, but both studies ignited controversy about what measure is meaningful for declaring that bariatric surgery has failed over the long term. None of the current thresholds for failure are based on evidence that clinical benefit has been lost. Rather, it appears that these are simply accepted conventions.
“It bothers me to hear the word failure in these presentations, because I think the paradigm is changing from success and failure to that of treating chronic disease,” said Stacy Brethauer, MD, a staff surgeon in the Cleveland Clinic Digestive Disease Institute. Dr. Brethauer, the moderator of the session at Obesity Week where both long-term follow-up papers were presented, agreed that the at least 50% EWL benchmark is “flawed.” He suggested that more clinically meaningful methods of evaluating long-term outcome are needed for both clinical and research purposes.
The discussant of Dr. Morell’s paper, Samer G. Mattar, MD, a bariatric surgeon at the Swedish Medical Center, Seattle, also called for metrics based on clinical benefit rather than on weight alone.
“I would caution against this overall emphasis that we seem to place on weight gain and weight loss as a benchmark and predominant objective for what we do,” he said. “Our nonsurgeon colleagues have repeatedly demonstrated clinical benefits from total body weight loss of 10% or even 5%. So let’s not beat up ourselves over trying to maintain a greater than 50% EWL in all our patients.”
NATIONAL HARBOR, MD. – A standard definition of bariatric surgery failure based on weight regain is needed to assess long-term outcomes in place of the seemingly arbitrary thresholds now in use, according to discussion generated by long-term outcome studies presented at Obesity Week 2017.
In another study, presented by Colin Martyn, MD, a general surgery resident at Texas Tech University Health Sciences Center, El Paso, the bariatric surgery failure rate at 11 years was characterized as an “alarming” 33.9%. In this study, bariatric surgery was considered a failure if the patient did not maintain excess weight loss (EWL) of 50% or greater.
The problem with this definition, like many others, is that “it fails to recognize that there could be significant health benefits and improvements in quality of life with less weight loss,” according to Philip Schauer, MD, director of the Cleveland Clinic Bariatric and Metabolic Institute. As the invited discussant for the data presented by Dr. Martyn, Dr. Schauer acknowledged that 50% EWL has been used by others as the dividing line between success and failure, but he called it “obsolete.”
This definition was one of several applied to weight recidivism in the study presented by Dr. Morell. Others included weight regain of more than 25% EWL over the postoperative nadir, an increase in body mass index to more than 35 kg/m2 after achieving a lower BMI, and a postsurgical BMI increase of more than 5 mg/m2. Not surprisingly, weight recidivism “varied widely with regard to the definitions used,” Dr. Morell reported.
Dr. Morell’s study involved evaluation of 1,766 patients with at least 1 year of follow-up after bariatric procedure. Most (1,490 patients) underwent laparoscopic Roux-en-y gastric bypass. After 2 years of follow-up, 93% achieved at least the 50% EWL threshold of treatment success, but Dr. Morell reported that the proportion above this or any threshold progressively diminished over time. For a definition of treatment success, Dr. Morell favors maintenance of at least 20% total weight loss as a threshold of long-term clinical success, a threshold met by 75% of patients at 5 years, in his analysis.
As has been shown in these studies and reported previously, the regaining of weight over time after bariatric surgery is common and progressive, but both studies ignited controversy about what measure is meaningful for declaring that bariatric surgery has failed over the long term. None of the current thresholds for failure are based on evidence that clinical benefit has been lost. Rather, it appears that these are simply accepted conventions.
“It bothers me to hear the word failure in these presentations, because I think the paradigm is changing from success and failure to that of treating chronic disease,” said Stacy Brethauer, MD, a staff surgeon in the Cleveland Clinic Digestive Disease Institute. Dr. Brethauer, the moderator of the session at Obesity Week where both long-term follow-up papers were presented, agreed that the at least 50% EWL benchmark is “flawed.” He suggested that more clinically meaningful methods of evaluating long-term outcome are needed for both clinical and research purposes.
The discussant of Dr. Morell’s paper, Samer G. Mattar, MD, a bariatric surgeon at the Swedish Medical Center, Seattle, also called for metrics based on clinical benefit rather than on weight alone.
“I would caution against this overall emphasis that we seem to place on weight gain and weight loss as a benchmark and predominant objective for what we do,” he said. “Our nonsurgeon colleagues have repeatedly demonstrated clinical benefits from total body weight loss of 10% or even 5%. So let’s not beat up ourselves over trying to maintain a greater than 50% EWL in all our patients.”
NATIONAL HARBOR, MD. – A standard definition of bariatric surgery failure based on weight regain is needed to assess long-term outcomes in place of the seemingly arbitrary thresholds now in use, according to discussion generated by long-term outcome studies presented at Obesity Week 2017.
In another study, presented by Colin Martyn, MD, a general surgery resident at Texas Tech University Health Sciences Center, El Paso, the bariatric surgery failure rate at 11 years was characterized as an “alarming” 33.9%. In this study, bariatric surgery was considered a failure if the patient did not maintain excess weight loss (EWL) of 50% or greater.
The problem with this definition, like many others, is that “it fails to recognize that there could be significant health benefits and improvements in quality of life with less weight loss,” according to Philip Schauer, MD, director of the Cleveland Clinic Bariatric and Metabolic Institute. As the invited discussant for the data presented by Dr. Martyn, Dr. Schauer acknowledged that 50% EWL has been used by others as the dividing line between success and failure, but he called it “obsolete.”
This definition was one of several applied to weight recidivism in the study presented by Dr. Morell. Others included weight regain of more than 25% EWL over the postoperative nadir, an increase in body mass index to more than 35 kg/m2 after achieving a lower BMI, and a postsurgical BMI increase of more than 5 mg/m2. Not surprisingly, weight recidivism “varied widely with regard to the definitions used,” Dr. Morell reported.
Dr. Morell’s study involved evaluation of 1,766 patients with at least 1 year of follow-up after bariatric procedure. Most (1,490 patients) underwent laparoscopic Roux-en-y gastric bypass. After 2 years of follow-up, 93% achieved at least the 50% EWL threshold of treatment success, but Dr. Morell reported that the proportion above this or any threshold progressively diminished over time. For a definition of treatment success, Dr. Morell favors maintenance of at least 20% total weight loss as a threshold of long-term clinical success, a threshold met by 75% of patients at 5 years, in his analysis.
As has been shown in these studies and reported previously, the regaining of weight over time after bariatric surgery is common and progressive, but both studies ignited controversy about what measure is meaningful for declaring that bariatric surgery has failed over the long term. None of the current thresholds for failure are based on evidence that clinical benefit has been lost. Rather, it appears that these are simply accepted conventions.
“It bothers me to hear the word failure in these presentations, because I think the paradigm is changing from success and failure to that of treating chronic disease,” said Stacy Brethauer, MD, a staff surgeon in the Cleveland Clinic Digestive Disease Institute. Dr. Brethauer, the moderator of the session at Obesity Week where both long-term follow-up papers were presented, agreed that the at least 50% EWL benchmark is “flawed.” He suggested that more clinically meaningful methods of evaluating long-term outcome are needed for both clinical and research purposes.
The discussant of Dr. Morell’s paper, Samer G. Mattar, MD, a bariatric surgeon at the Swedish Medical Center, Seattle, also called for metrics based on clinical benefit rather than on weight alone.
“I would caution against this overall emphasis that we seem to place on weight gain and weight loss as a benchmark and predominant objective for what we do,” he said. “Our nonsurgeon colleagues have repeatedly demonstrated clinical benefits from total body weight loss of 10% or even 5%. So let’s not beat up ourselves over trying to maintain a greater than 50% EWL in all our patients.”
AT OBESITY WEEK 2017
Key clinical point: Many patients regain weight after bariatric surgery, but experts argue over the definition of long-term treatment failure, for which there is no standard.
Major finding: After 5 or more years of follow-up, failure rates range from 25% to 70% depending on definition of unacceptable weight regain.
Data source: A retrospective review.
Disclosures: Dr. Morell and Dr. Martyn reported no financial relationships relevant to this topic.
Hep C screening falling short in neonatal abstinence syndrome infants
SAN DIEGO – A review of care for neonates born with neonatal abstinence syndrome (NAS) found that screening for hepatitis C virus (HCV) infection is low, based on Medicaid data from the state of Kentucky.
“These children are at high risk for HCV, and the screening rate should really be 100%. We think that it is important to get the message out there,” said Michael Smith, MD, of the department of pediatrics at the Duke University, Durham, N.C.
According to the Kentucky Medicaid data, the rates of NAS are not evenly distributed in the state. Stratifying the incidence rates by eight regions, Dr. Smith reported that 33% of the NAS births in 2016 were in region 8. Although region 8 is a rural Appalachian section on the eastern border of the state, the proportion in this region was more than 50% greater than any other region, including the more populated regions containing Louisville, the largest city, and Lexington, the capital.
Statewide, approximately one in three newborns with NAS were screened for HCV, but the rate was as low as 5% in some areas, and low rates were more common in those counties with the highest rates of opioid use and NAS, Dr. Smith said at an annual scientific meeting on infectious diseases. Although he acknowledged that rates of HCV screening in newborns with NAS appeared to be increasing when 2015 and 2012 data were compared, “there is still a long way to go.”
“Why is this important? There are a couple of reasons. One is that, if you get children into care early, you are more likely to have follow-up,” Dr. Smith said. Follow-up will be important if, as Dr. Smith predicted, HCV therapies become available for children. When providers know which children are infected, treatment can be initiated more efficiently, and this has implications for risk of transmission and, potentially, for outcomes.
At the University of Louisville, children with NAS are typically screened for HCV, HIV, and other transmissible infections that “travel together,” such as syphilis. The evaluation of the Medicaid data suggested that there were no differences in likelihood of HCV testing for sex and race, but Dr. Smith noted that children placed in foster care were significantly more likely to be tested, likely a reflection of processing regulations.
Overall, there are striking differences in the rates of opioid use, rates of NAS, and likelihood of HCV testing in NAS neonates in eastern Appalachian regions of Kentucky and those in regions in the center of the state closer to academic medical centers. The three regions near the University of Louisville, University of Kentucky in Lexington, and the Ohio River border with Cincinnati are known as “the Golden Triangle,” according to Dr. Smith; these regions are where HCV testing rates in neonates with NAS are higher, but testing still is not uniform.
Currently, HCV testing is mandated for adults in several states, but Dr. Smith emphasized that children with NAS are particularly “vulnerable.” He called for policy changes that would require testing in these children and urged HCV screening regardless of whether official policies are established.
SAN DIEGO – A review of care for neonates born with neonatal abstinence syndrome (NAS) found that screening for hepatitis C virus (HCV) infection is low, based on Medicaid data from the state of Kentucky.
“These children are at high risk for HCV, and the screening rate should really be 100%. We think that it is important to get the message out there,” said Michael Smith, MD, of the department of pediatrics at the Duke University, Durham, N.C.
