ICAAC 2015

SAN DIEGO – The evidence-based treatment of diabetic foot osteomyelitis has jumped up to the next level as a result of two recent randomized clinical trials, the first-ever to address a couple of key contentious issues, experts agreed recently at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Dr. Eric Senneville presented highlights of the two randomized trials, one of which examined the optimal duration of antibiotic therapy in patients with nonsurgically treated diabetic foot osteomyelitis. The other study was the first-ever head-to-head randomized comparison of antibiotics versus conservative surgery.

He also touched on another new development in the treatment of diabetic foot osteomyelitis: surgically implanted topical antibiotics, which show promise in specific situations.

Dr. Senneville of Gustave Dron Hospital in Tourcoing, France, was senior investigator in the prospective, randomized, multicenter comparison of outcomes with 6 versus 12 weeks of open-label antibiotic therapy in 40 patients. All participants had bone biopsy–confirmed osteomyelitis with no ischemia, and none underwent any bone resection during the treatment period.

The 6-week regimen proved to be the winning strategy. It resulted in remission in 12 of 20 patients, a result not significantly different from the 14 of 20 remission rate with 12 weeks of treatment. Moreover, significant drug-related gastrointestinal side effects occurred in only three patients in the 6-week-treatment arm, compared with nine patients treated for 12 weeks. There was no difference between the two groups in rates of relapse, need for later bone resection, or spread of osteomyelitis (Diabetes Care. 2015 Feb;38[2]:302-7).

In the surgery-versus-antibiotics trial, investigators at the University of Madrid prospectively randomized 52 patients with diabetic foot osteomyelitis to 90 days of antibiotics with no surgery or to conservative surgery with 10 days of postoperative antibiotics. Dr. Senneville emphasized that this was a select patient population and at this point the results apply only to similar groups; that is, all participants had forefoot osteomyelitis without ischemia or necrosis. There were six dropouts: one in the medically treated arm and five in the surgical group.

The key finding: At 12 weeks of follow-up, main outcomes were similar in the two groups. Eighteen of 24 patients in the medically managed group achieved primary healing, for a 75% cure rate, not significantly different from the 86% rate – 19 of 22 patients cured – in the surgical group. Median time to healing was 7 weeks with antibiotics only and similar at 6 weeks with surgery. Four patients in the antibiotic group worsened and required surgery, while three in the surgery group required reoperation (Diabetes Care. 2014 Mar;37[3]:789-95).

Dr. Senneville noted that the reulceration rate was 10% in the medically treated group and twice that in the surgical group. A higher reulceration rate has also been seen in retrospective studies. It’s thought to result from what has been termed pressure transfer syndrome, which is particularly common among patients who undergo surgery on the first metatarsal head.

Dr. Edgar J. G. Peters of VU Academic Medical Center, Amsterdam, commented that the Spanish randomized trial of antibiotics versus surgery in diabetic osteomyelitis was sorely needed. All too often, he observed, earlier retrospective studies conducted by surgeons concluded that surgery was best, while those carried out by infectious disease specialists found the antiobiotics-only strategy to be superior. Skeptical unbiased physicians were left in the dark.

He noted that this important clinical trial as well as the major randomized trial of 6 versus 12 weeks of antibiotic therapy were published too late for inclusion in the recently released systematic review of treatments for diabetic foot infections conducted by the International Working Group on the Diabetic Foot (Diabetes Metab Res Rev. 2015 Sep 7. doi: 10.1002/dmrr.2706), for which both Dr. Peters and Dr. Senneville were coauthors.

Turning to the novel use of topical antibiotics in patients with diabetic foot osteomyelitis, Dr. Senneville described several potential advantages, including the attainment of optimal drug levels in the presence of peripheral vascular disease and in avascular spaces.

The idea is to place antibiotic-impregnated beads or bone cement in the space created by debridement and removal of infected bone. By filling the dead space, the antibiotic-impregnated cement may control the infection simmering in any areas of infected bone unintentionally left behind, while also reducing the risk of pressure transfer syndrome. The use of antibiotic-eluting bone cement has recently been shown to reduce the need for reoperation (J Foot Ankle Surg. 2015 Jul-Aug;54[4]:536-40).

Dr. Senneville reported serving on speakers’ bureaus for Novartis and Merck and as an advisor to Pfizer.

SAN DIEGO – The evidence-based treatment of diabetic foot osteomyelitis has jumped up to the next level as a result of two recent randomized clinical trials, the first-ever to address a couple of key contentious issues, experts agreed recently at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Dr. Eric Senneville presented highlights of the two randomized trials, one of which examined the optimal duration of antibiotic therapy in patients with nonsurgically treated diabetic foot osteomyelitis. The other study was the first-ever head-to-head randomized comparison of antibiotics versus conservative surgery.

