Sherry Boschert

SAN FRANCISCO — For every $1 billed by the hepatology section at one institution, the hospital generated an additional $27 in charges, a retrospective study showed.

The data are the first to document why medical centers should support their hepatology sections and their hepatologists in this more consultative and less procedurally oriented specialty, Dr. Donald M. Jensen said at the annual meeting of the American Association for the Study of Liver Diseases.

The study was prompted by Dr. Jensen's experience of having to justify budgets and salaries in his hepatology section to hospital administrators—who focused mainly on practice-generated revenue and not downstream revenue.

“Every year I'd have to go through this genuflecting about why we're not generating more revenue,” said Dr. Jensen, who coauthored the study while at Rush University, Chicago, and now is the director of the center for liver diseases at the University of Chicago Hospitals. Dr. Stanley M. Cohen of Rush University was lead author of the study (Hepatology 2005;41:968–75).

The investigators analyzed data on new outpatient consultations and initial admissions over a 3-month period for 179 patients in the hepatology section and 179 patients in the gastroenterology section, who were followed for 12 months.

They calculated both direct charges (generated directly to the sections) and indirect charges (generated to the hospital system). The hepatology section had 3 full-time physicians, whereas the gastroenterology section had 7.5 full-time physicians.

In total, the hepatology section generated nearly $5.9 million in charges for the hospital, compared with $2.3 million generated by gastroenterology. Direct charges accounted for 4% of charges from hepatology and 16% of charges from gastroenterology. The mean charge per patient was $32,090 for hepatology patients and $12,700 for gastroenterology patients, he said.

Compared with the $27 generated for the hospital for every $1 charged to hepatology, in gastroenterology every $1 charged generated an additional $5 in charges for the hospital. Among the hepatology patients, 9 of the 179 underwent orthotopic liver transplant during the study period. These patients generated 64% of the hepatology revenues, 98% of which were hospital charges.

Every $1 charged to hepatology for the transplant patients generated an additional $51 for the hospital. Even without the transplant patients, every $1 in hepatology charges generated $14 in downstream charges, Dr. Jensen noted.

That compares favorably with previous data from studies of other specialties that do not rely heavily on procedures, he added. A study of primary care services found that every $1 in direct charges generated $7 in indirect charges for the hospital. “Hepatology was clearly above that range,” Dr. Jensen said. One limitation of the study is that the gastroenterology section at Rush University Medical Center sees more than twice as many patients as does the hepatology section during a 3-month period, he added.

SAN FRANCISCO — For every $1 billed by the hepatology section at one institution, the hospital generated an additional $27 in charges, a retrospective study showed.

The data are the first to document why medical centers should support their hepatology sections and their hepatologists in this more consultative and less procedurally oriented specialty, Dr. Donald M. Jensen said at the annual meeting of the American Association for the Study of Liver Diseases.

The study was prompted by Dr. Jensen's experience of having to justify budgets and salaries in his hepatology section to hospital administrators—who focused mainly on practice-generated revenue and not downstream revenue.

“Every year I'd have to go through this genuflecting about why we're not generating more revenue,” said Dr. Jensen, who coauthored the study while at Rush University, Chicago, and now is the director of the center for liver diseases at the University of Chicago Hospitals. Dr. Stanley M. Cohen of Rush University was lead author of the study (Hepatology 2005;41:968–75).

The investigators analyzed data on new outpatient consultations and initial admissions over a 3-month period for 179 patients in the hepatology section and 179 patients in the gastroenterology section, who were followed for 12 months.

They calculated both direct charges (generated directly to the sections) and indirect charges (generated to the hospital system). The hepatology section had 3 full-time physicians, whereas the gastroenterology section had 7.5 full-time physicians.

In total, the hepatology section generated nearly $5.9 million in charges for the hospital, compared with $2.3 million generated by gastroenterology. Direct charges accounted for 4% of charges from hepatology and 16% of charges from gastroenterology. The mean charge per patient was $32,090 for hepatology patients and $12,700 for gastroenterology patients, he said.

Compared with the $27 generated for the hospital for every $1 charged to hepatology, in gastroenterology every $1 charged generated an additional $5 in charges for the hospital. Among the hepatology patients, 9 of the 179 underwent orthotopic liver transplant during the study period. These patients generated 64% of the hepatology revenues, 98% of which were hospital charges.

Every $1 charged to hepatology for the transplant patients generated an additional $51 for the hospital. Even without the transplant patients, every $1 in hepatology charges generated $14 in downstream charges, Dr. Jensen noted.

That compares favorably with previous data from studies of other specialties that do not rely heavily on procedures, he added. A study of primary care services found that every $1 in direct charges generated $7 in indirect charges for the hospital. “Hepatology was clearly above that range,” Dr. Jensen said. One limitation of the study is that the gastroenterology section at Rush University Medical Center sees more than twice as many patients as does the hepatology section during a 3-month period, he added.

SAN FRANCISCO — For every $1 billed by the hepatology section at one institution, the hospital generated an additional $27 in charges, a retrospective study showed.

The data are the first to document why medical centers should support their hepatology sections and their hepatologists in this more consultative and less procedurally oriented specialty, Dr. Donald M. Jensen said at the annual meeting of the American Association for the Study of Liver Diseases.

The study was prompted by Dr. Jensen's experience of having to justify budgets and salaries in his hepatology section to hospital administrators—who focused mainly on practice-generated revenue and not downstream revenue.

“Every year I'd have to go through this genuflecting about why we're not generating more revenue,” said Dr. Jensen, who coauthored the study while at Rush University, Chicago, and now is the director of the center for liver diseases at the University of Chicago Hospitals. Dr. Stanley M. Cohen of Rush University was lead author of the study (Hepatology 2005;41:968–75).

The investigators analyzed data on new outpatient consultations and initial admissions over a 3-month period for 179 patients in the hepatology section and 179 patients in the gastroenterology section, who were followed for 12 months.

They calculated both direct charges (generated directly to the sections) and indirect charges (generated to the hospital system). The hepatology section had 3 full-time physicians, whereas the gastroenterology section had 7.5 full-time physicians.

In total, the hepatology section generated nearly $5.9 million in charges for the hospital, compared with $2.3 million generated by gastroenterology. Direct charges accounted for 4% of charges from hepatology and 16% of charges from gastroenterology. The mean charge per patient was $32,090 for hepatology patients and $12,700 for gastroenterology patients, he said.

Compared with the $27 generated for the hospital for every $1 charged to hepatology, in gastroenterology every $1 charged generated an additional $5 in charges for the hospital. Among the hepatology patients, 9 of the 179 underwent orthotopic liver transplant during the study period. These patients generated 64% of the hepatology revenues, 98% of which were hospital charges.

Every $1 charged to hepatology for the transplant patients generated an additional $51 for the hospital. Even without the transplant patients, every $1 in hepatology charges generated $14 in downstream charges, Dr. Jensen noted.

That compares favorably with previous data from studies of other specialties that do not rely heavily on procedures, he added. A study of primary care services found that every $1 in direct charges generated $7 in indirect charges for the hospital. “Hepatology was clearly above that range,” Dr. Jensen said. One limitation of the study is that the gastroenterology section at Rush University Medical Center sees more than twice as many patients as does the hepatology section during a 3-month period, he added.

SAN FRANCISCO — Many physicians who manage patients with chronic hepatitis C could increase their incomes simply by paying closer attention to coding, Dr. Imtiaz Alam said at the annual meeting of the American Association for the Study of Liver Diseases.

“Physicians tend to play it safe” when billing for hepatitis care by choosing Evaluation and Management (E&M) codes appropriate for visits with little complexity in the medical decision making, said Dr. Alam, medical director of a private hepatitis center in Austin, Tex.

Instead, visits with patients being treated for hepatitis C almost always should be coded at levels of moderate or high complexity, he said.

The difference can add up. For visits with established patients, Medicare reimburses an average of $38 for E&M code 99212 (the least complex medical decision-making), $52 for code 99213 (low complexity), $82 for code 99214 (moderate complexity), and $119 for code 99215 (the most complex decision making), he noted.

If there is a $30 difference in payment between codes 99213 and 99214, and a physician undercodes seven visits per day as 99213 even though they qualify as 99214, that would lead to a substantial loss of income—$1,050 per week, Dr. Alam said.

A common mistake is to assume that physicians must spend more time with more complex patients to qualify for the level 4 or 5 codes, he suggested. “Coding levels have little to do with how quickly or easily you come up with a plan of care,” but rather reflect the physician's effort and the level of risk to a patient in implementing a plan of care, he said.

An experienced hepatologist may spend only 10 minutes with a hepatitis C-infected patient and still determine the plan of care, Dr. Alam noted.

He described other conditions that typically qualify for codes 99212–99215. An office visit to provide reassurance to an established patient with an irritated skin tag would be code 99212. Code 99213 might be used for an office visit with an established patient with stable cirrhosis of the liver. “But how many of your hepatitis patients are stable? I suspect most of them are not,” he said.

Code 99214 would be appropriate for an office visit by an established 45-year-old patient on immunosuppressive therapy for rheumatoid arthritis. “How is that different from your hepatitis C patients who are on therapy?” he asked. Code 99215 might be used for an office visit with an established 36-year-old patient who is 3 months post transplant and is developing peripheral edema, increasing blood pressure, and progressive fatigue. “I suspect that many of your hepatitis C patients on interferon therapy are probably having many issues,” Dr. Alam said.