According to the Kentucky Medicaid data, the rates of NAS are not evenly distributed in the state. Stratifying the incidence rates by eight regions, Dr. Smith reported that 33% of the NAS births in 2016 were in region 8. Although region 8 is a rural Appalachian section on the eastern border of the state, the proportion in this region was more than 50% greater than any other region, including the more populated regions containing Louisville, the largest city, and Lexington, the capital.
Statewide, approximately one in three newborns with NAS were screened for HCV, but the rate was as low as 5% in some areas, and low rates were more common in those counties with the highest rates of opioid use and NAS, Dr. Smith said at an annual scientific meeting on infectious diseases. Although he acknowledged that rates of HCV screening in newborns with NAS appeared to be increasing when 2015 and 2012 data were compared, “there is still a long way to go.”
“Why is this important? There are a couple of reasons. One is that, if you get children into care early, you are more likely to have follow-up,” Dr. Smith said. Follow-up will be important if, as Dr. Smith predicted, HCV therapies become available for children. When providers know which children are infected, treatment can be initiated more efficiently, and this has implications for risk of transmission and, potentially, for outcomes.
At the University of Louisville, children with NAS are typically screened for HCV, HIV, and other transmissible infections that “travel together,” such as syphilis. The evaluation of the Medicaid data suggested that there were no differences in likelihood of HCV testing for sex and race, but Dr. Smith noted that children placed in foster care were significantly more likely to be tested, likely a reflection of processing regulations.
Overall, there are striking differences in the rates of opioid use, rates of NAS, and likelihood of HCV testing in NAS neonates in eastern Appalachian regions of Kentucky and those in regions in the center of the state closer to academic medical centers. The three regions near the University of Louisville, University of Kentucky in Lexington, and the Ohio River border with Cincinnati are known as “the Golden Triangle,” according to Dr. Smith; these regions are where HCV testing rates in neonates with NAS are higher, but testing still is not uniform.
Currently, HCV testing is mandated for adults in several states, but Dr. Smith emphasized that children with NAS are particularly “vulnerable.” He called for policy changes that would require testing in these children and urged HCV screening regardless of whether official policies are established.
SAN DIEGO – A review of care for neonates born with neonatal abstinence syndrome (NAS) found that screening for hepatitis C virus (HCV) infection is low, based on Medicaid data from the state of Kentucky.
“These children are at high risk for HCV, and the screening rate should really be 100%. We think that it is important to get the message out there,” said Michael Smith, MD, of the department of pediatrics at the Duke University, Durham, N.C.
According to the Kentucky Medicaid data, the rates of NAS are not evenly distributed in the state. Stratifying the incidence rates by eight regions, Dr. Smith reported that 33% of the NAS births in 2016 were in region 8. Although region 8 is a rural Appalachian section on the eastern border of the state, the proportion in this region was more than 50% greater than any other region, including the more populated regions containing Louisville, the largest city, and Lexington, the capital.
Statewide, approximately one in three newborns with NAS were screened for HCV, but the rate was as low as 5% in some areas, and low rates were more common in those counties with the highest rates of opioid use and NAS, Dr. Smith said at an annual scientific meeting on infectious diseases. Although he acknowledged that rates of HCV screening in newborns with NAS appeared to be increasing when 2015 and 2012 data were compared, “there is still a long way to go.”
“Why is this important? There are a couple of reasons. One is that, if you get children into care early, you are more likely to have follow-up,” Dr. Smith said. Follow-up will be important if, as Dr. Smith predicted, HCV therapies become available for children. When providers know which children are infected, treatment can be initiated more efficiently, and this has implications for risk of transmission and, potentially, for outcomes.
At the University of Louisville, children with NAS are typically screened for HCV, HIV, and other transmissible infections that “travel together,” such as syphilis. The evaluation of the Medicaid data suggested that there were no differences in likelihood of HCV testing for sex and race, but Dr. Smith noted that children placed in foster care were significantly more likely to be tested, likely a reflection of processing regulations.
Overall, there are striking differences in the rates of opioid use, rates of NAS, and likelihood of HCV testing in NAS neonates in eastern Appalachian regions of Kentucky and those in regions in the center of the state closer to academic medical centers. The three regions near the University of Louisville, University of Kentucky in Lexington, and the Ohio River border with Cincinnati are known as “the Golden Triangle,” according to Dr. Smith; these regions are where HCV testing rates in neonates with NAS are higher, but testing still is not uniform.
Currently, HCV testing is mandated for adults in several states, but Dr. Smith emphasized that children with NAS are particularly “vulnerable.” He called for policy changes that would require testing in these children and urged HCV screening regardless of whether official policies are established.
AT ID WEEK 2017
Key clinical point: In Kentucky, which has one of the highest rates of neonates with NAS, screening rates for HCV remain low.
Major finding:
Data source: Retrospective data analysis of Kentucky Medicaid data.
Disclosures: Dr. Smith reported no financial relationships relevant to this study.
Staph bloodstream infection algorithm shortens treatment course
SAN DIEGO – By standardizing antibiotic treatment for simple and uncomplicated staphylococcal bloodstream infections (BSI), an algorithm effectively shortens therapy and simplifies decision making, according to results of a multinational randomized trial.
“The data from the study confirm that the algorithm achieves more with less and verify that shorter antibiotic courses are sufficient,” reported Thomas L. Holland, MD, an infectious disease specialist at Duke University Hospital in Durham, N.C.
In this study, the patients randomized to algorithm treatment received vancomycin (or daptomycin in allergic or intolerant patients), which was administered for periods of duration based on clinical features. In those randomized to SOC, the choice and duration of antibiotics were left to the discretion of the treating physician without restrictions.
In those with simple staphylococcal BSI, the algorithm called for no further antibiotics beyond what had already been administered empirically prior to randomization. Key features of simple coagulase-negative staphylococcal (CONS) BSIs include absence of fever or evidence of metastatic infection, as well as no more than one positive follow-up blood culture. The key features of simple Staphylococcus aureus BSI are similar. However, no positive blood cultures are required for S. aureus BSI to be classified as simple.
“In the algorithm arm, no antibiotics were given to those with simple staphylococcal BSI unless antibiotics had been given prior to randomization,” Dr. Holland explained, but he acknowledged that empiric antibiotics prior to randomization reflect “clinical reality.”
In those with uncomplicated rather than simple staphylococcal BSI, vancomycin was given for 5 days to those with CONS BSI and for 14 days to those with S. aureus BSI. In those who were randomized and then subsequently found to have a complicated infection, defined as multiple positive blood cultures or evidence of metastatic infection, patients received as few as 7 days or as many as 28 days of antibiotics, “reflecting the heterogeneity of these infections,” Dr. Holland reported at an annual scientific meeting on infectious diseases.
The coprimary endpoints were treatment success at test of cure and treatment safety, both of which were adjudicated by an external committee consisting of infectious disease specialists blinded to the therapy.
There were 509 patients from 16 sites in both the United States and Spain. CONS BSIs represented approximately 75% of patients in both arms. The complicated staphylococcal infections, which also were evenly distributed in the two arms, were included in the intention-to-treat analysis. Of complicated staphylococcal infections in this study, the pathogen was CONS in 34 instances and S. aureus in 37.
Treatment success was achieved in 82.0% and 81.5% of patients in the algorithm and SOC arms, respectively. Significant adverse events occurred in 32.9% and 28.3% of patients, respectively. Neither difference approached statistical significance.
“In other words, the algorithm was as effective and safe as standard of care,” Dr. Holland confirmed.
However, the median duration of treatment was reduced substantially for those randomized to the algorithm arm, compared with that seen in the standard of care arm. Among evaluable patients without complicated BSI, the mean duration of therapy was 4.4 days in the algorithm group vs. 6.2 days in the SOC group (P = .003). Most of this nearly 2-day reduction in treatment was achieved in uncomplicated CONS BSI patients. In this group, the mean days of treatment were 5.3 days and 8.4 days for the algorithm and SOC groups, respectively. In the uncomplicated S. aureus group, the reduction (from 15.9 to 15.3 days) was not significant.
“The study has several messages. For one, it suggests that patients who meet the criteria of simple staphylococcal BSI can be managed safely with monitoring alone. In addition, this study “provides the best evidence to date that 14 days of vancomycin from the first negative blood culture is sufficient in uncomplicated S. aureus bloodstream infections,” Dr. Holland stated.
“For many, these data will validate what they are already doing,” said Dr. Holland, who reported that the algorithm is now being applied routinely at his institution. “The value is that we now have a randomized trial to demonstrate that shorter therapy can be provided in uncomplicated staphylococcal blood stream infections without increasing risk of serious adverse events.”
SAN DIEGO – By standardizing antibiotic treatment for simple and uncomplicated staphylococcal bloodstream infections (BSI), an algorithm effectively shortens therapy and simplifies decision making, according to results of a multinational randomized trial.
“The data from the study confirm that the algorithm achieves more with less and verify that shorter antibiotic courses are sufficient,” reported Thomas L. Holland, MD, an infectious disease specialist at Duke University Hospital in Durham, N.C.
In this study, the patients randomized to algorithm treatment received vancomycin (or daptomycin in allergic or intolerant patients), which was administered for periods of duration based on clinical features. In those randomized to SOC, the choice and duration of antibiotics were left to the discretion of the treating physician without restrictions.
In those with simple staphylococcal BSI, the algorithm called for no further antibiotics beyond what had already been administered empirically prior to randomization. Key features of simple coagulase-negative staphylococcal (CONS) BSIs include absence of fever or evidence of metastatic infection, as well as no more than one positive follow-up blood culture. The key features of simple Staphylococcus aureus BSI are similar. However, no positive blood cultures are required for S. aureus BSI to be classified as simple.
“In the algorithm arm, no antibiotics were given to those with simple staphylococcal BSI unless antibiotics had been given prior to randomization,” Dr. Holland explained, but he acknowledged that empiric antibiotics prior to randomization reflect “clinical reality.”
In those with uncomplicated rather than simple staphylococcal BSI, vancomycin was given for 5 days to those with CONS BSI and for 14 days to those with S. aureus BSI. In those who were randomized and then subsequently found to have a complicated infection, defined as multiple positive blood cultures or evidence of metastatic infection, patients received as few as 7 days or as many as 28 days of antibiotics, “reflecting the heterogeneity of these infections,” Dr. Holland reported at an annual scientific meeting on infectious diseases.
The coprimary endpoints were treatment success at test of cure and treatment safety, both of which were adjudicated by an external committee consisting of infectious disease specialists blinded to the therapy.
There were 509 patients from 16 sites in both the United States and Spain. CONS BSIs represented approximately 75% of patients in both arms. The complicated staphylococcal infections, which also were evenly distributed in the two arms, were included in the intention-to-treat analysis. Of complicated staphylococcal infections in this study, the pathogen was CONS in 34 instances and S. aureus in 37.