He also touched on another new development in the treatment of diabetic foot osteomyelitis: surgically implanted topical antibiotics, which show promise in specific situations.

Dr. Senneville of Gustave Dron Hospital in Tourcoing, France, was senior investigator in the prospective, randomized, multicenter comparison of outcomes with 6 versus 12 weeks of open-label antibiotic therapy in 40 patients. All participants had bone biopsy–confirmed osteomyelitis with no ischemia, and none underwent any bone resection during the treatment period.

The 6-week regimen proved to be the winning strategy. It resulted in remission in 12 of 20 patients, a result not significantly different from the 14 of 20 remission rate with 12 weeks of treatment. Moreover, significant drug-related gastrointestinal side effects occurred in only three patients in the 6-week-treatment arm, compared with nine patients treated for 12 weeks. There was no difference between the two groups in rates of relapse, need for later bone resection, or spread of osteomyelitis (Diabetes Care. 2015 Feb;38[2]:302-7).

In the surgery-versus-antibiotics trial, investigators at the University of Madrid prospectively randomized 52 patients with diabetic foot osteomyelitis to 90 days of antibiotics with no surgery or to conservative surgery with 10 days of postoperative antibiotics. Dr. Senneville emphasized that this was a select patient population and at this point the results apply only to similar groups; that is, all participants had forefoot osteomyelitis without ischemia or necrosis. There were six dropouts: one in the medically treated arm and five in the surgical group.

The key finding: At 12 weeks of follow-up, main outcomes were similar in the two groups. Eighteen of 24 patients in the medically managed group achieved primary healing, for a 75% cure rate, not significantly different from the 86% rate – 19 of 22 patients cured – in the surgical group. Median time to healing was 7 weeks with antibiotics only and similar at 6 weeks with surgery. Four patients in the antibiotic group worsened and required surgery, while three in the surgery group required reoperation (Diabetes Care. 2014 Mar;37[3]:789-95).

Dr. Senneville noted that the reulceration rate was 10% in the medically treated group and twice that in the surgical group. A higher reulceration rate has also been seen in retrospective studies. It’s thought to result from what has been termed pressure transfer syndrome, which is particularly common among patients who undergo surgery on the first metatarsal head.

Dr. Edgar J. G. Peters of VU Academic Medical Center, Amsterdam, commented that the Spanish randomized trial of antibiotics versus surgery in diabetic osteomyelitis was sorely needed. All too often, he observed, earlier retrospective studies conducted by surgeons concluded that surgery was best, while those carried out by infectious disease specialists found the antiobiotics-only strategy to be superior. Skeptical unbiased physicians were left in the dark.

He noted that this important clinical trial as well as the major randomized trial of 6 versus 12 weeks of antibiotic therapy were published too late for inclusion in the recently released systematic review of treatments for diabetic foot infections conducted by the International Working Group on the Diabetic Foot (Diabetes Metab Res Rev. 2015 Sep 7. doi: 10.1002/dmrr.2706), for which both Dr. Peters and Dr. Senneville were coauthors.

Turning to the novel use of topical antibiotics in patients with diabetic foot osteomyelitis, Dr. Senneville described several potential advantages, including the attainment of optimal drug levels in the presence of peripheral vascular disease and in avascular spaces.

The idea is to place antibiotic-impregnated beads or bone cement in the space created by debridement and removal of infected bone. By filling the dead space, the antibiotic-impregnated cement may control the infection simmering in any areas of infected bone unintentionally left behind, while also reducing the risk of pressure transfer syndrome. The use of antibiotic-eluting bone cement has recently been shown to reduce the need for reoperation (J Foot Ankle Surg. 2015 Jul-Aug;54[4]:536-40).

Dr. Senneville reported serving on speakers’ bureaus for Novartis and Merck and as an advisor to Pfizer.

SAN DIEGO – The evidence-based treatment of diabetic foot osteomyelitis has jumped up to the next level as a result of two recent randomized clinical trials, the first-ever to address a couple of key contentious issues, experts agreed recently at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Dr. Eric Senneville presented highlights of the two randomized trials, one of which examined the optimal duration of antibiotic therapy in patients with nonsurgically treated diabetic foot osteomyelitis. The other study was the first-ever head-to-head randomized comparison of antibiotics versus conservative surgery.

He also touched on another new development in the treatment of diabetic foot osteomyelitis: surgically implanted topical antibiotics, which show promise in specific situations.

Dr. Senneville of Gustave Dron Hospital in Tourcoing, France, was senior investigator in the prospective, randomized, multicenter comparison of outcomes with 6 versus 12 weeks of open-label antibiotic therapy in 40 patients. All participants had bone biopsy–confirmed osteomyelitis with no ischemia, and none underwent any bone resection during the treatment period.