For office visits by new patients, there can be a $38 difference between coding for 99244 (moderate complexity of decision making) and 99245 (the most complex cases). Code 99245 would be appropriate for a first visit for initial evaluation and management of Cushing's disease. “How is that different from your initial evaluation of hepatitis C when you're going to consider them for therapy? I don't believe there's any difference,” he said.

The key to feeling comfortable with appropriate coding is to document the steps needed to qualify for those codes, he added. New patient visits require a history, exam, and medical decision making.

Only two of those three are required for visits with established patients. An exam isn't necessarily essential if the patient fills out a Review of Systems form and the physician documents height, weight, and blood pressure and engages in the appropriate level of medical decision making. For higher-complexity coding, the physician also should ask about changes in family or social history (such as alcohol consumption).

SAN FRANCISCO — Many physicians who manage patients with chronic hepatitis C could increase their incomes simply by paying closer attention to coding, Dr. Imtiaz Alam said at the annual meeting of the American Association for the Study of Liver Diseases.

“Physicians tend to play it safe” when billing for hepatitis care by choosing Evaluation and Management (E&M) codes appropriate for visits with little complexity in the medical decision making, said Dr. Alam, medical director of a private hepatitis center in Austin, Tex.

Instead, visits with patients being treated for hepatitis C almost always should be coded at levels of moderate or high complexity, he said.

The difference can add up. For visits with established patients, Medicare reimburses an average of $38 for E&M code 99212 (the least complex medical decision-making), $52 for code 99213 (low complexity), $82 for code 99214 (moderate complexity), and $119 for code 99215 (the most complex decision making), he noted.

If there is a $30 difference in payment between codes 99213 and 99214, and a physician undercodes seven visits per day as 99213 even though they qualify as 99214, that would lead to a substantial loss of income—$1,050 per week, Dr. Alam said.

A common mistake is to assume that physicians must spend more time with more complex patients to qualify for the level 4 or 5 codes, he suggested. “Coding levels have little to do with how quickly or easily you come up with a plan of care,” but rather reflect the physician's effort and the level of risk to a patient in implementing a plan of care, he said.

An experienced hepatologist may spend only 10 minutes with a hepatitis C-infected patient and still determine the plan of care, Dr. Alam noted.

He described other conditions that typically qualify for codes 99212–99215. An office visit to provide reassurance to an established patient with an irritated skin tag would be code 99212. Code 99213 might be used for an office visit with an established patient with stable cirrhosis of the liver. “But how many of your hepatitis patients are stable? I suspect most of them are not,” he said.

Code 99214 would be appropriate for an office visit by an established 45-year-old patient on immunosuppressive therapy for rheumatoid arthritis. “How is that different from your hepatitis C patients who are on therapy?” he asked. Code 99215 might be used for an office visit with an established 36-year-old patient who is 3 months post transplant and is developing peripheral edema, increasing blood pressure, and progressive fatigue. “I suspect that many of your hepatitis C patients on interferon therapy are probably having many issues,” Dr. Alam said.

For office visits by new patients, there can be a $38 difference between coding for 99244 (moderate complexity of decision making) and 99245 (the most complex cases). Code 99245 would be appropriate for a first visit for initial evaluation and management of Cushing's disease. “How is that different from your initial evaluation of hepatitis C when you're going to consider them for therapy? I don't believe there's any difference,” he said.

The key to feeling comfortable with appropriate coding is to document the steps needed to qualify for those codes, he added. New patient visits require a history, exam, and medical decision making.

Only two of those three are required for visits with established patients. An exam isn't necessarily essential if the patient fills out a Review of Systems form and the physician documents height, weight, and blood pressure and engages in the appropriate level of medical decision making. For higher-complexity coding, the physician also should ask about changes in family or social history (such as alcohol consumption).

SAN FRANCISCO — Many physicians who manage patients with chronic hepatitis C could increase their incomes simply by paying closer attention to coding, Dr. Imtiaz Alam said at the annual meeting of the American Association for the Study of Liver Diseases.

“Physicians tend to play it safe” when billing for hepatitis care by choosing Evaluation and Management (E&M) codes appropriate for visits with little complexity in the medical decision making, said Dr. Alam, medical director of a private hepatitis center in Austin, Tex.

Instead, visits with patients being treated for hepatitis C almost always should be coded at levels of moderate or high complexity, he said.

The difference can add up. For visits with established patients, Medicare reimburses an average of $38 for E&M code 99212 (the least complex medical decision-making), $52 for code 99213 (low complexity), $82 for code 99214 (moderate complexity), and $119 for code 99215 (the most complex decision making), he noted.

If there is a $30 difference in payment between codes 99213 and 99214, and a physician undercodes seven visits per day as 99213 even though they qualify as 99214, that would lead to a substantial loss of income—$1,050 per week, Dr. Alam said.

A common mistake is to assume that physicians must spend more time with more complex patients to qualify for the level 4 or 5 codes, he suggested. “Coding levels have little to do with how quickly or easily you come up with a plan of care,” but rather reflect the physician's effort and the level of risk to a patient in implementing a plan of care, he said.

An experienced hepatologist may spend only 10 minutes with a hepatitis C-infected patient and still determine the plan of care, Dr. Alam noted.

He described other conditions that typically qualify for codes 99212–99215. An office visit to provide reassurance to an established patient with an irritated skin tag would be code 99212. Code 99213 might be used for an office visit with an established patient with stable cirrhosis of the liver. “But how many of your hepatitis patients are stable? I suspect most of them are not,” he said.

Code 99214 would be appropriate for an office visit by an established 45-year-old patient on immunosuppressive therapy for rheumatoid arthritis. “How is that different from your hepatitis C patients who are on therapy?” he asked. Code 99215 might be used for an office visit with an established 36-year-old patient who is 3 months post transplant and is developing peripheral edema, increasing blood pressure, and progressive fatigue. “I suspect that many of your hepatitis C patients on interferon therapy are probably having many issues,” Dr. Alam said.

For office visits by new patients, there can be a $38 difference between coding for 99244 (moderate complexity of decision making) and 99245 (the most complex cases). Code 99245 would be appropriate for a first visit for initial evaluation and management of Cushing's disease. “How is that different from your initial evaluation of hepatitis C when you're going to consider them for therapy? I don't believe there's any difference,” he said.

The key to feeling comfortable with appropriate coding is to document the steps needed to qualify for those codes, he added. New patient visits require a history, exam, and medical decision making.

Only two of those three are required for visits with established patients. An exam isn't necessarily essential if the patient fills out a Review of Systems form and the physician documents height, weight, and blood pressure and engages in the appropriate level of medical decision making. For higher-complexity coding, the physician also should ask about changes in family or social history (such as alcohol consumption).

SAN FRANCISCO — The first randomized, controlled clinical study of an antiviral medication's effects on human herpesvirus 8 found a 79% reduction in viral shedding in the oropharynx of 26 men taking 900 mg/day of valganciclovir, Dr. Corey Casper reported.

Human herpesvirus 8 (HHV-8) causes Kaposi's sarcoma, multicentric Castleman disease, and primary effusion lymphoma. The virus must actively replicate to cause and maintain Kaposi's sarcoma and multicentric Castleman disease. The study's results suggest that valganciclovir may be an effective and safe way to both prevent and treat these HHV-8-related diseases, he said at the annual meeting of the Infectious Diseases Society of America.

Sixteen of the 26 participants had HIV infection. Subjects were randomized to 8 weeks of oral valganciclovir or placebo, followed by a 2-week washout period. Then participants took the alternative treatment for an additional 8 weeks.

All 26 subjects completed the study, and all but 1 adhered to the study regimen, according to pill counts. Participants collected oropharyngeal secretions daily at home.

While patients were taking valganciclovir, the median percentage of days with HHV-8 DNA detected decreased to 9%, compared with 43% on placebo—a 79% reduction, said Dr. Casper of the University of Washington, Seattle.

The effect was seen regardless of HIV status. The median shedding rate decreased from 63% to 23% in HIV-positive men and from 15% to 5% in HIV-negative men, a 64% drop in each subgroup. The greatest suppression in viral shedding was seen at 2 weeks, after which the effect remained stable until the drug was stopped. Shedding rates returned to baseline levels within 1 week of stopping valganciclovir.

The study was funded by Roche Laboratories Inc., which makes valganciclovir, and the National Institutes of Health.

Seven men on valganciclovir and four on placebo developed diarrhea—the only significant difference in side effects observed between the groups.

It's not yet known whether a different dose of valganciclovir, or another antiviral medication, might more effectively limit HHV-8 replication, he said.

SAN FRANCISCO — The first randomized, controlled clinical study of an antiviral medication's effects on human herpesvirus 8 found a 79% reduction in viral shedding in the oropharynx of 26 men taking 900 mg/day of valganciclovir, Dr. Corey Casper reported.

Human herpesvirus 8 (HHV-8) causes Kaposi's sarcoma, multicentric Castleman disease, and primary effusion lymphoma. The virus must actively replicate to cause and maintain Kaposi's sarcoma and multicentric Castleman disease. The study's results suggest that valganciclovir may be an effective and safe way to both prevent and treat these HHV-8-related diseases, he said at the annual meeting of the Infectious Diseases Society of America.