Treatment success was achieved in 82.0% and 81.5% of patients in the algorithm and SOC arms, respectively. Significant adverse events occurred in 32.9% and 28.3% of patients, respectively. Neither difference approached statistical significance.
“In other words, the algorithm was as effective and safe as standard of care,” Dr. Holland confirmed.
However, the median duration of treatment was reduced substantially for those randomized to the algorithm arm, compared with that seen in the standard of care arm. Among evaluable patients without complicated BSI, the mean duration of therapy was 4.4 days in the algorithm group vs. 6.2 days in the SOC group (P = .003). Most of this nearly 2-day reduction in treatment was achieved in uncomplicated CONS BSI patients. In this group, the mean days of treatment were 5.3 days and 8.4 days for the algorithm and SOC groups, respectively. In the uncomplicated S. aureus group, the reduction (from 15.9 to 15.3 days) was not significant.
“The study has several messages. For one, it suggests that patients who meet the criteria of simple staphylococcal BSI can be managed safely with monitoring alone. In addition, this study “provides the best evidence to date that 14 days of vancomycin from the first negative blood culture is sufficient in uncomplicated S. aureus bloodstream infections,” Dr. Holland stated.
“For many, these data will validate what they are already doing,” said Dr. Holland, who reported that the algorithm is now being applied routinely at his institution. “The value is that we now have a randomized trial to demonstrate that shorter therapy can be provided in uncomplicated staphylococcal blood stream infections without increasing risk of serious adverse events.”
SAN DIEGO – By standardizing antibiotic treatment for simple and uncomplicated staphylococcal bloodstream infections (BSI), an algorithm effectively shortens therapy and simplifies decision making, according to results of a multinational randomized trial.
“The data from the study confirm that the algorithm achieves more with less and verify that shorter antibiotic courses are sufficient,” reported Thomas L. Holland, MD, an infectious disease specialist at Duke University Hospital in Durham, N.C.
In this study, the patients randomized to algorithm treatment received vancomycin (or daptomycin in allergic or intolerant patients), which was administered for periods of duration based on clinical features. In those randomized to SOC, the choice and duration of antibiotics were left to the discretion of the treating physician without restrictions.
In those with simple staphylococcal BSI, the algorithm called for no further antibiotics beyond what had already been administered empirically prior to randomization. Key features of simple coagulase-negative staphylococcal (CONS) BSIs include absence of fever or evidence of metastatic infection, as well as no more than one positive follow-up blood culture. The key features of simple Staphylococcus aureus BSI are similar. However, no positive blood cultures are required for S. aureus BSI to be classified as simple.
“In the algorithm arm, no antibiotics were given to those with simple staphylococcal BSI unless antibiotics had been given prior to randomization,” Dr. Holland explained, but he acknowledged that empiric antibiotics prior to randomization reflect “clinical reality.”
In those with uncomplicated rather than simple staphylococcal BSI, vancomycin was given for 5 days to those with CONS BSI and for 14 days to those with S. aureus BSI. In those who were randomized and then subsequently found to have a complicated infection, defined as multiple positive blood cultures or evidence of metastatic infection, patients received as few as 7 days or as many as 28 days of antibiotics, “reflecting the heterogeneity of these infections,” Dr. Holland reported at an annual scientific meeting on infectious diseases.
The coprimary endpoints were treatment success at test of cure and treatment safety, both of which were adjudicated by an external committee consisting of infectious disease specialists blinded to the therapy.
There were 509 patients from 16 sites in both the United States and Spain. CONS BSIs represented approximately 75% of patients in both arms. The complicated staphylococcal infections, which also were evenly distributed in the two arms, were included in the intention-to-treat analysis. Of complicated staphylococcal infections in this study, the pathogen was CONS in 34 instances and S. aureus in 37.
Treatment success was achieved in 82.0% and 81.5% of patients in the algorithm and SOC arms, respectively. Significant adverse events occurred in 32.9% and 28.3% of patients, respectively. Neither difference approached statistical significance.
“In other words, the algorithm was as effective and safe as standard of care,” Dr. Holland confirmed.
However, the median duration of treatment was reduced substantially for those randomized to the algorithm arm, compared with that seen in the standard of care arm. Among evaluable patients without complicated BSI, the mean duration of therapy was 4.4 days in the algorithm group vs. 6.2 days in the SOC group (P = .003). Most of this nearly 2-day reduction in treatment was achieved in uncomplicated CONS BSI patients. In this group, the mean days of treatment were 5.3 days and 8.4 days for the algorithm and SOC groups, respectively. In the uncomplicated S. aureus group, the reduction (from 15.9 to 15.3 days) was not significant.
“The study has several messages. For one, it suggests that patients who meet the criteria of simple staphylococcal BSI can be managed safely with monitoring alone. In addition, this study “provides the best evidence to date that 14 days of vancomycin from the first negative blood culture is sufficient in uncomplicated S. aureus bloodstream infections,” Dr. Holland stated.
“For many, these data will validate what they are already doing,” said Dr. Holland, who reported that the algorithm is now being applied routinely at his institution. “The value is that we now have a randomized trial to demonstrate that shorter therapy can be provided in uncomplicated staphylococcal blood stream infections without increasing risk of serious adverse events.”
AT ID WEEK 2017
Key clinical point:
Major finding: With no change in outcome or differences in adverse events, the algorithm reduced average antibiotic duration by 1.9 days (P = .003).
Data source: A randomized, prospective, multicenter trial of 509 patients randomized at 16 sites in the United States and Spain.
Disclosures: Dr. Holland reports no financial relationships relevant to this study.
CDC data show decline in some hospital-acquired infections
SAN DIEGO – There was an encouraging 22% reduction in hospital-acquired infections (HAIs) after adjustment for clinical variables when 2015 and 2011 data from national Centers for Disease Control and Prevention hospital surveys were compared.
“The data suggest that national efforts toward preventing HAIs are succeeding,” reported Shelley S. Magill, MD, PhD, a medical epidemiologist in the Division of Healthcare Quality Promotion at the CDC who summarized the data at an annual scientific meeting on infectious diseases .
The comparative data were drawn from point prevalence surveys conducted in 2011 and 2015 as part of the CDC’s Emerging Infections Program. In this type of survey, the data are collected over 1 day, providing a snapshot in time among selected hospitals. The analysis presented by Dr. Magill was restricted to the 148 hospitals that participated in both the 2011 and 2015 surveys, although the 2015 survey included a total of 199 hospitals, of which other data analyses are planned.
Due to the change in incidence, the rank order of HAIs was different in 2015 relative to 2011. While surgical site infections (SSIs) represented the most frequent HAI in 2011, they fell to the third most frequent HAI in 2015; pneumonia and gastrointestinal (GI) infections assumed the first and second spots, respectively. The GI HAI infection category includes Clostridium difficile infection.
The incidence of SSI HAI among all hospitalized patients in the survey fell by 41% between 2011 and 2015 (from 1.00% to 0.59%; P = .001). The other big contributor to the overall reduction in HAIs was the fall in the incidence of urinary tract infections, which fell 36% (from 0.55% to 0.35%; P = .04). The decrease in pneumonia (from 0.97% to 0.89%) was not significant, nor was the even more modest reduction in bloodstream HAI (from 0.45% to 0.43%). There was a modest increase in GI/Clostridium difficile infections (from 0.56% to 0.59%).
The surveys do not permit the reduction in HAI rates to be attributed to any specific prevention practices, but Dr. Magill pointed out that the overall reductions correlate with reduced use of urinary catheters and central lines; reductions of both have been advocated as a means for improved infection control. Of several factors that might contribute to a reduction in SSI HAI, Dr. Magill speculated that better adherence to guidelines and more rigorous steps at preoperative infection control strategies might be among them.
Detailed analyses of the data collected from all of the hospitals that participated in the 2015 survey are planned, including an evaluation of which antibiotics were used to treat the HAIs found in this survey. Although the findings so far encourage speculation that infection control practices, such as prudent use of urinary catheters, are having a positive effect, Dr. Magill said that the data also point out the challenges.
“Given that pneumonia continues to represent a large proportion of HAIs in hospitals, more work is needed to identify risk factors; understand the factors that are preventable, particularly in the nonventilated patients; and develop better preventive approaches,” Dr. Magill said.
Dr. Magill reported no financial relationships relevant to this study.
SAN DIEGO – There was an encouraging 22% reduction in hospital-acquired infections (HAIs) after adjustment for clinical variables when 2015 and 2011 data from national Centers for Disease Control and Prevention hospital surveys were compared.
“The data suggest that national efforts toward preventing HAIs are succeeding,” reported Shelley S. Magill, MD, PhD, a medical epidemiologist in the Division of Healthcare Quality Promotion at the CDC who summarized the data at an annual scientific meeting on infectious diseases .
The comparative data were drawn from point prevalence surveys conducted in 2011 and 2015 as part of the CDC’s Emerging Infections Program. In this type of survey, the data are collected over 1 day, providing a snapshot in time among selected hospitals. The analysis presented by Dr. Magill was restricted to the 148 hospitals that participated in both the 2011 and 2015 surveys, although the 2015 survey included a total of 199 hospitals, of which other data analyses are planned.
Due to the change in incidence, the rank order of HAIs was different in 2015 relative to 2011. While surgical site infections (SSIs) represented the most frequent HAI in 2011, they fell to the third most frequent HAI in 2015; pneumonia and gastrointestinal (GI) infections assumed the first and second spots, respectively. The GI HAI infection category includes Clostridium difficile infection.
The incidence of SSI HAI among all hospitalized patients in the survey fell by 41% between 2011 and 2015 (from 1.00% to 0.59%; P = .001). The other big contributor to the overall reduction in HAIs was the fall in the incidence of urinary tract infections, which fell 36% (from 0.55% to 0.35%; P = .04). The decrease in pneumonia (from 0.97% to 0.89%) was not significant, nor was the even more modest reduction in bloodstream HAI (from 0.45% to 0.43%). There was a modest increase in GI/Clostridium difficile infections (from 0.56% to 0.59%).
The surveys do not permit the reduction in HAI rates to be attributed to any specific prevention practices, but Dr. Magill pointed out that the overall reductions correlate with reduced use of urinary catheters and central lines; reductions of both have been advocated as a means for improved infection control. Of several factors that might contribute to a reduction in SSI HAI, Dr. Magill speculated that better adherence to guidelines and more rigorous steps at preoperative infection control strategies might be among them.
Detailed analyses of the data collected from all of the hospitals that participated in the 2015 survey are planned, including an evaluation of which antibiotics were used to treat the HAIs found in this survey. Although the findings so far encourage speculation that infection control practices, such as prudent use of urinary catheters, are having a positive effect, Dr. Magill said that the data also point out the challenges.