The 6-week regimen proved to be the winning strategy. It resulted in remission in 12 of 20 patients, a result not significantly different from the 14 of 20 remission rate with 12 weeks of treatment. Moreover, significant drug-related gastrointestinal side effects occurred in only three patients in the 6-week-treatment arm, compared with nine patients treated for 12 weeks. There was no difference between the two groups in rates of relapse, need for later bone resection, or spread of osteomyelitis (Diabetes Care. 2015 Feb;38[2]:302-7).

In the surgery-versus-antibiotics trial, investigators at the University of Madrid prospectively randomized 52 patients with diabetic foot osteomyelitis to 90 days of antibiotics with no surgery or to conservative surgery with 10 days of postoperative antibiotics. Dr. Senneville emphasized that this was a select patient population and at this point the results apply only to similar groups; that is, all participants had forefoot osteomyelitis without ischemia or necrosis. There were six dropouts: one in the medically treated arm and five in the surgical group.

The key finding: At 12 weeks of follow-up, main outcomes were similar in the two groups. Eighteen of 24 patients in the medically managed group achieved primary healing, for a 75% cure rate, not significantly different from the 86% rate – 19 of 22 patients cured – in the surgical group. Median time to healing was 7 weeks with antibiotics only and similar at 6 weeks with surgery. Four patients in the antibiotic group worsened and required surgery, while three in the surgery group required reoperation (Diabetes Care. 2014 Mar;37[3]:789-95).

Dr. Senneville noted that the reulceration rate was 10% in the medically treated group and twice that in the surgical group. A higher reulceration rate has also been seen in retrospective studies. It’s thought to result from what has been termed pressure transfer syndrome, which is particularly common among patients who undergo surgery on the first metatarsal head.

Dr. Edgar J. G. Peters of VU Academic Medical Center, Amsterdam, commented that the Spanish randomized trial of antibiotics versus surgery in diabetic osteomyelitis was sorely needed. All too often, he observed, earlier retrospective studies conducted by surgeons concluded that surgery was best, while those carried out by infectious disease specialists found the antiobiotics-only strategy to be superior. Skeptical unbiased physicians were left in the dark.

He noted that this important clinical trial as well as the major randomized trial of 6 versus 12 weeks of antibiotic therapy were published too late for inclusion in the recently released systematic review of treatments for diabetic foot infections conducted by the International Working Group on the Diabetic Foot (Diabetes Metab Res Rev. 2015 Sep 7. doi: 10.1002/dmrr.2706), for which both Dr. Peters and Dr. Senneville were coauthors.

Turning to the novel use of topical antibiotics in patients with diabetic foot osteomyelitis, Dr. Senneville described several potential advantages, including the attainment of optimal drug levels in the presence of peripheral vascular disease and in avascular spaces.

The idea is to place antibiotic-impregnated beads or bone cement in the space created by debridement and removal of infected bone. By filling the dead space, the antibiotic-impregnated cement may control the infection simmering in any areas of infected bone unintentionally left behind, while also reducing the risk of pressure transfer syndrome. The use of antibiotic-eluting bone cement has recently been shown to reduce the need for reoperation (J Foot Ankle Surg. 2015 Jul-Aug;54[4]:536-40).

Dr. Senneville reported serving on speakers’ bureaus for Novartis and Merck and as an advisor to Pfizer.

SAN DIEGO – Chlorhexidine-containing intravenous catheter securement dressings significantly reduced the incidence of central venous catheter–related bloodstream infections in neutropenic patients, a multicenter randomized trial showed.

“Central venous catheters impose a risk of catheter-related bloodstream infections, especially when used in neutropenic patients, and the mortality risk has been reported to be up to 36%,” Dr. Lena M. Biehl said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

One way to prevent catheter-related bloodstream infections is to use chlorhexidine-containing intravenous catheter securement dressings in an effort to decrease skin colonization, said Dr. Biehl of the department of internal medicine at University Hospital of Cologne (Germany). “A few studies have looked at this, but most of them used chlorhexidine-containing sponges. There’s only one study using a more advanced chlorhexidine-containing gel pad, and this study was done in the ICU setting. The gel pad enables you to evaluate the insertion site, so you can see if there are signs of infection without removing the dressing.”

In a multicenter, randomized trial known as the COAT study that was conducted at 10 hematology departments in Germany from February 2012 to September 2014, Dr. Biehl and her associates set out to compare the incidence of central venous catheter–related bloodstream infections in two groups of neutropenic patients: those with chlorhexidine-containing IV catheter-securement dressings that included a gel pad (the chlorhexidine group) and those with conventional IV catheter-securement dressings that lacked a gel pad (the control group). They limited the analysis to patients undergoing intensive chemotherapy with expected neutropenia for at least 5 days and expected central venous catheter use of at least 10 days. The primary endpoint was the incidence of definite catheter-related bloodstream infections within 14 days of central venous catheter placement. The secondary endpoints were overall incidence of definite or probable central venous catheter–related bloodstream infections at 14 days and the overall incidence of definite or probable central venous catheter–related bloodstream infections.