Sixteen of the 26 participants had HIV infection. Subjects were randomized to 8 weeks of oral valganciclovir or placebo, followed by a 2-week washout period. Then participants took the alternative treatment for an additional 8 weeks.

All 26 subjects completed the study, and all but 1 adhered to the study regimen, according to pill counts. Participants collected oropharyngeal secretions daily at home.

While patients were taking valganciclovir, the median percentage of days with HHV-8 DNA detected decreased to 9%, compared with 43% on placebo—a 79% reduction, said Dr. Casper of the University of Washington, Seattle.

The effect was seen regardless of HIV status. The median shedding rate decreased from 63% to 23% in HIV-positive men and from 15% to 5% in HIV-negative men, a 64% drop in each subgroup. The greatest suppression in viral shedding was seen at 2 weeks, after which the effect remained stable until the drug was stopped. Shedding rates returned to baseline levels within 1 week of stopping valganciclovir.

The study was funded by Roche Laboratories Inc., which makes valganciclovir, and the National Institutes of Health.

Seven men on valganciclovir and four on placebo developed diarrhea—the only significant difference in side effects observed between the groups.

It's not yet known whether a different dose of valganciclovir, or another antiviral medication, might more effectively limit HHV-8 replication, he said.

SAN FRANCISCO — The first randomized, controlled clinical study of an antiviral medication's effects on human herpesvirus 8 found a 79% reduction in viral shedding in the oropharynx of 26 men taking 900 mg/day of valganciclovir, Dr. Corey Casper reported.

Human herpesvirus 8 (HHV-8) causes Kaposi's sarcoma, multicentric Castleman disease, and primary effusion lymphoma. The virus must actively replicate to cause and maintain Kaposi's sarcoma and multicentric Castleman disease. The study's results suggest that valganciclovir may be an effective and safe way to both prevent and treat these HHV-8-related diseases, he said at the annual meeting of the Infectious Diseases Society of America.

Sixteen of the 26 participants had HIV infection. Subjects were randomized to 8 weeks of oral valganciclovir or placebo, followed by a 2-week washout period. Then participants took the alternative treatment for an additional 8 weeks.

All 26 subjects completed the study, and all but 1 adhered to the study regimen, according to pill counts. Participants collected oropharyngeal secretions daily at home.

While patients were taking valganciclovir, the median percentage of days with HHV-8 DNA detected decreased to 9%, compared with 43% on placebo—a 79% reduction, said Dr. Casper of the University of Washington, Seattle.

The effect was seen regardless of HIV status. The median shedding rate decreased from 63% to 23% in HIV-positive men and from 15% to 5% in HIV-negative men, a 64% drop in each subgroup. The greatest suppression in viral shedding was seen at 2 weeks, after which the effect remained stable until the drug was stopped. Shedding rates returned to baseline levels within 1 week of stopping valganciclovir.

The study was funded by Roche Laboratories Inc., which makes valganciclovir, and the National Institutes of Health.

Seven men on valganciclovir and four on placebo developed diarrhea—the only significant difference in side effects observed between the groups.

It's not yet known whether a different dose of valganciclovir, or another antiviral medication, might more effectively limit HHV-8 replication, he said.

SAN FRANCISCO — Invasive methicillin-resistant Staphylococcus aureus was more likely to cause skin and soft tissue disease or joint infections if acquired in the community rather than in a hospital, according to preliminary data from a large surveillance study.

Skin or soft tissue infection occurred in 34% of community-associated methicillin-resistant S. aureus (MRSA), compared with 10% of hospital-associated MRSA infections in the study of 6,413 cases of invasive MRSA in nine U.S. sites with a total population of about 16 million people, Dr. Susan M. Ray reported at the annual meeting of the Infectious Diseases Society of America.

Endocarditis was more common among patients with community-associated MRSA than among patients with hospital-associated MRSA (12% vs. 4%), as were internal or deep-seated abscesses (9% vs. 4%) and septic arthritis, said Dr. Ray of Emory University, Atlanta.

“These differences may be explained by virulence factors in the staph strain, and/or by delay in presentation for care,” Dr. Ray said. “The clinical evaluation of community-associated MRSA should include the investigation of deep-seated foci of infections.”

Patients who had hospital-associated invasive MRSA were more likely than other patients to have uncomplicated bacteremia, she said.

A previous analysis of 2001–2002 data from the Centers for Disease Control and Prevention revealed that about 17% of cases of MRSA in three sites were community associated, and about 7% of these were invasive disease (with a culture from a normally sterile site).

The current study analyzed federal data from 2004 and 2005 in nine geographic areas to identify culture-positive invasive MRSA infections. Surveillance officers reviewed patient records to classify 86% of the cases as hospital-associated based on risk-factor criteria; all of the others were deemed community-associated infections (14%) or uncertain (less than 0.5%), Dr. Ray said.

The rate of community-associated MRSA varied widely by geography, comprising 24% of the invasive MRSA cases in Maryland but only 3% of the cases in New York.

Compared with hospital-associated invasive MRSA, community-associated MRSA occurred at higher rates among children, smokers, and men who had a history of intravenous drug use, HIV, or AIDS.

Compared with hospital-associated MRSA, community-associated MRSA was less likely to be resistant to antimicrobials other than methicillin or to be resistant to multiple classes of antibiotics, Dr. Ray reported.

Community-associated MRSA accounted for 35% of cases of invasive MRSA in children aged 3 years or younger, 50% of cases in 4− to 19-year-olds, 25% of patients aged 20–49 years, and 7% of those aged 50 years or older.

Cases were defined as hospital-associated MRSA if records showed at least one of the following criteria: previous MRSA colonization or infection; a culture obtained more than 48 hours after hospitalization; the presence of an invasive device at the time of evaluation; or a history within the past year of hospitalization, surgery, dialysis, or residence in a long-term care facility.

Investigators in the study began collecting isolates from a sample of cases in 2005.

“In the future, this will allow us to compare the epidemiologic classification of community-associated MRSA with its microbiologic characteristics,” Dr. Ray said.

SAN FRANCISCO — Invasive methicillin-resistant Staphylococcus aureus was more likely to cause skin and soft tissue disease or joint infections if acquired in the community rather than in a hospital, according to preliminary data from a large surveillance study.

Skin or soft tissue infection occurred in 34% of community-associated methicillin-resistant S. aureus (MRSA), compared with 10% of hospital-associated MRSA infections in the study of 6,413 cases of invasive MRSA in nine U.S. sites with a total population of about 16 million people, Dr. Susan M. Ray reported at the annual meeting of the Infectious Diseases Society of America.

Endocarditis was more common among patients with community-associated MRSA than among patients with hospital-associated MRSA (12% vs. 4%), as were internal or deep-seated abscesses (9% vs. 4%) and septic arthritis, said Dr. Ray of Emory University, Atlanta.

“These differences may be explained by virulence factors in the staph strain, and/or by delay in presentation for care,” Dr. Ray said. “The clinical evaluation of community-associated MRSA should include the investigation of deep-seated foci of infections.”

Patients who had hospital-associated invasive MRSA were more likely than other patients to have uncomplicated bacteremia, she said.

A previous analysis of 2001–2002 data from the Centers for Disease Control and Prevention revealed that about 17% of cases of MRSA in three sites were community associated, and about 7% of these were invasive disease (with a culture from a normally sterile site).

The current study analyzed federal data from 2004 and 2005 in nine geographic areas to identify culture-positive invasive MRSA infections. Surveillance officers reviewed patient records to classify 86% of the cases as hospital-associated based on risk-factor criteria; all of the others were deemed community-associated infections (14%) or uncertain (less than 0.5%), Dr. Ray said.

The rate of community-associated MRSA varied widely by geography, comprising 24% of the invasive MRSA cases in Maryland but only 3% of the cases in New York.

Compared with hospital-associated invasive MRSA, community-associated MRSA occurred at higher rates among children, smokers, and men who had a history of intravenous drug use, HIV, or AIDS.

Compared with hospital-associated MRSA, community-associated MRSA was less likely to be resistant to antimicrobials other than methicillin or to be resistant to multiple classes of antibiotics, Dr. Ray reported.

Community-associated MRSA accounted for 35% of cases of invasive MRSA in children aged 3 years or younger, 50% of cases in 4− to 19-year-olds, 25% of patients aged 20–49 years, and 7% of those aged 50 years or older.

Cases were defined as hospital-associated MRSA if records showed at least one of the following criteria: previous MRSA colonization or infection; a culture obtained more than 48 hours after hospitalization; the presence of an invasive device at the time of evaluation; or a history within the past year of hospitalization, surgery, dialysis, or residence in a long-term care facility.

Investigators in the study began collecting isolates from a sample of cases in 2005.

“In the future, this will allow us to compare the epidemiologic classification of community-associated MRSA with its microbiologic characteristics,” Dr. Ray said.

SAN FRANCISCO — Invasive methicillin-resistant Staphylococcus aureus was more likely to cause skin and soft tissue disease or joint infections if acquired in the community rather than in a hospital, according to preliminary data from a large surveillance study.

Skin or soft tissue infection occurred in 34% of community-associated methicillin-resistant S. aureus (MRSA), compared with 10% of hospital-associated MRSA infections in the study of 6,413 cases of invasive MRSA in nine U.S. sites with a total population of about 16 million people, Dr. Susan M. Ray reported at the annual meeting of the Infectious Diseases Society of America.