“Given that pneumonia continues to represent a large proportion of HAIs in hospitals, more work is needed to identify risk factors; understand the factors that are preventable, particularly in the nonventilated patients; and develop better preventive approaches,” Dr. Magill said.
Dr. Magill reported no financial relationships relevant to this study.
SAN DIEGO – There was an encouraging 22% reduction in hospital-acquired infections (HAIs) after adjustment for clinical variables when 2015 and 2011 data from national Centers for Disease Control and Prevention hospital surveys were compared.
“The data suggest that national efforts toward preventing HAIs are succeeding,” reported Shelley S. Magill, MD, PhD, a medical epidemiologist in the Division of Healthcare Quality Promotion at the CDC who summarized the data at an annual scientific meeting on infectious diseases .
The comparative data were drawn from point prevalence surveys conducted in 2011 and 2015 as part of the CDC’s Emerging Infections Program. In this type of survey, the data are collected over 1 day, providing a snapshot in time among selected hospitals. The analysis presented by Dr. Magill was restricted to the 148 hospitals that participated in both the 2011 and 2015 surveys, although the 2015 survey included a total of 199 hospitals, of which other data analyses are planned.
Due to the change in incidence, the rank order of HAIs was different in 2015 relative to 2011. While surgical site infections (SSIs) represented the most frequent HAI in 2011, they fell to the third most frequent HAI in 2015; pneumonia and gastrointestinal (GI) infections assumed the first and second spots, respectively. The GI HAI infection category includes Clostridium difficile infection.
The incidence of SSI HAI among all hospitalized patients in the survey fell by 41% between 2011 and 2015 (from 1.00% to 0.59%; P = .001). The other big contributor to the overall reduction in HAIs was the fall in the incidence of urinary tract infections, which fell 36% (from 0.55% to 0.35%; P = .04). The decrease in pneumonia (from 0.97% to 0.89%) was not significant, nor was the even more modest reduction in bloodstream HAI (from 0.45% to 0.43%). There was a modest increase in GI/Clostridium difficile infections (from 0.56% to 0.59%).
The surveys do not permit the reduction in HAI rates to be attributed to any specific prevention practices, but Dr. Magill pointed out that the overall reductions correlate with reduced use of urinary catheters and central lines; reductions of both have been advocated as a means for improved infection control. Of several factors that might contribute to a reduction in SSI HAI, Dr. Magill speculated that better adherence to guidelines and more rigorous steps at preoperative infection control strategies might be among them.
Detailed analyses of the data collected from all of the hospitals that participated in the 2015 survey are planned, including an evaluation of which antibiotics were used to treat the HAIs found in this survey. Although the findings so far encourage speculation that infection control practices, such as prudent use of urinary catheters, are having a positive effect, Dr. Magill said that the data also point out the challenges.
“Given that pneumonia continues to represent a large proportion of HAIs in hospitals, more work is needed to identify risk factors; understand the factors that are preventable, particularly in the nonventilated patients; and develop better preventive approaches,” Dr. Magill said.
Dr. Magill reported no financial relationships relevant to this study.
AT ID WEEK 2017
Key clinical point:
Major finding: In two point prevalence surveys conducted in the same hospitals, the rate of HAI was 22% lower in 2015 (P = .001), compared with 2011.
Data source: CDC national surveys of HAIs in 148 hospitals in two different years (2011 and 2015) were compared.
Disclosures: Dr. Magill reported no financial relationships relevant to this study.
Rio Olympics tally for U.S. athletes is 6% West Nile infections, no Zika
SAN DIEGO – When compared with pretravel blood screening, new arboviral infections were detected in 7% of U.S. athletes and support staff who attended the 2016 Olympic Games in Rio de Janeiro, according to study results revealed at an annual scientific meeting on infectious diseases.
Although the prospective screening program was largely set up and driven by concern about the risk of Zika virus infection, this was not among the arboviral infections identified, reported Krow Ampofo, MD, professor of pediatrics in the division of pediatric infectious diseases, University of Utah, Salt Lake City.
“The stories and images of children with microencephalopathy and other complications of the Zika syndrome were a major concern of athletes,” said Dr. Ampofo, who noted that many were threatening not to attend. The concern was reasonable, he said, given the scope of the epidemic and the fact that the majority of female athletes were of reproductive age.
At the time the screening program was being planned, the Zika virus epidemic in Brazil had, in fact, already peaked. Although it was not then known that the peak had been reached, the incidence rates began falling sharply beginning in about March 2016. New cases still were being reported, but the threat was greatly diminished by the time that the summer games were held.
In the screening program, blood samples were obtained prior to the games from 950 U.S. athletes and support staff. In most cases, these samples were obtained in Houston, where the Olympic team was processed just prior to departure. At that same time, the U.S. Centers for Disease Control and Prevention provided pretravel counseling about infection risk prevention.
For follow-up, the goal was to obtain blood samples within 2-12 weeks after return of all those who participated in the pretravel screening. Completion of a post-travel survey about activities in Rio de Janeiro, particularly their participation in risk prevention strategies, also was requested.
Blood samples were evaluated for four arboviral infections: Zika virus, dengue virus, chikungunya virus, and West Nile virus. The calculation of infection rates was based on the 457 (48%) of those screened prior to travel who provided blood samples after their return. Of these, 11% had antibody evidence of arboviral infections, but new infections were confirmed in only 7%.
The post-games survey was completed by 169 of those evaluated. A comparison of risk prevention behaviors in those who were and were not infected suggested that use of mosquito repellent did provide risk reduction, said Dr. Ampofo.
The substantial rate of new West Nile virus infections was “surprising,” Dr. Ampofo said. He recounted that there were no prior warnings from Brazilian authorities that West Nile virus was circulating. Infection with West Nile virus in Houston prior to departure was not considered an alternative explanation. According to Dr. Ampofo, Houston was not an endemic area for West Nile virus, and the stay in Houston for most athletes was 2 or 3 days.
SAN DIEGO – When compared with pretravel blood screening, new arboviral infections were detected in 7% of U.S. athletes and support staff who attended the 2016 Olympic Games in Rio de Janeiro, according to study results revealed at an annual scientific meeting on infectious diseases.
Although the prospective screening program was largely set up and driven by concern about the risk of Zika virus infection, this was not among the arboviral infections identified, reported Krow Ampofo, MD, professor of pediatrics in the division of pediatric infectious diseases, University of Utah, Salt Lake City.
“The stories and images of children with microencephalopathy and other complications of the Zika syndrome were a major concern of athletes,” said Dr. Ampofo, who noted that many were threatening not to attend. The concern was reasonable, he said, given the scope of the epidemic and the fact that the majority of female athletes were of reproductive age.
At the time the screening program was being planned, the Zika virus epidemic in Brazil had, in fact, already peaked. Although it was not then known that the peak had been reached, the incidence rates began falling sharply beginning in about March 2016. New cases still were being reported, but the threat was greatly diminished by the time that the summer games were held.
In the screening program, blood samples were obtained prior to the games from 950 U.S. athletes and support staff. In most cases, these samples were obtained in Houston, where the Olympic team was processed just prior to departure. At that same time, the U.S. Centers for Disease Control and Prevention provided pretravel counseling about infection risk prevention.
For follow-up, the goal was to obtain blood samples within 2-12 weeks after return of all those who participated in the pretravel screening. Completion of a post-travel survey about activities in Rio de Janeiro, particularly their participation in risk prevention strategies, also was requested.
Blood samples were evaluated for four arboviral infections: Zika virus, dengue virus, chikungunya virus, and West Nile virus. The calculation of infection rates was based on the 457 (48%) of those screened prior to travel who provided blood samples after their return. Of these, 11% had antibody evidence of arboviral infections, but new infections were confirmed in only 7%.
The post-games survey was completed by 169 of those evaluated. A comparison of risk prevention behaviors in those who were and were not infected suggested that use of mosquito repellent did provide risk reduction, said Dr. Ampofo.
The substantial rate of new West Nile virus infections was “surprising,” Dr. Ampofo said. He recounted that there were no prior warnings from Brazilian authorities that West Nile virus was circulating. Infection with West Nile virus in Houston prior to departure was not considered an alternative explanation. According to Dr. Ampofo, Houston was not an endemic area for West Nile virus, and the stay in Houston for most athletes was 2 or 3 days.
SAN DIEGO – When compared with pretravel blood screening, new arboviral infections were detected in 7% of U.S. athletes and support staff who attended the 2016 Olympic Games in Rio de Janeiro, according to study results revealed at an annual scientific meeting on infectious diseases.
Although the prospective screening program was largely set up and driven by concern about the risk of Zika virus infection, this was not among the arboviral infections identified, reported Krow Ampofo, MD, professor of pediatrics in the division of pediatric infectious diseases, University of Utah, Salt Lake City.
“The stories and images of children with microencephalopathy and other complications of the Zika syndrome were a major concern of athletes,” said Dr. Ampofo, who noted that many were threatening not to attend. The concern was reasonable, he said, given the scope of the epidemic and the fact that the majority of female athletes were of reproductive age.
At the time the screening program was being planned, the Zika virus epidemic in Brazil had, in fact, already peaked. Although it was not then known that the peak had been reached, the incidence rates began falling sharply beginning in about March 2016. New cases still were being reported, but the threat was greatly diminished by the time that the summer games were held.
In the screening program, blood samples were obtained prior to the games from 950 U.S. athletes and support staff. In most cases, these samples were obtained in Houston, where the Olympic team was processed just prior to departure. At that same time, the U.S. Centers for Disease Control and Prevention provided pretravel counseling about infection risk prevention.
For follow-up, the goal was to obtain blood samples within 2-12 weeks after return of all those who participated in the pretravel screening. Completion of a post-travel survey about activities in Rio de Janeiro, particularly their participation in risk prevention strategies, also was requested.
Blood samples were evaluated for four arboviral infections: Zika virus, dengue virus, chikungunya virus, and West Nile virus. The calculation of infection rates was based on the 457 (48%) of those screened prior to travel who provided blood samples after their return. Of these, 11% had antibody evidence of arboviral infections, but new infections were confirmed in only 7%.
The post-games survey was completed by 169 of those evaluated. A comparison of risk prevention behaviors in those who were and were not infected suggested that use of mosquito repellent did provide risk reduction, said Dr. Ampofo.
The substantial rate of new West Nile virus infections was “surprising,” Dr. Ampofo said. He recounted that there were no prior warnings from Brazilian authorities that West Nile virus was circulating. Infection with West Nile virus in Houston prior to departure was not considered an alternative explanation. According to Dr. Ampofo, Houston was not an endemic area for West Nile virus, and the stay in Houston for most athletes was 2 or 3 days.
AT ID WEEK 2017
Key clinical point: Prospective surveillance among U.S. athletes and staff attending the 2016 Olympics documented several arboviral infections, but not Zika.
Major finding: When pre- versus post-Olympics blood studies were evaluated, 6% had developed West Nile virus while no other arboviral infection incidence exceeded 1%.
Data source: Prospective and post-Olympics blood studies of 457 U.S. athletes and staff and survey results.
Disclosures: Dr. Ampofo reported no financial relationships relevant to this study.
Involving experts in S. aureus bacteremia treatment reduces mortality
SAN DIEGO – Thirty-day mortality associated with Staphylococcus aureus bacteremia is reduced if there is guidance from either an antimicrobial stewardship team (AST) or an infectious disease consultant (IDC), according to a multivariate experience at Yale New Haven Hospital presented at an annual scientific meeting on infectious diseases.
“This has been a hot area, because there have been a lot of recent studies suggesting that expert infectious disease advice improves care, but not every study has associated expert advice with a mortality benefit,” said Jacqueline Sherbuk, MD, a fellow in the division of infectious diseases and international health at the University of Virginia, Charlottesville. She was a resident at Yale University when this study was conducted.
In this study, the impact of an IDC on outcome in patients with S. aureus bacteremia was evaluated relative to no expert advice. By itself, an IDC was associated with improved adherence to standards of care for S. aureus bacteremia management, but the reduction in mortality was not statistically significant for those who received IDC guidance relative to those who did not.
“Given that patient care may be guided by consultations from the AST independent of IDC, we looked at the overall impact of expert opinion versus no expert involvement, and this achieved significance on multivariate analysis,” Dr. Sherbuk reported.
For adherence to guidelines, IDC guidance was better than no expert advice on multiple measures, including proportion obtaining an echocardiogram (89% vs. 67%; P less than .001), appropriate definitive antibiotics (98% vs. 80%; P less than .001), and appropriate treatment duration (92% vs. 35%; P less than .001). However, the advantage for 30-day mortality rates was only a trend (11% vs. 21%, P = .07). It was only when patients who received IDC guidance or a consultation from the AST were combined that the difference climbed to significance (11% vs. 23%; P = .04).
“On multivariate analysis, the OR [odds ratio] was substantial, predicting a 60% reduction [OR 0.40; P = .03) in 30-day mortality for expert advice vs. no expert advice,” Dr. Sherbuk reported.
In this retrospective observational study, 261 unique cases of S. aureus bacteremia cases in adult patients established with positive blood cultures were evaluated. The cases were collected over a 1-year period at Yale New Haven Hospital. After exclusion of those who died within 3 days of the initial positive culture or who were transferred to other facilities, 236 were included in this analysis.
IDC guidance, which is not required for S. aureus bacteremia at Yale New Haven Hospital, was provided for 74.5% of the patients. Another 4% of patients received guidance from the AST, which is an independent service often provided prior to IDC guidance, according to Dr. Sherbuk.
Relapse (3% vs. 5%) and reinfection (6% vs. 4%) rates were low in both those who did and did not receive expert advice, respectively. These rates were not significantly different. On multivariate analysis, the two factors associated with increased 30-day mortality were patient age greater than 60 years and sepsis based on sequential organ failure assessment.
Several previous studies have associated IDC advice with improved outcomes in S. aureus bacteremia, according to Dr. Sherbuk, but this study suggests that the AST “can be a meaningful adjunct” to IDC guidance to improve outcomes. She noted that several other sets of data presented at this year’s ID Week also associated AST with improved infection management.
SAN DIEGO – Thirty-day mortality associated with Staphylococcus aureus bacteremia is reduced if there is guidance from either an antimicrobial stewardship team (AST) or an infectious disease consultant (IDC), according to a multivariate experience at Yale New Haven Hospital presented at an annual scientific meeting on infectious diseases.
“This has been a hot area, because there have been a lot of recent studies suggesting that expert infectious disease advice improves care, but not every study has associated expert advice with a mortality benefit,” said Jacqueline Sherbuk, MD, a fellow in the division of infectious diseases and international health at the University of Virginia, Charlottesville. She was a resident at Yale University when this study was conducted.
In this study, the impact of an IDC on outcome in patients with S. aureus bacteremia was evaluated relative to no expert advice. By itself, an IDC was associated with improved adherence to standards of care for S. aureus bacteremia management, but the reduction in mortality was not statistically significant for those who received IDC guidance relative to those who did not.
“Given that patient care may be guided by consultations from the AST independent of IDC, we looked at the overall impact of expert opinion versus no expert involvement, and this achieved significance on multivariate analysis,” Dr. Sherbuk reported.
For adherence to guidelines, IDC guidance was better than no expert advice on multiple measures, including proportion obtaining an echocardiogram (89% vs. 67%; P less than .001), appropriate definitive antibiotics (98% vs. 80%; P less than .001), and appropriate treatment duration (92% vs. 35%; P less than .001). However, the advantage for 30-day mortality rates was only a trend (11% vs. 21%, P = .07). It was only when patients who received IDC guidance or a consultation from the AST were combined that the difference climbed to significance (11% vs. 23%; P = .04).
“On multivariate analysis, the OR [odds ratio] was substantial, predicting a 60% reduction [OR 0.40; P = .03) in 30-day mortality for expert advice vs. no expert advice,” Dr. Sherbuk reported.
In this retrospective observational study, 261 unique cases of S. aureus bacteremia cases in adult patients established with positive blood cultures were evaluated. The cases were collected over a 1-year period at Yale New Haven Hospital. After exclusion of those who died within 3 days of the initial positive culture or who were transferred to other facilities, 236 were included in this analysis.
IDC guidance, which is not required for S. aureus bacteremia at Yale New Haven Hospital, was provided for 74.5% of the patients. Another 4% of patients received guidance from the AST, which is an independent service often provided prior to IDC guidance, according to Dr. Sherbuk.
Relapse (3% vs. 5%) and reinfection (6% vs. 4%) rates were low in both those who did and did not receive expert advice, respectively. These rates were not significantly different. On multivariate analysis, the two factors associated with increased 30-day mortality were patient age greater than 60 years and sepsis based on sequential organ failure assessment.
Several previous studies have associated IDC advice with improved outcomes in S. aureus bacteremia, according to Dr. Sherbuk, but this study suggests that the AST “can be a meaningful adjunct” to IDC guidance to improve outcomes. She noted that several other sets of data presented at this year’s ID Week also associated AST with improved infection management.
SAN DIEGO – Thirty-day mortality associated with Staphylococcus aureus bacteremia is reduced if there is guidance from either an antimicrobial stewardship team (AST) or an infectious disease consultant (IDC), according to a multivariate experience at Yale New Haven Hospital presented at an annual scientific meeting on infectious diseases.
“This has been a hot area, because there have been a lot of recent studies suggesting that expert infectious disease advice improves care, but not every study has associated expert advice with a mortality benefit,” said Jacqueline Sherbuk, MD, a fellow in the division of infectious diseases and international health at the University of Virginia, Charlottesville. She was a resident at Yale University when this study was conducted.
In this study, the impact of an IDC on outcome in patients with S. aureus bacteremia was evaluated relative to no expert advice. By itself, an IDC was associated with improved adherence to standards of care for S. aureus bacteremia management, but the reduction in mortality was not statistically significant for those who received IDC guidance relative to those who did not.
“Given that patient care may be guided by consultations from the AST independent of IDC, we looked at the overall impact of expert opinion versus no expert involvement, and this achieved significance on multivariate analysis,” Dr. Sherbuk reported.
For adherence to guidelines, IDC guidance was better than no expert advice on multiple measures, including proportion obtaining an echocardiogram (89% vs. 67%; P less than .001), appropriate definitive antibiotics (98% vs. 80%; P less than .001), and appropriate treatment duration (92% vs. 35%; P less than .001). However, the advantage for 30-day mortality rates was only a trend (11% vs. 21%, P = .07). It was only when patients who received IDC guidance or a consultation from the AST were combined that the difference climbed to significance (11% vs. 23%; P = .04).
“On multivariate analysis, the OR [odds ratio] was substantial, predicting a 60% reduction [OR 0.40; P = .03) in 30-day mortality for expert advice vs. no expert advice,” Dr. Sherbuk reported.
In this retrospective observational study, 261 unique cases of S. aureus bacteremia cases in adult patients established with positive blood cultures were evaluated. The cases were collected over a 1-year period at Yale New Haven Hospital. After exclusion of those who died within 3 days of the initial positive culture or who were transferred to other facilities, 236 were included in this analysis.
IDC guidance, which is not required for S. aureus bacteremia at Yale New Haven Hospital, was provided for 74.5% of the patients. Another 4% of patients received guidance from the AST, which is an independent service often provided prior to IDC guidance, according to Dr. Sherbuk.
Relapse (3% vs. 5%) and reinfection (6% vs. 4%) rates were low in both those who did and did not receive expert advice, respectively. These rates were not significantly different. On multivariate analysis, the two factors associated with increased 30-day mortality were patient age greater than 60 years and sepsis based on sequential organ failure assessment.
Several previous studies have associated IDC advice with improved outcomes in S. aureus bacteremia, according to Dr. Sherbuk, but this study suggests that the AST “can be a meaningful adjunct” to IDC guidance to improve outcomes. She noted that several other sets of data presented at this year’s ID Week also associated AST with improved infection management.
AT ID WEEK 2017
Key clinical point:
Major finding: For those receiving expert involvement in S. aureus bacteremia management, the odds ratio for 30-day mortality was reduced 60% (OR 0.40; P = .03) on multivariate analysis.
Data source: Retrospective, single-center study exploring the management of 236 S. aureus bacteremia cases in adult patients.
Disclosures: Dr. Sherbuk reported no financial relationships relevant to this study.
Iceland is making progress toward total eradication of HCV
SAN DIEGO, CA – A public health program in Iceland is on schedule to eliminate the potential for hepatitis C virus (HCV) transmission by curing all infected patients, according to a progress report presented at ID Week 2017.
“Our results are from a real-world setting, where the difficult-to-treat patients are actually prioritized,” explained Magnus Gottfredsson, MD, PhD, an infectious disease specialist affiliated with the National University Hospital, Reykjavik, Iceland.
“If we only scaled up treatment, we would not reach the goal of eliminating HCV infection. We needed something else,” Dr. Gottfredsson explained. This something else has been to reach out aggressively to those most likely to transmit disease. The multidisciplinary test-and-treat program engages physicians, nurses, and those providing psychosocial support across a variety of settings, including those involving addiction treatment, prison administration, and homeless outreach.
Of the 480 patients treated so far in the program, which offers treatment to all HCV-infected patients 16 years of age or older, Dr. Gottfredsson presented followup data on 322. All treatment is based on the direct acting antiviral (DAA) combination of sofosbuvir/ledipasvir (sof/ldv), usually given for 8 to 12 weeks. In selected cases, such as in HCV-infected patients with cirrhosis, patients also receive ribavirin. Gilead, the manufacturer of sof/ldv, has donated the therapy for the initial phase of the program.