Endocarditis was more common among patients with community-associated MRSA than among patients with hospital-associated MRSA (12% vs. 4%), as were internal or deep-seated abscesses (9% vs. 4%) and septic arthritis, said Dr. Ray of Emory University, Atlanta.

“These differences may be explained by virulence factors in the staph strain, and/or by delay in presentation for care,” Dr. Ray said. “The clinical evaluation of community-associated MRSA should include the investigation of deep-seated foci of infections.”

Patients who had hospital-associated invasive MRSA were more likely than other patients to have uncomplicated bacteremia, she said.

A previous analysis of 2001–2002 data from the Centers for Disease Control and Prevention revealed that about 17% of cases of MRSA in three sites were community associated, and about 7% of these were invasive disease (with a culture from a normally sterile site).

The current study analyzed federal data from 2004 and 2005 in nine geographic areas to identify culture-positive invasive MRSA infections. Surveillance officers reviewed patient records to classify 86% of the cases as hospital-associated based on risk-factor criteria; all of the others were deemed community-associated infections (14%) or uncertain (less than 0.5%), Dr. Ray said.

The rate of community-associated MRSA varied widely by geography, comprising 24% of the invasive MRSA cases in Maryland but only 3% of the cases in New York.

Compared with hospital-associated invasive MRSA, community-associated MRSA occurred at higher rates among children, smokers, and men who had a history of intravenous drug use, HIV, or AIDS.

Compared with hospital-associated MRSA, community-associated MRSA was less likely to be resistant to antimicrobials other than methicillin or to be resistant to multiple classes of antibiotics, Dr. Ray reported.

Community-associated MRSA accounted for 35% of cases of invasive MRSA in children aged 3 years or younger, 50% of cases in 4− to 19-year-olds, 25% of patients aged 20–49 years, and 7% of those aged 50 years or older.

Cases were defined as hospital-associated MRSA if records showed at least one of the following criteria: previous MRSA colonization or infection; a culture obtained more than 48 hours after hospitalization; the presence of an invasive device at the time of evaluation; or a history within the past year of hospitalization, surgery, dialysis, or residence in a long-term care facility.

Investigators in the study began collecting isolates from a sample of cases in 2005.

“In the future, this will allow us to compare the epidemiologic classification of community-associated MRSA with its microbiologic characteristics,” Dr. Ray said.

SAN FRANCISCO — The SSRI sertraline improved pruritus from cholestatic liver disease in a small double-blind crossover study of 12 patients, Dr. Marlyn J. Mayo said at the annual meeting of the American Association for the Study of Liver Diseases.

The findings support the results of previous small, retrospective case series that also suggested that SSRIs may improve pruritus, which often is the most debilitating symptom of cholestatic liver disease, said Dr. Mayo of the University of Texas Southwestern Medical Center at Dallas and her associates. Pfizer Inc., which makes sertraline, paid Dr. Mayo's travel expenses to the meeting. The drug is not approved for this indication.

To determine the best dose of sertraline for itching, the investigators first performed an open-label dose-escalation study in 21 patients with chronic pruritus due to primary biliary cirrhosis, primary sclerosing cholangitis, chronic hepatitis C cirrhosis, or postnecrotic cirrhosis. Patients took no other medications that might alter itching and rated their pruritus using a visual analog scale.

Doses of 25–50 mg/day sertraline for 4 weeks had little effect on itching. The greatest improvement overall came from 4 weeks of treatment with 75 mg/day, though some patients who didn't respond to these doses improved on 100 mg/day of sertraline for 4 weeks. The optimal dose seems to be 75–100 mg/day, Dr. Mayo said.

After a 2-week washout period, patients were randomized in a double-blind fashion to 6 weeks of sertraline 75 mg/day or placebo. A subsequent 2-week washout followed, and then patients were crossed over to the other treatment group for 6 more weeks. They were asked to rate their pruritus in a daily diary using the visual analog scale, and clinicians assessed the pruritus and depressive symptoms in visits after each study phase.

Twelve patients completed the study. Itching improved significantly more with sertraline than with placebo independent of the presence of depression, and was well tolerated even in patients with severe cholestatic liver disease, Dr. Mayo said.

The greatest improvements were seen in patients with the most severe pruritus, but itching resolved completely only in some patients with mild itching.

On a 10-point severity scale, itching scores decreased 2 points on sertraline but increased half a point on placebo.

Of the nine patients who did not complete both the open-label and randomized portions of the study, two died of causes unrelated to the study, and two underwent transplants. Three said they found the clinic visits too cumbersome, one developed severe dizziness on sertraline during the dose-escalation study, and one was unwilling to stop sertraline after the open-label dose-escalation phase.

All 12 patients who completed the randomized study had excoriations at baseline. On sertraline, lesions improved in 10 patients and were unchanged in 2. On placebo, lesions worsened in eight patients and were unchanged in four.

Eight of the 12 patients had red-crusted nodules at baseline. These lesions improved in seven patients on sertraline and were unchanged in one. On placebo, the red-crusted nodules worsened in four patients, were unchanged in three, and improved in one patient.

The duration of itching decreased from 12–18 hours per day in many patients on placebo to less than 6 hours/day in all but one patient who itched 6–12 hours/day.

The distribution of pruritus improved on sertraline. A median of 13 itchy body areas at baseline did not change significantly on placebo but decreased to 8 areas on sertraline.

Most patients in the study were not depressed, and mild depressive symptoms did not change significantly, Dr. Mayo said. One patient with moderate depression improved on sertraline but not placebo, and one patient with severe depression improved on both sertraline and placebo.

SAN FRANCISCO — The SSRI sertraline improved pruritus from cholestatic liver disease in a small double-blind crossover study of 12 patients, Dr. Marlyn J. Mayo said at the annual meeting of the American Association for the Study of Liver Diseases.

The findings support the results of previous small, retrospective case series that also suggested that SSRIs may improve pruritus, which often is the most debilitating symptom of cholestatic liver disease, said Dr. Mayo of the University of Texas Southwestern Medical Center at Dallas and her associates. Pfizer Inc., which makes sertraline, paid Dr. Mayo's travel expenses to the meeting. The drug is not approved for this indication.

To determine the best dose of sertraline for itching, the investigators first performed an open-label dose-escalation study in 21 patients with chronic pruritus due to primary biliary cirrhosis, primary sclerosing cholangitis, chronic hepatitis C cirrhosis, or postnecrotic cirrhosis. Patients took no other medications that might alter itching and rated their pruritus using a visual analog scale.

Doses of 25–50 mg/day sertraline for 4 weeks had little effect on itching. The greatest improvement overall came from 4 weeks of treatment with 75 mg/day, though some patients who didn't respond to these doses improved on 100 mg/day of sertraline for 4 weeks. The optimal dose seems to be 75–100 mg/day, Dr. Mayo said.

After a 2-week washout period, patients were randomized in a double-blind fashion to 6 weeks of sertraline 75 mg/day or placebo. A subsequent 2-week washout followed, and then patients were crossed over to the other treatment group for 6 more weeks. They were asked to rate their pruritus in a daily diary using the visual analog scale, and clinicians assessed the pruritus and depressive symptoms in visits after each study phase.

Twelve patients completed the study. Itching improved significantly more with sertraline than with placebo independent of the presence of depression, and was well tolerated even in patients with severe cholestatic liver disease, Dr. Mayo said.

The greatest improvements were seen in patients with the most severe pruritus, but itching resolved completely only in some patients with mild itching.

On a 10-point severity scale, itching scores decreased 2 points on sertraline but increased half a point on placebo.

Of the nine patients who did not complete both the open-label and randomized portions of the study, two died of causes unrelated to the study, and two underwent transplants. Three said they found the clinic visits too cumbersome, one developed severe dizziness on sertraline during the dose-escalation study, and one was unwilling to stop sertraline after the open-label dose-escalation phase.

All 12 patients who completed the randomized study had excoriations at baseline. On sertraline, lesions improved in 10 patients and were unchanged in 2. On placebo, lesions worsened in eight patients and were unchanged in four.

Eight of the 12 patients had red-crusted nodules at baseline. These lesions improved in seven patients on sertraline and were unchanged in one. On placebo, the red-crusted nodules worsened in four patients, were unchanged in three, and improved in one patient.

The duration of itching decreased from 12–18 hours per day in many patients on placebo to less than 6 hours/day in all but one patient who itched 6–12 hours/day.

The distribution of pruritus improved on sertraline. A median of 13 itchy body areas at baseline did not change significantly on placebo but decreased to 8 areas on sertraline.

Most patients in the study were not depressed, and mild depressive symptoms did not change significantly, Dr. Mayo said. One patient with moderate depression improved on sertraline but not placebo, and one patient with severe depression improved on both sertraline and placebo.

SAN FRANCISCO — The SSRI sertraline improved pruritus from cholestatic liver disease in a small double-blind crossover study of 12 patients, Dr. Marlyn J. Mayo said at the annual meeting of the American Association for the Study of Liver Diseases.

The findings support the results of previous small, retrospective case series that also suggested that SSRIs may improve pruritus, which often is the most debilitating symptom of cholestatic liver disease, said Dr. Mayo of the University of Texas Southwestern Medical Center at Dallas and her associates. Pfizer Inc., which makes sertraline, paid Dr. Mayo's travel expenses to the meeting. The drug is not approved for this indication.