Of the 322 patients treated, 298 patients completed therapy in accordance with the protocol and all were negative for HCV on polymerase chain reaction (PCR) testing at the end of treatment. When re-evaluated 12 weeks after treatment was completed, 6% were HCV positive. It is believed that most or all of these represented reinfection.
Of the 24 patients who did not complete therapy, 2 died and 19 were initially lost to follow-up. However, an intensive search was launched to locate the missing patients, and 17 of 19 were located. When evaluated with PCR, half were negative. As a result, the outcomes to data on an intention-to-treat analysis are 90% PCR negative, 8% still HCV positive and presumed reinfected, and 2% deceased or missing.
All of those who are reinfected have been or will be retreated.
“We prioritize those who are reinfected for retreatment because they are the individuals at greatest risk of transmitting infection,” Dr. Gottfredsson explained.
The rate of success is encouraging, because one third of the patients treated so far are active drug users. Of the 322 patients treated, 11% were living in halfway houses, 6% were homeless, and 5% were in prisons. One third of all DAA prescriptions in the TraP HepC program have been written by clinicians working in addiction medicine. The high rate of success was achieved despite the fact that 48% of HCV infections were genotype 3A virus, which is not the most responsive genotype to the DAAs offered.
Due to the presence of universal healthcare and universal HCV reporting, Iceland may be in an exceptional position to reduce HCV transmission to zero. Like many countries in northern Europe, the estimated prevalence of HCV is approximately 0.3%, which is 70% lower than that of the United States.
The World Health Organization has set a goal of a 90% reduction in the incidence of HCV by the year 2030, but Iceland is on track to eradicate HCV infection completely or nearly completely by the end of next year. If achieved, it will prevent transmission and produce 100% reduction in the incidence of HCV by 2019.
However, Dr. Gottfredsson acknowledged that treating all individuals currently infected with HCV in Iceland does not eliminate the threat of new cases and new transmissions. While he reported that procedures for routine screening of refugees and foreign workers are already in place, tourists and other visitors remain a potential source of new infections and a need for continued surveillance. Dr. Gottfredsson reports financial relationships with Astellas and Gilead.
SAN DIEGO, CA – A public health program in Iceland is on schedule to eliminate the potential for hepatitis C virus (HCV) transmission by curing all infected patients, according to a progress report presented at ID Week 2017.
“Our results are from a real-world setting, where the difficult-to-treat patients are actually prioritized,” explained Magnus Gottfredsson, MD, PhD, an infectious disease specialist affiliated with the National University Hospital, Reykjavik, Iceland.
“If we only scaled up treatment, we would not reach the goal of eliminating HCV infection. We needed something else,” Dr. Gottfredsson explained. This something else has been to reach out aggressively to those most likely to transmit disease. The multidisciplinary test-and-treat program engages physicians, nurses, and those providing psychosocial support across a variety of settings, including those involving addiction treatment, prison administration, and homeless outreach.
Of the 480 patients treated so far in the program, which offers treatment to all HCV-infected patients 16 years of age or older, Dr. Gottfredsson presented followup data on 322. All treatment is based on the direct acting antiviral (DAA) combination of sofosbuvir/ledipasvir (sof/ldv), usually given for 8 to 12 weeks. In selected cases, such as in HCV-infected patients with cirrhosis, patients also receive ribavirin. Gilead, the manufacturer of sof/ldv, has donated the therapy for the initial phase of the program.
Of the 322 patients treated, 298 patients completed therapy in accordance with the protocol and all were negative for HCV on polymerase chain reaction (PCR) testing at the end of treatment. When re-evaluated 12 weeks after treatment was completed, 6% were HCV positive. It is believed that most or all of these represented reinfection.
Of the 24 patients who did not complete therapy, 2 died and 19 were initially lost to follow-up. However, an intensive search was launched to locate the missing patients, and 17 of 19 were located. When evaluated with PCR, half were negative. As a result, the outcomes to data on an intention-to-treat analysis are 90% PCR negative, 8% still HCV positive and presumed reinfected, and 2% deceased or missing.
All of those who are reinfected have been or will be retreated.
“We prioritize those who are reinfected for retreatment because they are the individuals at greatest risk of transmitting infection,” Dr. Gottfredsson explained.
The rate of success is encouraging, because one third of the patients treated so far are active drug users. Of the 322 patients treated, 11% were living in halfway houses, 6% were homeless, and 5% were in prisons. One third of all DAA prescriptions in the TraP HepC program have been written by clinicians working in addiction medicine. The high rate of success was achieved despite the fact that 48% of HCV infections were genotype 3A virus, which is not the most responsive genotype to the DAAs offered.
Due to the presence of universal healthcare and universal HCV reporting, Iceland may be in an exceptional position to reduce HCV transmission to zero. Like many countries in northern Europe, the estimated prevalence of HCV is approximately 0.3%, which is 70% lower than that of the United States.
The World Health Organization has set a goal of a 90% reduction in the incidence of HCV by the year 2030, but Iceland is on track to eradicate HCV infection completely or nearly completely by the end of next year. If achieved, it will prevent transmission and produce 100% reduction in the incidence of HCV by 2019.
However, Dr. Gottfredsson acknowledged that treating all individuals currently infected with HCV in Iceland does not eliminate the threat of new cases and new transmissions. While he reported that procedures for routine screening of refugees and foreign workers are already in place, tourists and other visitors remain a potential source of new infections and a need for continued surveillance. Dr. Gottfredsson reports financial relationships with Astellas and Gilead.
SAN DIEGO, CA – A public health program in Iceland is on schedule to eliminate the potential for hepatitis C virus (HCV) transmission by curing all infected patients, according to a progress report presented at ID Week 2017.
“Our results are from a real-world setting, where the difficult-to-treat patients are actually prioritized,” explained Magnus Gottfredsson, MD, PhD, an infectious disease specialist affiliated with the National University Hospital, Reykjavik, Iceland.
“If we only scaled up treatment, we would not reach the goal of eliminating HCV infection. We needed something else,” Dr. Gottfredsson explained. This something else has been to reach out aggressively to those most likely to transmit disease. The multidisciplinary test-and-treat program engages physicians, nurses, and those providing psychosocial support across a variety of settings, including those involving addiction treatment, prison administration, and homeless outreach.
Of the 480 patients treated so far in the program, which offers treatment to all HCV-infected patients 16 years of age or older, Dr. Gottfredsson presented followup data on 322. All treatment is based on the direct acting antiviral (DAA) combination of sofosbuvir/ledipasvir (sof/ldv), usually given for 8 to 12 weeks. In selected cases, such as in HCV-infected patients with cirrhosis, patients also receive ribavirin. Gilead, the manufacturer of sof/ldv, has donated the therapy for the initial phase of the program.
Of the 322 patients treated, 298 patients completed therapy in accordance with the protocol and all were negative for HCV on polymerase chain reaction (PCR) testing at the end of treatment. When re-evaluated 12 weeks after treatment was completed, 6% were HCV positive. It is believed that most or all of these represented reinfection.
Of the 24 patients who did not complete therapy, 2 died and 19 were initially lost to follow-up. However, an intensive search was launched to locate the missing patients, and 17 of 19 were located. When evaluated with PCR, half were negative. As a result, the outcomes to data on an intention-to-treat analysis are 90% PCR negative, 8% still HCV positive and presumed reinfected, and 2% deceased or missing.
All of those who are reinfected have been or will be retreated.
“We prioritize those who are reinfected for retreatment because they are the individuals at greatest risk of transmitting infection,” Dr. Gottfredsson explained.
The rate of success is encouraging, because one third of the patients treated so far are active drug users. Of the 322 patients treated, 11% were living in halfway houses, 6% were homeless, and 5% were in prisons. One third of all DAA prescriptions in the TraP HepC program have been written by clinicians working in addiction medicine. The high rate of success was achieved despite the fact that 48% of HCV infections were genotype 3A virus, which is not the most responsive genotype to the DAAs offered.
Due to the presence of universal healthcare and universal HCV reporting, Iceland may be in an exceptional position to reduce HCV transmission to zero. Like many countries in northern Europe, the estimated prevalence of HCV is approximately 0.3%, which is 70% lower than that of the United States.
The World Health Organization has set a goal of a 90% reduction in the incidence of HCV by the year 2030, but Iceland is on track to eradicate HCV infection completely or nearly completely by the end of next year. If achieved, it will prevent transmission and produce 100% reduction in the incidence of HCV by 2019.
However, Dr. Gottfredsson acknowledged that treating all individuals currently infected with HCV in Iceland does not eliminate the threat of new cases and new transmissions. While he reported that procedures for routine screening of refugees and foreign workers are already in place, tourists and other visitors remain a potential source of new infections and a need for continued surveillance. Dr. Gottfredsson reports financial relationships with Astellas and Gilead.
ID WEEK 2017
Key clinical point:
Major finding: Just 20 months into the program, there has been a nearly 50% reduction in HCV infections, and the plan is to reach all patients by end of 2018.
Data source: Update on national public health initiative.
Disclosures: Dr. Gottfredsson reports financial relationships with Astellas and Gilead.
Inappropriate C. diff. testing reduced with ‘Hard Stop’ protocol
SAN DIEGO – After other strategies to reduce inappropriate testing for Clostridium difficile infection did not provide adequate reductions in inappropriate orders, a “hard stop” protocol, which prevents testing if specific conditions are not met, reduced the rate of testing by 42% without any incidence of delayed diagnosis, according to data presented at ID Week 2017.
“Testing stewardship is really critical to minimize the frequency of false-positive [Clostridium difficile infection] cases, which of course lead to harm. They lead to inappropriate treatment, prolonged length of stay, and patient dissatisfaction,” reported Marci L. Drees, MD, Infection Prevention Officer and Hospital Epidemiologist, Christiana Care Health System, Newark, Del.
“Of course, we did, at the time, educate our clinicians about this new testing algorithm, explaining how it is so much more sensitive and that they need to be smarter about who they are testing. But as we saw the cases roll in, we noticed that many of the [colonization] cases were in patients with a history of recent laxative use,” Dr. Drees recounted.
This led initially to a “soft stop” protocol in which clinicians ordering C. difficile–infection testing received an alert if laxatives had been ordered within the previous 24 hours. The alert provided details about the laxatives and suggested that the order for C. difficile–infection testing be reconsidered. This alert was no more than a suggestion, but it did reduce C. difficile–infection testing orders by 25% at first.
“The problem was that the alert lost effect over time as people got used to seeing it and clicked right through it,” Dr. Drees explained.
Despite the diminishing effect of the soft stop, no further steps were planned until a new set of data alerted the infectious disease department that C. difficile–infection rates were higher than benchmarks. This prompted concern among the hospital leadership and led to creation of a multidisciplinary team that was given the task to dig deeper for the source of problems and develop strategies to lower rates of inappropriate testing.
When that team did their initial analysis, what really came to the front was that about half the cases that had been identified as hospital-onset C. difficile were likely only C. difficile colonizations. They either had received laxatives prior to their test or they did not have significant diarrhea,” Dr. Drees said.
It was this finding that prompted a hard stop protocol to be built into C. difficile–infection test orders. In this protocol, which is executed only in patients who have been hospitalized for at least 36 hours, two conditions must be met sequentially for the testing order to proceed. The first is there must be documentation of at least two episodes of diarrhea in the prior 24 hours. If this condition is met, then the ordering system asks for verification that the patient has not received a laxative in the prior 24 hours.
“If either of these criteria are not met, the order can only proceed if the clinician calls the lab for an override,” Dr. Drees explained. Although the person answering the phone in the laboratory does not require any additional documentation or justification, the person ordering the test must enter the name of the person in the laboratory with whom they spoke. If this field is not filled in, the order will not proceed.
Prior to the hard stop, there was an average of 12 C. difficile–infection tests ordered per day. After the hard stop, the average fell to 7 per day, a 42% decline, according to Dr. Drees. C. difficile-infection cases did not increase, and there were no incidences of delayed diagnosis resulting in adverse clinical consequences.
Of the 157 overrides on the hard stop, representing 15% of all orders, only 11% produced a positive C. difficile-infection result. It was noted that almost one third of the overrides did not follow the protocol.
“What I mean is that they did not actually call the lab. They put in their own name [for the field requiring the name of a lab worker] or they put in Mickey Mouse or they put in something, so the order would proceed,” Dr. Drees said. After followup in those cases, “we have not had repeat offenders.”
Even a hard stop is likely to have diminishing efficacy over time as clinicians identify work-arounds, Dr. Drees acknowledged. For example, there is concern that therapy for CDI will be ordered without testing, although this has not yet been detected. However, the hard stop has been more effective and shown a longer duration of effect than the soft stop, according to Dr. Drees. Although Dr. Drees acknowledged that there have been exceptions, the hard stop has “generally been well accepted.”
Dr. Drees reported that she has no financial relationships relevant to this topic.
SAN DIEGO – After other strategies to reduce inappropriate testing for Clostridium difficile infection did not provide adequate reductions in inappropriate orders, a “hard stop” protocol, which prevents testing if specific conditions are not met, reduced the rate of testing by 42% without any incidence of delayed diagnosis, according to data presented at ID Week 2017.
“Testing stewardship is really critical to minimize the frequency of false-positive [Clostridium difficile infection] cases, which of course lead to harm. They lead to inappropriate treatment, prolonged length of stay, and patient dissatisfaction,” reported Marci L. Drees, MD, Infection Prevention Officer and Hospital Epidemiologist, Christiana Care Health System, Newark, Del.
“Of course, we did, at the time, educate our clinicians about this new testing algorithm, explaining how it is so much more sensitive and that they need to be smarter about who they are testing. But as we saw the cases roll in, we noticed that many of the [colonization] cases were in patients with a history of recent laxative use,” Dr. Drees recounted.
This led initially to a “soft stop” protocol in which clinicians ordering C. difficile–infection testing received an alert if laxatives had been ordered within the previous 24 hours. The alert provided details about the laxatives and suggested that the order for C. difficile–infection testing be reconsidered. This alert was no more than a suggestion, but it did reduce C. difficile–infection testing orders by 25% at first.
“The problem was that the alert lost effect over time as people got used to seeing it and clicked right through it,” Dr. Drees explained.
Despite the diminishing effect of the soft stop, no further steps were planned until a new set of data alerted the infectious disease department that C. difficile–infection rates were higher than benchmarks. This prompted concern among the hospital leadership and led to creation of a multidisciplinary team that was given the task to dig deeper for the source of problems and develop strategies to lower rates of inappropriate testing.
When that team did their initial analysis, what really came to the front was that about half the cases that had been identified as hospital-onset C. difficile were likely only C. difficile colonizations. They either had received laxatives prior to their test or they did not have significant diarrhea,” Dr. Drees said.
It was this finding that prompted a hard stop protocol to be built into C. difficile–infection test orders. In this protocol, which is executed only in patients who have been hospitalized for at least 36 hours, two conditions must be met sequentially for the testing order to proceed. The first is there must be documentation of at least two episodes of diarrhea in the prior 24 hours. If this condition is met, then the ordering system asks for verification that the patient has not received a laxative in the prior 24 hours.
“If either of these criteria are not met, the order can only proceed if the clinician calls the lab for an override,” Dr. Drees explained. Although the person answering the phone in the laboratory does not require any additional documentation or justification, the person ordering the test must enter the name of the person in the laboratory with whom they spoke. If this field is not filled in, the order will not proceed.
Prior to the hard stop, there was an average of 12 C. difficile–infection tests ordered per day. After the hard stop, the average fell to 7 per day, a 42% decline, according to Dr. Drees. C. difficile-infection cases did not increase, and there were no incidences of delayed diagnosis resulting in adverse clinical consequences.
Of the 157 overrides on the hard stop, representing 15% of all orders, only 11% produced a positive C. difficile-infection result. It was noted that almost one third of the overrides did not follow the protocol.
“What I mean is that they did not actually call the lab. They put in their own name [for the field requiring the name of a lab worker] or they put in Mickey Mouse or they put in something, so the order would proceed,” Dr. Drees said. After followup in those cases, “we have not had repeat offenders.”
Even a hard stop is likely to have diminishing efficacy over time as clinicians identify work-arounds, Dr. Drees acknowledged. For example, there is concern that therapy for CDI will be ordered without testing, although this has not yet been detected. However, the hard stop has been more effective and shown a longer duration of effect than the soft stop, according to Dr. Drees. Although Dr. Drees acknowledged that there have been exceptions, the hard stop has “generally been well accepted.”
Dr. Drees reported that she has no financial relationships relevant to this topic.
SAN DIEGO – After other strategies to reduce inappropriate testing for Clostridium difficile infection did not provide adequate reductions in inappropriate orders, a “hard stop” protocol, which prevents testing if specific conditions are not met, reduced the rate of testing by 42% without any incidence of delayed diagnosis, according to data presented at ID Week 2017.
“Testing stewardship is really critical to minimize the frequency of false-positive [Clostridium difficile infection] cases, which of course lead to harm. They lead to inappropriate treatment, prolonged length of stay, and patient dissatisfaction,” reported Marci L. Drees, MD, Infection Prevention Officer and Hospital Epidemiologist, Christiana Care Health System, Newark, Del.
“Of course, we did, at the time, educate our clinicians about this new testing algorithm, explaining how it is so much more sensitive and that they need to be smarter about who they are testing. But as we saw the cases roll in, we noticed that many of the [colonization] cases were in patients with a history of recent laxative use,” Dr. Drees recounted.
This led initially to a “soft stop” protocol in which clinicians ordering C. difficile–infection testing received an alert if laxatives had been ordered within the previous 24 hours. The alert provided details about the laxatives and suggested that the order for C. difficile–infection testing be reconsidered. This alert was no more than a suggestion, but it did reduce C. difficile–infection testing orders by 25% at first.
“The problem was that the alert lost effect over time as people got used to seeing it and clicked right through it,” Dr. Drees explained.
Despite the diminishing effect of the soft stop, no further steps were planned until a new set of data alerted the infectious disease department that C. difficile–infection rates were higher than benchmarks. This prompted concern among the hospital leadership and led to creation of a multidisciplinary team that was given the task to dig deeper for the source of problems and develop strategies to lower rates of inappropriate testing.
When that team did their initial analysis, what really came to the front was that about half the cases that had been identified as hospital-onset C. difficile were likely only C. difficile colonizations. They either had received laxatives prior to their test or they did not have significant diarrhea,” Dr. Drees said.
It was this finding that prompted a hard stop protocol to be built into C. difficile–infection test orders. In this protocol, which is executed only in patients who have been hospitalized for at least 36 hours, two conditions must be met sequentially for the testing order to proceed. The first is there must be documentation of at least two episodes of diarrhea in the prior 24 hours. If this condition is met, then the ordering system asks for verification that the patient has not received a laxative in the prior 24 hours.
“If either of these criteria are not met, the order can only proceed if the clinician calls the lab for an override,” Dr. Drees explained. Although the person answering the phone in the laboratory does not require any additional documentation or justification, the person ordering the test must enter the name of the person in the laboratory with whom they spoke. If this field is not filled in, the order will not proceed.
Prior to the hard stop, there was an average of 12 C. difficile–infection tests ordered per day. After the hard stop, the average fell to 7 per day, a 42% decline, according to Dr. Drees. C. difficile-infection cases did not increase, and there were no incidences of delayed diagnosis resulting in adverse clinical consequences.
Of the 157 overrides on the hard stop, representing 15% of all orders, only 11% produced a positive C. difficile-infection result. It was noted that almost one third of the overrides did not follow the protocol.
“What I mean is that they did not actually call the lab. They put in their own name [for the field requiring the name of a lab worker] or they put in Mickey Mouse or they put in something, so the order would proceed,” Dr. Drees said. After followup in those cases, “we have not had repeat offenders.”
Even a hard stop is likely to have diminishing efficacy over time as clinicians identify work-arounds, Dr. Drees acknowledged. For example, there is concern that therapy for CDI will be ordered without testing, although this has not yet been detected. However, the hard stop has been more effective and shown a longer duration of effect than the soft stop, according to Dr. Drees. Although Dr. Drees acknowledged that there have been exceptions, the hard stop has “generally been well accepted.”
Dr. Drees reported that she has no financial relationships relevant to this topic.
ID WEEK 2017
Key clinical point:
Major finding: After a hard stop protocol was implemented, the average per day rate of C. diff testing at a tertiary medical center was reduced 42%.
Data source: Prospective performance improvement project.
Disclosures: Dr. Drees reported that she has no financial relationships relevant to this topic.
Dentist-prescribed antibiotics implicated in community-acquired C. diff
SAN DIEGO – Antibiotic prescriptions written by dentists make a substantial but largely unrecognized contribution to the risk of community-acquired Clostridium difficile (CA-CDI) infections, according to results of a public health initiative that was presented at an annual scientific meeting on infectious diseases.
When nearly 1,000 cases of CA-CDI suspected of being the result of antibiotic exposure were evaluated, it was found that 15% of the prescriptions were written by dentists, often for indications that are counter to current guidelines, reported Maria Bye, MPH, an officer in the Infectious Disease Epidemiology, Prevention, and Control Division of the Minnesota Department of Health, St. Paul.
In another finding from this study relevant to infection control, a substantial proportion of dentist-prescribed antibiotics associated with CA-CDI were not in the medical record. Rather, they were discovered in interviews conducted to isolate risk factors. “This is concerning since clinicians unaware of these exposures will not think about CA-CDI or other complications of antibiotic use, possibly delaying therapy,” Ms. Bye said.