To determine the best dose of sertraline for itching, the investigators first performed an open-label dose-escalation study in 21 patients with chronic pruritus due to primary biliary cirrhosis, primary sclerosing cholangitis, chronic hepatitis C cirrhosis, or postnecrotic cirrhosis. Patients took no other medications that might alter itching and rated their pruritus using a visual analog scale.

Doses of 25–50 mg/day sertraline for 4 weeks had little effect on itching. The greatest improvement overall came from 4 weeks of treatment with 75 mg/day, though some patients who didn't respond to these doses improved on 100 mg/day of sertraline for 4 weeks. The optimal dose seems to be 75–100 mg/day, Dr. Mayo said.

After a 2-week washout period, patients were randomized in a double-blind fashion to 6 weeks of sertraline 75 mg/day or placebo. A subsequent 2-week washout followed, and then patients were crossed over to the other treatment group for 6 more weeks. They were asked to rate their pruritus in a daily diary using the visual analog scale, and clinicians assessed the pruritus and depressive symptoms in visits after each study phase.

Twelve patients completed the study. Itching improved significantly more with sertraline than with placebo independent of the presence of depression, and was well tolerated even in patients with severe cholestatic liver disease, Dr. Mayo said.

The greatest improvements were seen in patients with the most severe pruritus, but itching resolved completely only in some patients with mild itching.

On a 10-point severity scale, itching scores decreased 2 points on sertraline but increased half a point on placebo.

Of the nine patients who did not complete both the open-label and randomized portions of the study, two died of causes unrelated to the study, and two underwent transplants. Three said they found the clinic visits too cumbersome, one developed severe dizziness on sertraline during the dose-escalation study, and one was unwilling to stop sertraline after the open-label dose-escalation phase.

All 12 patients who completed the randomized study had excoriations at baseline. On sertraline, lesions improved in 10 patients and were unchanged in 2. On placebo, lesions worsened in eight patients and were unchanged in four.

Eight of the 12 patients had red-crusted nodules at baseline. These lesions improved in seven patients on sertraline and were unchanged in one. On placebo, the red-crusted nodules worsened in four patients, were unchanged in three, and improved in one patient.

The duration of itching decreased from 12–18 hours per day in many patients on placebo to less than 6 hours/day in all but one patient who itched 6–12 hours/day.

The distribution of pruritus improved on sertraline. A median of 13 itchy body areas at baseline did not change significantly on placebo but decreased to 8 areas on sertraline.

Most patients in the study were not depressed, and mild depressive symptoms did not change significantly, Dr. Mayo said. One patient with moderate depression improved on sertraline but not placebo, and one patient with severe depression improved on both sertraline and placebo.

The bisphosphonate risedronate significantly reduced the risk of hip fracture in elderly men with a history of stroke, in the first randomized, double-blind study on this topic.

Risedronate sodium, an inhibitor of bone resorption, previously was shown to decrease the risk of nonvertebral fractures in postmenopausal women with osteoporosis and of hip fractures in women who had a stroke.

The current study randomized 280 consecutive ambulatory men aged 65 years or older with a previous stroke to a daily dosage of 2.5 mg risedronate or placebo for 18 months. By the study's end, 10 patients in the placebo group and 2 in the risedronate group had sustained hip fractures, representing an 80% reduction in risk of fracture in the risedronate group, reported Dr. Yoshihiro Sato of Mitate Hospital, Tagawa, Japan, and his associates (Arch. Intern. Med. 2005;165:1743–8).

The investigators estimated that 16 elderly men who had previous strokes would need to be treated with risedronate to prevent one hip fracture.

All of the hip fractures were on the patient's hemiplegic side. In addition to hip fractures, wrist or ankle fractures occurred in two patients in the risedronate group, and six patients in the placebo group sustained other fractures—two at the proximal femur, two at the ribs, one at the proximal humerus, and one at the pelvis.

Bone mineral density on the hemiplegic side increased by 2.5% in men in the risedronate group, compared with baseline measurements, but decreased by 3.5% in men in the placebo group, compared with baseline, a significant difference.

On the nonhemiplegic side, bone density increased by more than 3% in the risedronate group and decreased by 2% in the placebo group. Bone density was significantly lower on the hemiplegic side in both groups. A key marker of bone resorption—urinary deoxypyridinoline—decreased by 59% in the risedronate group and by 37% in the placebo group. Bone resorption typically increases during the first year after a stroke in both men and women, studies have shown.

Patients in the current study were advised to take risedronate with water 30–60 minutes before breakfast and not to take any other drugs that could affect bone or calcium metabolism. Patients were asked to return pills not taken, which were counted to check adherence to therapy. A single physician who was blinded to treatment assignment did the follow-up assessments of all patients, evaluating them every 4 weeks for falls or possible hip fractures and performing hematologic and biochemical tests.

Six patients in the risedronate group and seven in the placebo group dropped out of the study or were lost to follow-up, illness, or death.

The bisphosphonate risedronate significantly reduced the risk of hip fracture in elderly men with a history of stroke, in the first randomized, double-blind study on this topic.

Risedronate sodium, an inhibitor of bone resorption, previously was shown to decrease the risk of nonvertebral fractures in postmenopausal women with osteoporosis and of hip fractures in women who had a stroke.

The current study randomized 280 consecutive ambulatory men aged 65 years or older with a previous stroke to a daily dosage of 2.5 mg risedronate or placebo for 18 months. By the study's end, 10 patients in the placebo group and 2 in the risedronate group had sustained hip fractures, representing an 80% reduction in risk of fracture in the risedronate group, reported Dr. Yoshihiro Sato of Mitate Hospital, Tagawa, Japan, and his associates (Arch. Intern. Med. 2005;165:1743–8).

The investigators estimated that 16 elderly men who had previous strokes would need to be treated with risedronate to prevent one hip fracture.

All of the hip fractures were on the patient's hemiplegic side. In addition to hip fractures, wrist or ankle fractures occurred in two patients in the risedronate group, and six patients in the placebo group sustained other fractures—two at the proximal femur, two at the ribs, one at the proximal humerus, and one at the pelvis.

Bone mineral density on the hemiplegic side increased by 2.5% in men in the risedronate group, compared with baseline measurements, but decreased by 3.5% in men in the placebo group, compared with baseline, a significant difference.

On the nonhemiplegic side, bone density increased by more than 3% in the risedronate group and decreased by 2% in the placebo group. Bone density was significantly lower on the hemiplegic side in both groups. A key marker of bone resorption—urinary deoxypyridinoline—decreased by 59% in the risedronate group and by 37% in the placebo group. Bone resorption typically increases during the first year after a stroke in both men and women, studies have shown.

Patients in the current study were advised to take risedronate with water 30–60 minutes before breakfast and not to take any other drugs that could affect bone or calcium metabolism. Patients were asked to return pills not taken, which were counted to check adherence to therapy. A single physician who was blinded to treatment assignment did the follow-up assessments of all patients, evaluating them every 4 weeks for falls or possible hip fractures and performing hematologic and biochemical tests.

Six patients in the risedronate group and seven in the placebo group dropped out of the study or were lost to follow-up, illness, or death.

The bisphosphonate risedronate significantly reduced the risk of hip fracture in elderly men with a history of stroke, in the first randomized, double-blind study on this topic.

Risedronate sodium, an inhibitor of bone resorption, previously was shown to decrease the risk of nonvertebral fractures in postmenopausal women with osteoporosis and of hip fractures in women who had a stroke.

The current study randomized 280 consecutive ambulatory men aged 65 years or older with a previous stroke to a daily dosage of 2.5 mg risedronate or placebo for 18 months. By the study's end, 10 patients in the placebo group and 2 in the risedronate group had sustained hip fractures, representing an 80% reduction in risk of fracture in the risedronate group, reported Dr. Yoshihiro Sato of Mitate Hospital, Tagawa, Japan, and his associates (Arch. Intern. Med. 2005;165:1743–8).

The investigators estimated that 16 elderly men who had previous strokes would need to be treated with risedronate to prevent one hip fracture.

All of the hip fractures were on the patient's hemiplegic side. In addition to hip fractures, wrist or ankle fractures occurred in two patients in the risedronate group, and six patients in the placebo group sustained other fractures—two at the proximal femur, two at the ribs, one at the proximal humerus, and one at the pelvis.

Bone mineral density on the hemiplegic side increased by 2.5% in men in the risedronate group, compared with baseline measurements, but decreased by 3.5% in men in the placebo group, compared with baseline, a significant difference.

On the nonhemiplegic side, bone density increased by more than 3% in the risedronate group and decreased by 2% in the placebo group. Bone density was significantly lower on the hemiplegic side in both groups. A key marker of bone resorption—urinary deoxypyridinoline—decreased by 59% in the risedronate group and by 37% in the placebo group. Bone resorption typically increases during the first year after a stroke in both men and women, studies have shown.

Patients in the current study were advised to take risedronate with water 30–60 minutes before breakfast and not to take any other drugs that could affect bone or calcium metabolism. Patients were asked to return pills not taken, which were counted to check adherence to therapy. A single physician who was blinded to treatment assignment did the follow-up assessments of all patients, evaluating them every 4 weeks for falls or possible hip fractures and performing hematologic and biochemical tests.

Six patients in the risedronate group and seven in the placebo group dropped out of the study or were lost to follow-up, illness, or death.