The importance of dental antibiotic prescriptions in CA-CDI was identified in an ongoing infectious disease program managed by the Minnesota Department of Health in collaboration with the Centers for Disease Control and Prevention. In the years 2009-2015, medical records and interviews were conducted to identify risk factors in 1,626 confirmed cases of CA-CDI in five Minnesota counties. All cases were among patients without an overnight stay in a health care facility in the previous 12 weeks, which was an exclusion criterion.
After the review of medical records and patient interviews, 926 (57%) of the CA-CDI cases were deemed likely to be related to antibiotic exposure. Of these antibiotic exposures, 136 (15%) were from prescriptions written by dentists, a figure reached only when patients were interviewed. According to Ms. Bye, 34% of the antibiotics prescribed by dentists were not in the medical record.
There were also notable differences in antibiotic exposures stemming from dentist prescriptions relative to prescriptions from other sources. Perhaps most significantly, dental-related antibiotic prescriptions were far more likely to be for clindamycin (50% vs. 10%; P less than .001), which is commonly associated with increased risk of C. difficile, according to Ms. Bye. Fluoroquinolones (6% vs. 19%; P less than .001) and cephalosporins (7% vs. 30%; P less than .001) were significantly less likely to be prescribed by dentists. Patients who developed CA-CDI associated with antibiotics prescribed by dentists were also significantly older than were those receiving antibiotics from another source (mean age 57 years vs. 45 years; P less than .001).
For the first years of this analysis, information on the indication for dentist-prescribed antibiotics was not collected, but these data were collected beginning in 2015. In the data collected so far, a substantial proportion of prescriptions were written for prophylaxis against systemic infections, including prevention of endocarditis or infection of prosthetic joints. However, few of these prescriptions were indicated.
“The American Dental Association stated that antibiotic prophylaxis is not generally recommended in patients with prosthetic joints,” said Ms. Bye, noting that this is consistent with similar statements issued by the American Academy of Orthopedic Surgery. In 2007, the American Heart Association narrowed its recommendations for prophylactic antibiotics to patients at the highest risk of adverse consequences from endocarditis.
Of the four patients who received prophylactic antibiotics from their dentists for a cardiovascular or orthopedic indication, only one met current criteria, Ms. Bye reported.
The contribution of antibiotic exposures from dentist prescriptions to CA-CDI should not be surprising, according to Ms. Bye. In the United States, dentists prescribe 10% of all outpatient antibiotics. Although there are many valid indications for these prescriptions, Ms. Bye cited a survey that found that the proportion of dentists familiar with current guidelines and the risks of adverse events produced by antibiotics, including CA-CDI, is less than 50%.
“Dentists need to be included in antibiotic stewardship programs,” she advised. This will include educating dentists about the indications for antibiotic prophylaxis for medical conditions. She also suggested that clinicians should routinely ask patients about whether they have received antibiotics from a dentist so that this information gets into the medical record.
The event was 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.
SAN DIEGO – Antibiotic prescriptions written by dentists make a substantial but largely unrecognized contribution to the risk of community-acquired Clostridium difficile (CA-CDI) infections, according to results of a public health initiative that was presented at an annual scientific meeting on infectious diseases.
When nearly 1,000 cases of CA-CDI suspected of being the result of antibiotic exposure were evaluated, it was found that 15% of the prescriptions were written by dentists, often for indications that are counter to current guidelines, reported Maria Bye, MPH, an officer in the Infectious Disease Epidemiology, Prevention, and Control Division of the Minnesota Department of Health, St. Paul.
In another finding from this study relevant to infection control, a substantial proportion of dentist-prescribed antibiotics associated with CA-CDI were not in the medical record. Rather, they were discovered in interviews conducted to isolate risk factors. “This is concerning since clinicians unaware of these exposures will not think about CA-CDI or other complications of antibiotic use, possibly delaying therapy,” Ms. Bye said.
The importance of dental antibiotic prescriptions in CA-CDI was identified in an ongoing infectious disease program managed by the Minnesota Department of Health in collaboration with the Centers for Disease Control and Prevention. In the years 2009-2015, medical records and interviews were conducted to identify risk factors in 1,626 confirmed cases of CA-CDI in five Minnesota counties. All cases were among patients without an overnight stay in a health care facility in the previous 12 weeks, which was an exclusion criterion.
After the review of medical records and patient interviews, 926 (57%) of the CA-CDI cases were deemed likely to be related to antibiotic exposure. Of these antibiotic exposures, 136 (15%) were from prescriptions written by dentists, a figure reached only when patients were interviewed. According to Ms. Bye, 34% of the antibiotics prescribed by dentists were not in the medical record.
There were also notable differences in antibiotic exposures stemming from dentist prescriptions relative to prescriptions from other sources. Perhaps most significantly, dental-related antibiotic prescriptions were far more likely to be for clindamycin (50% vs. 10%; P less than .001), which is commonly associated with increased risk of C. difficile, according to Ms. Bye. Fluoroquinolones (6% vs. 19%; P less than .001) and cephalosporins (7% vs. 30%; P less than .001) were significantly less likely to be prescribed by dentists. Patients who developed CA-CDI associated with antibiotics prescribed by dentists were also significantly older than were those receiving antibiotics from another source (mean age 57 years vs. 45 years; P less than .001).
For the first years of this analysis, information on the indication for dentist-prescribed antibiotics was not collected, but these data were collected beginning in 2015. In the data collected so far, a substantial proportion of prescriptions were written for prophylaxis against systemic infections, including prevention of endocarditis or infection of prosthetic joints. However, few of these prescriptions were indicated.
“The American Dental Association stated that antibiotic prophylaxis is not generally recommended in patients with prosthetic joints,” said Ms. Bye, noting that this is consistent with similar statements issued by the American Academy of Orthopedic Surgery. In 2007, the American Heart Association narrowed its recommendations for prophylactic antibiotics to patients at the highest risk of adverse consequences from endocarditis.
Of the four patients who received prophylactic antibiotics from their dentists for a cardiovascular or orthopedic indication, only one met current criteria, Ms. Bye reported.
The contribution of antibiotic exposures from dentist prescriptions to CA-CDI should not be surprising, according to Ms. Bye. In the United States, dentists prescribe 10% of all outpatient antibiotics. Although there are many valid indications for these prescriptions, Ms. Bye cited a survey that found that the proportion of dentists familiar with current guidelines and the risks of adverse events produced by antibiotics, including CA-CDI, is less than 50%.
“Dentists need to be included in antibiotic stewardship programs,” she advised. This will include educating dentists about the indications for antibiotic prophylaxis for medical conditions. She also suggested that clinicians should routinely ask patients about whether they have received antibiotics from a dentist so that this information gets into the medical record.
The event was 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.
SAN DIEGO – Antibiotic prescriptions written by dentists make a substantial but largely unrecognized contribution to the risk of community-acquired Clostridium difficile (CA-CDI) infections, according to results of a public health initiative that was presented at an annual scientific meeting on infectious diseases.
When nearly 1,000 cases of CA-CDI suspected of being the result of antibiotic exposure were evaluated, it was found that 15% of the prescriptions were written by dentists, often for indications that are counter to current guidelines, reported Maria Bye, MPH, an officer in the Infectious Disease Epidemiology, Prevention, and Control Division of the Minnesota Department of Health, St. Paul.
In another finding from this study relevant to infection control, a substantial proportion of dentist-prescribed antibiotics associated with CA-CDI were not in the medical record. Rather, they were discovered in interviews conducted to isolate risk factors. “This is concerning since clinicians unaware of these exposures will not think about CA-CDI or other complications of antibiotic use, possibly delaying therapy,” Ms. Bye said.
The importance of dental antibiotic prescriptions in CA-CDI was identified in an ongoing infectious disease program managed by the Minnesota Department of Health in collaboration with the Centers for Disease Control and Prevention. In the years 2009-2015, medical records and interviews were conducted to identify risk factors in 1,626 confirmed cases of CA-CDI in five Minnesota counties. All cases were among patients without an overnight stay in a health care facility in the previous 12 weeks, which was an exclusion criterion.
After the review of medical records and patient interviews, 926 (57%) of the CA-CDI cases were deemed likely to be related to antibiotic exposure. Of these antibiotic exposures, 136 (15%) were from prescriptions written by dentists, a figure reached only when patients were interviewed. According to Ms. Bye, 34% of the antibiotics prescribed by dentists were not in the medical record.
There were also notable differences in antibiotic exposures stemming from dentist prescriptions relative to prescriptions from other sources. Perhaps most significantly, dental-related antibiotic prescriptions were far more likely to be for clindamycin (50% vs. 10%; P less than .001), which is commonly associated with increased risk of C. difficile, according to Ms. Bye. Fluoroquinolones (6% vs. 19%; P less than .001) and cephalosporins (7% vs. 30%; P less than .001) were significantly less likely to be prescribed by dentists. Patients who developed CA-CDI associated with antibiotics prescribed by dentists were also significantly older than were those receiving antibiotics from another source (mean age 57 years vs. 45 years; P less than .001).
For the first years of this analysis, information on the indication for dentist-prescribed antibiotics was not collected, but these data were collected beginning in 2015. In the data collected so far, a substantial proportion of prescriptions were written for prophylaxis against systemic infections, including prevention of endocarditis or infection of prosthetic joints. However, few of these prescriptions were indicated.
“The American Dental Association stated that antibiotic prophylaxis is not generally recommended in patients with prosthetic joints,” said Ms. Bye, noting that this is consistent with similar statements issued by the American Academy of Orthopedic Surgery. In 2007, the American Heart Association narrowed its recommendations for prophylactic antibiotics to patients at the highest risk of adverse consequences from endocarditis.
Of the four patients who received prophylactic antibiotics from their dentists for a cardiovascular or orthopedic indication, only one met current criteria, Ms. Bye reported.
The contribution of antibiotic exposures from dentist prescriptions to CA-CDI should not be surprising, according to Ms. Bye. In the United States, dentists prescribe 10% of all outpatient antibiotics. Although there are many valid indications for these prescriptions, Ms. Bye cited a survey that found that the proportion of dentists familiar with current guidelines and the risks of adverse events produced by antibiotics, including CA-CDI, is less than 50%.
“Dentists need to be included in antibiotic stewardship programs,” she advised. This will include educating dentists about the indications for antibiotic prophylaxis for medical conditions. She also suggested that clinicians should routinely ask patients about whether they have received antibiotics from a dentist so that this information gets into the medical record.
The event was 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.
AT ID WEEK 2017
Key clinical point: A public health initiative tracking community-acquired Clostridium difficile infections suggests dental antibiotic prescribing is a significant source.
Major finding: When traced, 15% of the antibiotics related to community-acquired C. difficile infections were from a dentist prescription.
Data source: Population-based surveillance study.
Disclosures: Ms. Bye reported that she has no financial relationships relevant to this topic.