SAN FRANCISCO — An increase in community-acquired methicillin-resistant Staphylococcus aureus over the past 5 years was accompanied by an increase in myositis and pyomyositis in children at one hospital, reported Dr. Pia S. Pannaraj.

Until recently, infective pyomyositis primarily was a tropical disease and affected only 1 in every 300,000–400,000 U.S. hospital admissions. Published reports of acute bacterial myositis were less common than pyomyositis and mainly described disease in adults, not children. Acute bacterial myositis moves beyond distinct abscesses within the muscle to extend inflammation through one or more muscle groups.

A review of records at Texas Children's Hospital, Houston, for the 5-year period 2000–2004 found 96 cases of infective bacterial myositis in children who had no underlying condition. S. aureus caused 66 of these infections, she said at the annual meeting of the Infectious Diseases Society of America.

“It's important to know that myositis … is not as rare as people once thought. At least, we're seeing more cases of it. It correlates with the increase in Staph aureus” acquired in the community, Dr. Pannaraj of Baylor College of Medicine, Houston, said in an interview at her poster presentation.

In all, 38 (58%) of the 66 cases due to S. aureus were community-acquired methicillin-resistant S. aureus (MRSA), and 28 (42%) were due to community-acquired methicillin-sensitive S. aureus (MSSA).

The frequency of infective bacterial myositis cases increased from 10 cases in 2000 to 36 cases in 2004 at Dr. Pannaraj's institution. Most of the increase came from community-acquired MRSA. Frequencies of other isolates did not change significantly over time.

Children with muscular disease due to MRSA had a more severe course of illness than did children with MSSA. Those with MRSA had longer fevers, larger abscesses, higher white blood cell counts, higher C-reactive protein levels, higher erythrocyte sedimentation rates, greater need for muscle drainage, and greater sequelae necessitating physical therapy.

“There's definitely something there in terms of the virulence factors” with MRSA, Dr. Pannaraj said. “We're trying to figure out what that is.”

Other etiologies of the muscular infections were group A Streptococcus in six patients, group C Streptococcus in one patient, and Haemophilus influenzae in one patient. Bacteria were not isolated in the rest of the cases.

Bacterial etiologies did not differ significantly between cases of myositis or pyomyositis.

SAN FRANCISCO — An increase in community-acquired methicillin-resistant Staphylococcus aureus over the past 5 years was accompanied by an increase in myositis and pyomyositis in children at one hospital, reported Dr. Pia S. Pannaraj.

Until recently, infective pyomyositis primarily was a tropical disease and affected only 1 in every 300,000–400,000 U.S. hospital admissions. Published reports of acute bacterial myositis were less common than pyomyositis and mainly described disease in adults, not children. Acute bacterial myositis moves beyond distinct abscesses within the muscle to extend inflammation through one or more muscle groups.

A review of records at Texas Children's Hospital, Houston, for the 5-year period 2000–2004 found 96 cases of infective bacterial myositis in children who had no underlying condition. S. aureus caused 66 of these infections, she said at the annual meeting of the Infectious Diseases Society of America.

“It's important to know that myositis … is not as rare as people once thought. At least, we're seeing more cases of it. It correlates with the increase in Staph aureus” acquired in the community, Dr. Pannaraj of Baylor College of Medicine, Houston, said in an interview at her poster presentation.

In all, 38 (58%) of the 66 cases due to S. aureus were community-acquired methicillin-resistant S. aureus (MRSA), and 28 (42%) were due to community-acquired methicillin-sensitive S. aureus (MSSA).

The frequency of infective bacterial myositis cases increased from 10 cases in 2000 to 36 cases in 2004 at Dr. Pannaraj's institution. Most of the increase came from community-acquired MRSA. Frequencies of other isolates did not change significantly over time.

Children with muscular disease due to MRSA had a more severe course of illness than did children with MSSA. Those with MRSA had longer fevers, larger abscesses, higher white blood cell counts, higher C-reactive protein levels, higher erythrocyte sedimentation rates, greater need for muscle drainage, and greater sequelae necessitating physical therapy.

“There's definitely something there in terms of the virulence factors” with MRSA, Dr. Pannaraj said. “We're trying to figure out what that is.”

Other etiologies of the muscular infections were group A Streptococcus in six patients, group C Streptococcus in one patient, and Haemophilus influenzae in one patient. Bacteria were not isolated in the rest of the cases.

Bacterial etiologies did not differ significantly between cases of myositis or pyomyositis.

SAN FRANCISCO — An increase in community-acquired methicillin-resistant Staphylococcus aureus over the past 5 years was accompanied by an increase in myositis and pyomyositis in children at one hospital, reported Dr. Pia S. Pannaraj.

Until recently, infective pyomyositis primarily was a tropical disease and affected only 1 in every 300,000–400,000 U.S. hospital admissions. Published reports of acute bacterial myositis were less common than pyomyositis and mainly described disease in adults, not children. Acute bacterial myositis moves beyond distinct abscesses within the muscle to extend inflammation through one or more muscle groups.

A review of records at Texas Children's Hospital, Houston, for the 5-year period 2000–2004 found 96 cases of infective bacterial myositis in children who had no underlying condition. S. aureus caused 66 of these infections, she said at the annual meeting of the Infectious Diseases Society of America.

“It's important to know that myositis … is not as rare as people once thought. At least, we're seeing more cases of it. It correlates with the increase in Staph aureus” acquired in the community, Dr. Pannaraj of Baylor College of Medicine, Houston, said in an interview at her poster presentation.

In all, 38 (58%) of the 66 cases due to S. aureus were community-acquired methicillin-resistant S. aureus (MRSA), and 28 (42%) were due to community-acquired methicillin-sensitive S. aureus (MSSA).

The frequency of infective bacterial myositis cases increased from 10 cases in 2000 to 36 cases in 2004 at Dr. Pannaraj's institution. Most of the increase came from community-acquired MRSA. Frequencies of other isolates did not change significantly over time.

Children with muscular disease due to MRSA had a more severe course of illness than did children with MSSA. Those with MRSA had longer fevers, larger abscesses, higher white blood cell counts, higher C-reactive protein levels, higher erythrocyte sedimentation rates, greater need for muscle drainage, and greater sequelae necessitating physical therapy.

“There's definitely something there in terms of the virulence factors” with MRSA, Dr. Pannaraj said. “We're trying to figure out what that is.”

Other etiologies of the muscular infections were group A Streptococcus in six patients, group C Streptococcus in one patient, and Haemophilus influenzae in one patient. Bacteria were not isolated in the rest of the cases.

Bacterial etiologies did not differ significantly between cases of myositis or pyomyositis.

SAN FRANCISCO — The incidence of pediatric pneumococcal parapneumonic empyema doubled in Utah and surrounding areas since introduction of the pneumococcal conjugate vaccine, Carrie L. Byington, M.D., said in a poster presentation at the annual meeting of the Infectious Diseases Society of America.

Serotypes of Streptococcus pneumoniae not covered by the vaccine caused most of the recent cases.

The activity of bacterial serotypes varies by geographical region. In the past decade, Utah has had one of the highest rates of pneumococcal parapneumonic empyema (PPE) in children due to S. pneumoniae serotype 1, which the vaccine does not cover, said Dr. Byington of the University of Utah, Salt Lake City, and her associates.

A search of the Intermountain Health Care data warehouse found 776 cases of pediatric PPE between March 1996 and June 2005, 62% of which were treated at Primary Children's Medical Center, Salt Lake City.

In the period 1996–2000, before introduction of 7-valent pneumococcal conjugate vaccine (PCV7 or Prevnar), the center saw 38 cases per year, compared with 72 cases annually between 2001 and 2004, a significant difference.

Among 295 cases of culture-confirmed invasive pneumococcal disease in children at the center, 74 were PPE, representing 18% of invasive pneumococcal disease in the prevaccine years and 32% since the vaccine.

The investigators retrieved and serotyped pleural and fluid isolates of S. pneumoniae from the 74 cases.

The proportion of PPE due to serotypes covered in the vaccine decreased from 37% (9 of 24 cases) in the prevaccine era to 14% (7 of 50 cases) in more recent years.

Serotype 1 was the most common cause of PPE due to nonvaccine serotypes in both time periods, but disease due to other nonvaccine serotypes has become more common.

Serotype 1 caused 11 (46%) of 24 PPE cases in the earlier period and 17 (34%) of 50 cases since the vaccine, she said.

Other nonvaccine serotypes caused only four cases (16%) of PPE in the prevaccine years but 26 cases (52%) of PPE in the postvaccine years.

The pneumococcal vaccine may need to be broadened to cover some of these serotypes, Dr. Byington suggested in an interview.

Clinical records for the 74 PPE cases reported concomitant bacteremia in 28 children, lung abscesses in 3, and peritonitis in 1 child.

Four children developed hemolytic uremic syndrome, and 38 required intensive care, primarily to manage respiratory failure or following surgical decortication.

Four children died, two of them from PPE due to a nonvaccine serotype.

SAN FRANCISCO — The incidence of pediatric pneumococcal parapneumonic empyema doubled in Utah and surrounding areas since introduction of the pneumococcal conjugate vaccine, Carrie L. Byington, M.D., said in a poster presentation at the annual meeting of the Infectious Diseases Society of America.

Serotypes of Streptococcus pneumoniae not covered by the vaccine caused most of the recent cases.

The activity of bacterial serotypes varies by geographical region. In the past decade, Utah has had one of the highest rates of pneumococcal parapneumonic empyema (PPE) in children due to S. pneumoniae serotype 1, which the vaccine does not cover, said Dr. Byington of the University of Utah, Salt Lake City, and her associates.

A search of the Intermountain Health Care data warehouse found 776 cases of pediatric PPE between March 1996 and June 2005, 62% of which were treated at Primary Children's Medical Center, Salt Lake City.

In the period 1996–2000, before introduction of 7-valent pneumococcal conjugate vaccine (PCV7 or Prevnar), the center saw 38 cases per year, compared with 72 cases annually between 2001 and 2004, a significant difference.

Among 295 cases of culture-confirmed invasive pneumococcal disease in children at the center, 74 were PPE, representing 18% of invasive pneumococcal disease in the prevaccine years and 32% since the vaccine.

The investigators retrieved and serotyped pleural and fluid isolates of S. pneumoniae from the 74 cases.

The proportion of PPE due to serotypes covered in the vaccine decreased from 37% (9 of 24 cases) in the prevaccine era to 14% (7 of 50 cases) in more recent years.

Serotype 1 was the most common cause of PPE due to nonvaccine serotypes in both time periods, but disease due to other nonvaccine serotypes has become more common.

Serotype 1 caused 11 (46%) of 24 PPE cases in the earlier period and 17 (34%) of 50 cases since the vaccine, she said.

Other nonvaccine serotypes caused only four cases (16%) of PPE in the prevaccine years but 26 cases (52%) of PPE in the postvaccine years.

The pneumococcal vaccine may need to be broadened to cover some of these serotypes, Dr. Byington suggested in an interview.

Clinical records for the 74 PPE cases reported concomitant bacteremia in 28 children, lung abscesses in 3, and peritonitis in 1 child.

Four children developed hemolytic uremic syndrome, and 38 required intensive care, primarily to manage respiratory failure or following surgical decortication.

Four children died, two of them from PPE due to a nonvaccine serotype.

SAN FRANCISCO — The incidence of pediatric pneumococcal parapneumonic empyema doubled in Utah and surrounding areas since introduction of the pneumococcal conjugate vaccine, Carrie L. Byington, M.D., said in a poster presentation at the annual meeting of the Infectious Diseases Society of America.

Serotypes of Streptococcus pneumoniae not covered by the vaccine caused most of the recent cases.

The activity of bacterial serotypes varies by geographical region. In the past decade, Utah has had one of the highest rates of pneumococcal parapneumonic empyema (PPE) in children due to S. pneumoniae serotype 1, which the vaccine does not cover, said Dr. Byington of the University of Utah, Salt Lake City, and her associates.

A search of the Intermountain Health Care data warehouse found 776 cases of pediatric PPE between March 1996 and June 2005, 62% of which were treated at Primary Children's Medical Center, Salt Lake City.

In the period 1996–2000, before introduction of 7-valent pneumococcal conjugate vaccine (PCV7 or Prevnar), the center saw 38 cases per year, compared with 72 cases annually between 2001 and 2004, a significant difference.

Among 295 cases of culture-confirmed invasive pneumococcal disease in children at the center, 74 were PPE, representing 18% of invasive pneumococcal disease in the prevaccine years and 32% since the vaccine.

The investigators retrieved and serotyped pleural and fluid isolates of S. pneumoniae from the 74 cases.

The proportion of PPE due to serotypes covered in the vaccine decreased from 37% (9 of 24 cases) in the prevaccine era to 14% (7 of 50 cases) in more recent years.

Serotype 1 was the most common cause of PPE due to nonvaccine serotypes in both time periods, but disease due to other nonvaccine serotypes has become more common.

Serotype 1 caused 11 (46%) of 24 PPE cases in the earlier period and 17 (34%) of 50 cases since the vaccine, she said.

Other nonvaccine serotypes caused only four cases (16%) of PPE in the prevaccine years but 26 cases (52%) of PPE in the postvaccine years.

The pneumococcal vaccine may need to be broadened to cover some of these serotypes, Dr. Byington suggested in an interview.

Clinical records for the 74 PPE cases reported concomitant bacteremia in 28 children, lung abscesses in 3, and peritonitis in 1 child.

Four children developed hemolytic uremic syndrome, and 38 required intensive care, primarily to manage respiratory failure or following surgical decortication.

Four children died, two of them from PPE due to a nonvaccine serotype.

SAN FRANCISCO — An increase in community-acquired methicillin-resistant Staphylococcus aureus over the past 5 years was accompanied by an increase in myositis and pyomyositis in children at one hospital, reported Dr. Pia S. Pannaraj.

Until recently, infective pyomyositis primarily was a tropical disease and affected only 1 in every 300,000-400,000 U.S. hospital admissions. Published reports of acute bacterial myositis were less common than pyomyositis and mainly described disease in adults, not children. Acute bacterial myositis moves beyond distinct abscesses within the muscle to extend inflammation through one or more muscle groups.

Records at Texas Children's Hospital, Houston, for the 5-year period 2000-2004 indicated 96 cases of infective bacterial myositis in children who had no underlying condition. S. aureus caused 66 of these infections, she said at the annual meeting of the Infectious Diseases Society of America.

“It's important to know that myositis … is not as rare as people once thought. At least, we're seeing more cases of it. It correlates with the increase in Staph aureus” acquired in the community, Dr. Pannaraj of Baylor College of Medicine, Houston, said in an interview at her poster presentation.

In all, 38 (58%) of the 66 cases due to S. aureus were community-acquired methicillin-resistant S. aureus (MRSA), and 28 (42%) were due to community-acquired methicillin-sensitive S. aureus (MSSA).

The frequency of infective bacterial myositis cases increased from 10 cases in 2000 to 36 cases in 2004 at Dr. Pannaraj's institution. Most of the increase came from community-acquired MRSA. Frequencies of other isolates did not change significantly over time.

Children with muscular disease due to MRSA had a more severe course of illness than children with MSSA.

SAN FRANCISCO — An increase in community-acquired methicillin-resistant Staphylococcus aureus over the past 5 years was accompanied by an increase in myositis and pyomyositis in children at one hospital, reported Dr. Pia S. Pannaraj.

Until recently, infective pyomyositis primarily was a tropical disease and affected only 1 in every 300,000-400,000 U.S. hospital admissions. Published reports of acute bacterial myositis were less common than pyomyositis and mainly described disease in adults, not children. Acute bacterial myositis moves beyond distinct abscesses within the muscle to extend inflammation through one or more muscle groups.

Records at Texas Children's Hospital, Houston, for the 5-year period 2000-2004 indicated 96 cases of infective bacterial myositis in children who had no underlying condition. S. aureus caused 66 of these infections, she said at the annual meeting of the Infectious Diseases Society of America.

“It's important to know that myositis … is not as rare as people once thought. At least, we're seeing more cases of it. It correlates with the increase in Staph aureus” acquired in the community, Dr. Pannaraj of Baylor College of Medicine, Houston, said in an interview at her poster presentation.

In all, 38 (58%) of the 66 cases due to S. aureus were community-acquired methicillin-resistant S. aureus (MRSA), and 28 (42%) were due to community-acquired methicillin-sensitive S. aureus (MSSA).

The frequency of infective bacterial myositis cases increased from 10 cases in 2000 to 36 cases in 2004 at Dr. Pannaraj's institution. Most of the increase came from community-acquired MRSA. Frequencies of other isolates did not change significantly over time.

Children with muscular disease due to MRSA had a more severe course of illness than children with MSSA.

SAN FRANCISCO — An increase in community-acquired methicillin-resistant Staphylococcus aureus over the past 5 years was accompanied by an increase in myositis and pyomyositis in children at one hospital, reported Dr. Pia S. Pannaraj.

Until recently, infective pyomyositis primarily was a tropical disease and affected only 1 in every 300,000-400,000 U.S. hospital admissions. Published reports of acute bacterial myositis were less common than pyomyositis and mainly described disease in adults, not children. Acute bacterial myositis moves beyond distinct abscesses within the muscle to extend inflammation through one or more muscle groups.

Records at Texas Children's Hospital, Houston, for the 5-year period 2000-2004 indicated 96 cases of infective bacterial myositis in children who had no underlying condition. S. aureus caused 66 of these infections, she said at the annual meeting of the Infectious Diseases Society of America.

“It's important to know that myositis … is not as rare as people once thought. At least, we're seeing more cases of it. It correlates with the increase in Staph aureus” acquired in the community, Dr. Pannaraj of Baylor College of Medicine, Houston, said in an interview at her poster presentation.

In all, 38 (58%) of the 66 cases due to S. aureus were community-acquired methicillin-resistant S. aureus (MRSA), and 28 (42%) were due to community-acquired methicillin-sensitive S. aureus (MSSA).

The frequency of infective bacterial myositis cases increased from 10 cases in 2000 to 36 cases in 2004 at Dr. Pannaraj's institution. Most of the increase came from community-acquired MRSA. Frequencies of other isolates did not change significantly over time.

Children with muscular disease due to MRSA had a more severe course of illness than children with MSSA.

SAN FRANCISCO — Low levels of immunity to pertussis in adolescent Hispanic mothers and their newborns may help explain their overrepresentation in pertussis cases and in deaths from the disease, Dr. C. Mary Healy said in a poster presentation at the annual meeting of the Infectious Diseases Society of America.

A study of pertussis toxin-specific IgG concentrations found low concentrations in umbilical cord blood from 220 consecutive term singletons born to Hispanic women, with the lowest geometric mean concentrations in infants born to adolescent mothers.

The low antibody levels likely reflect waning of vaccine- induced or natural immunity, she said.

Dr. Healy of Baylor College of Medicine, Houston, and her associates also compared pertussis toxin-specific IgG concentrations in blood samples from 55 mothers and their infants and found a ratio indicating efficient transfer of antibodies across the placenta. That suggests that one reason infants may be so susceptible to acquiring life-threatening pertussis in the first 4 months of life is because their mothers supply them with few antibodies.

“If you have high levels in the mothers, for example through vaccination, then the likelihood is that the antibodies will transmit very efficiently to infants and, hopefully, protect them at that most vulnerable period in the first few months of life before they begin their primary series of immunizations,” she said in an interview at the meeting.

Currently there are no recommendations to vaccinate pregnant women against pertussis. Discussions are underway about whether to give pregnant women one of two relatively new acellular pertussis vaccines licensed for use in adolescents, Dr. Healy said.

“Hispanic women, especially adolescents, should be immunized with newly licensed acellular pertussis vaccine to prevent pertussis in themselves and life-threatening disease in their infants,” she concluded in her poster.

Pertussis incidence is increasing among infants younger than 4 months of age, too young to have completed the DTaP primary vaccination series at ages 2, 4, and 6 months. The annual incidence of pertussis in the United States increased fivefold since 1980 despite childhood immunization rates above 80%, mainly due to disease in the youngest infants, according to federal statistics.

Pertussis incidence was 74% higher in Hispanic infants than in infants of other ethnicities throughout the 1990s despite comparable childhood immunization rates. Pertussis was reported in 68/100,000 Hispanic infants, compared with 39/100,000 non-Hispanic infants.

Among infant deaths from pertussis between 1990 and 2000, 36%-41% who died were Hispanic infants. Hispanics made up 19% of children in 2003, according to U.S. Census data.

The reasons for this ethnic difference in pertussis are unclear and require further study, Dr. Healy said.

Mothers of the 220 infants in the study had a mean age of 26 years (ranging from 14 to 42 years), and they reported a mean of 8 years of education. Thirty percent did not begin prenatal care until the second trimester and 28% had fewer than nine prenatal care visits, which the investigators considered to be delayed prenatal care and inadequate prenatal care, respectively.

For the 55 matched mother-infant pairs, investigators stratified them by age groups of Hispanic mothers in Texas: 10% aged 10-19 years; 30% aged 20-24 years; 30% aged 25-29 years; and 30% aged 30 years or older.

The investigators quantified pertussis antibody levels using enzyme-linked immunosorbent assay (ELISA). The geometric mean concentration of pertussis toxin-specific IgG was 8.45 ELISA U/mL for all infants and 4.63 ELISA U/mL for infants of adolescent mothers, which was a significant difference, Dr. Healy said.

SAN FRANCISCO — Low levels of immunity to pertussis in adolescent Hispanic mothers and their newborns may help explain their overrepresentation in pertussis cases and in deaths from the disease, Dr. C. Mary Healy said in a poster presentation at the annual meeting of the Infectious Diseases Society of America.

A study of pertussis toxin-specific IgG concentrations found low concentrations in umbilical cord blood from 220 consecutive term singletons born to Hispanic women, with the lowest geometric mean concentrations in infants born to adolescent mothers.

The low antibody levels likely reflect waning of vaccine- induced or natural immunity, she said.

Dr. Healy of Baylor College of Medicine, Houston, and her associates also compared pertussis toxin-specific IgG concentrations in blood samples from 55 mothers and their infants and found a ratio indicating efficient transfer of antibodies across the placenta. That suggests that one reason infants may be so susceptible to acquiring life-threatening pertussis in the first 4 months of life is because their mothers supply them with few antibodies.

“If you have high levels in the mothers, for example through vaccination, then the likelihood is that the antibodies will transmit very efficiently to infants and, hopefully, protect them at that most vulnerable period in the first few months of life before they begin their primary series of immunizations,” she said in an interview at the meeting.

Currently there are no recommendations to vaccinate pregnant women against pertussis. Discussions are underway about whether to give pregnant women one of two relatively new acellular pertussis vaccines licensed for use in adolescents, Dr. Healy said.

“Hispanic women, especially adolescents, should be immunized with newly licensed acellular pertussis vaccine to prevent pertussis in themselves and life-threatening disease in their infants,” she concluded in her poster.

Pertussis incidence is increasing among infants younger than 4 months of age, too young to have completed the DTaP primary vaccination series at ages 2, 4, and 6 months. The annual incidence of pertussis in the United States increased fivefold since 1980 despite childhood immunization rates above 80%, mainly due to disease in the youngest infants, according to federal statistics.

Pertussis incidence was 74% higher in Hispanic infants than in infants of other ethnicities throughout the 1990s despite comparable childhood immunization rates. Pertussis was reported in 68/100,000 Hispanic infants, compared with 39/100,000 non-Hispanic infants.

Among infant deaths from pertussis between 1990 and 2000, 36%-41% who died were Hispanic infants. Hispanics made up 19% of children in 2003, according to U.S. Census data.

The reasons for this ethnic difference in pertussis are unclear and require further study, Dr. Healy said.

Mothers of the 220 infants in the study had a mean age of 26 years (ranging from 14 to 42 years), and they reported a mean of 8 years of education. Thirty percent did not begin prenatal care until the second trimester and 28% had fewer than nine prenatal care visits, which the investigators considered to be delayed prenatal care and inadequate prenatal care, respectively.

For the 55 matched mother-infant pairs, investigators stratified them by age groups of Hispanic mothers in Texas: 10% aged 10-19 years; 30% aged 20-24 years; 30% aged 25-29 years; and 30% aged 30 years or older.

The investigators quantified pertussis antibody levels using enzyme-linked immunosorbent assay (ELISA). The geometric mean concentration of pertussis toxin-specific IgG was 8.45 ELISA U/mL for all infants and 4.63 ELISA U/mL for infants of adolescent mothers, which was a significant difference, Dr. Healy said.

SAN FRANCISCO — Low levels of immunity to pertussis in adolescent Hispanic mothers and their newborns may help explain their overrepresentation in pertussis cases and in deaths from the disease, Dr. C. Mary Healy said in a poster presentation at the annual meeting of the Infectious Diseases Society of America.

A study of pertussis toxin-specific IgG concentrations found low concentrations in umbilical cord blood from 220 consecutive term singletons born to Hispanic women, with the lowest geometric mean concentrations in infants born to adolescent mothers.

The low antibody levels likely reflect waning of vaccine- induced or natural immunity, she said.

Dr. Healy of Baylor College of Medicine, Houston, and her associates also compared pertussis toxin-specific IgG concentrations in blood samples from 55 mothers and their infants and found a ratio indicating efficient transfer of antibodies across the placenta. That suggests that one reason infants may be so susceptible to acquiring life-threatening pertussis in the first 4 months of life is because their mothers supply them with few antibodies.

“If you have high levels in the mothers, for example through vaccination, then the likelihood is that the antibodies will transmit very efficiently to infants and, hopefully, protect them at that most vulnerable period in the first few months of life before they begin their primary series of immunizations,” she said in an interview at the meeting.

Currently there are no recommendations to vaccinate pregnant women against pertussis. Discussions are underway about whether to give pregnant women one of two relatively new acellular pertussis vaccines licensed for use in adolescents, Dr. Healy said.

“Hispanic women, especially adolescents, should be immunized with newly licensed acellular pertussis vaccine to prevent pertussis in themselves and life-threatening disease in their infants,” she concluded in her poster.

Pertussis incidence is increasing among infants younger than 4 months of age, too young to have completed the DTaP primary vaccination series at ages 2, 4, and 6 months. The annual incidence of pertussis in the United States increased fivefold since 1980 despite childhood immunization rates above 80%, mainly due to disease in the youngest infants, according to federal statistics.

Pertussis incidence was 74% higher in Hispanic infants than in infants of other ethnicities throughout the 1990s despite comparable childhood immunization rates. Pertussis was reported in 68/100,000 Hispanic infants, compared with 39/100,000 non-Hispanic infants.

Among infant deaths from pertussis between 1990 and 2000, 36%-41% who died were Hispanic infants. Hispanics made up 19% of children in 2003, according to U.S. Census data.

The reasons for this ethnic difference in pertussis are unclear and require further study, Dr. Healy said.

Mothers of the 220 infants in the study had a mean age of 26 years (ranging from 14 to 42 years), and they reported a mean of 8 years of education. Thirty percent did not begin prenatal care until the second trimester and 28% had fewer than nine prenatal care visits, which the investigators considered to be delayed prenatal care and inadequate prenatal care, respectively.

For the 55 matched mother-infant pairs, investigators stratified them by age groups of Hispanic mothers in Texas: 10% aged 10-19 years; 30% aged 20-24 years; 30% aged 25-29 years; and 30% aged 30 years or older.

The investigators quantified pertussis antibody levels using enzyme-linked immunosorbent assay (ELISA). The geometric mean concentration of pertussis toxin-specific IgG was 8.45 ELISA U/mL for all infants and 4.63 ELISA U/mL for infants of adolescent mothers, which was a significant difference, Dr. Healy said.