Dr. Biehl presented results from 613 patients. Of these, 307 were in the chlorhexidine group and 306 were in the control group. The median age was 58 years and 59% were male, and the distribution of causative pathogens was similar between the two groups. The incidence of definite catheter-related bloodstream infections at 14 days was 2.6% in the chlorhexidine group, compared with 3.9% in the control group, a difference that did not reach statistical significance (P = .375). However, the overall incidence of definite and probable central venous catheter–related bloodstream infections together at 14 days was 6.5% in the chlorhexidine group, compared with 11.1% in the control group, a difference that reached statistical significance (P = .047). Finally, the overall incidence of definite and probable central venous catheter–related bloodstream infections was 10.4% in the chlorhexidine group, compared with 17% in the control group, a difference that also reached statistical significance (P = .019).

“The chlorhexidine dressings were very well tolerated, and in contrast to previous studies we saw no increase in skin and soft tissue abnormalities or contact dermatitis,” Dr. Biehl said. The researchers also observed no significant difference in mortality between the chlorhexidine and control groups (6.2 % vs. 5.6%, respectively).

The study was supported by a grant from 3M. Dr. Biehl disclosed that she is a member of the speakers bureau for Astellas Pharma and Merck/MSD. She has received travel grants from 3M and Gilead Sciences. Another study investigator, Dr. Maria J. G. T. Vehreschild, disclosed numerous financial ties to industry.

dbrunk@frontlinemedcom.com

SAN DIEGO – Chlorhexidine-containing intravenous catheter securement dressings significantly reduced the incidence of central venous catheter–related bloodstream infections in neutropenic patients, a multicenter randomized trial showed.

“Central venous catheters impose a risk of catheter-related bloodstream infections, especially when used in neutropenic patients, and the mortality risk has been reported to be up to 36%,” Dr. Lena M. Biehl said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

One way to prevent catheter-related bloodstream infections is to use chlorhexidine-containing intravenous catheter securement dressings in an effort to decrease skin colonization, said Dr. Biehl of the department of internal medicine at University Hospital of Cologne (Germany). “A few studies have looked at this, but most of them used chlorhexidine-containing sponges. There’s only one study using a more advanced chlorhexidine-containing gel pad, and this study was done in the ICU setting. The gel pad enables you to evaluate the insertion site, so you can see if there are signs of infection without removing the dressing.”

In a multicenter, randomized trial known as the COAT study that was conducted at 10 hematology departments in Germany from February 2012 to September 2014, Dr. Biehl and her associates set out to compare the incidence of central venous catheter–related bloodstream infections in two groups of neutropenic patients: those with chlorhexidine-containing IV catheter-securement dressings that included a gel pad (the chlorhexidine group) and those with conventional IV catheter-securement dressings that lacked a gel pad (the control group). They limited the analysis to patients undergoing intensive chemotherapy with expected neutropenia for at least 5 days and expected central venous catheter use of at least 10 days. The primary endpoint was the incidence of definite catheter-related bloodstream infections within 14 days of central venous catheter placement. The secondary endpoints were overall incidence of definite or probable central venous catheter–related bloodstream infections at 14 days and the overall incidence of definite or probable central venous catheter–related bloodstream infections.

Dr. Biehl presented results from 613 patients. Of these, 307 were in the chlorhexidine group and 306 were in the control group. The median age was 58 years and 59% were male, and the distribution of causative pathogens was similar between the two groups. The incidence of definite catheter-related bloodstream infections at 14 days was 2.6% in the chlorhexidine group, compared with 3.9% in the control group, a difference that did not reach statistical significance (P = .375). However, the overall incidence of definite and probable central venous catheter–related bloodstream infections together at 14 days was 6.5% in the chlorhexidine group, compared with 11.1% in the control group, a difference that reached statistical significance (P = .047). Finally, the overall incidence of definite and probable central venous catheter–related bloodstream infections was 10.4% in the chlorhexidine group, compared with 17% in the control group, a difference that also reached statistical significance (P = .019).

“The chlorhexidine dressings were very well tolerated, and in contrast to previous studies we saw no increase in skin and soft tissue abnormalities or contact dermatitis,” Dr. Biehl said. The researchers also observed no significant difference in mortality between the chlorhexidine and control groups (6.2 % vs. 5.6%, respectively).

The study was supported by a grant from 3M. Dr. Biehl disclosed that she is a member of the speakers bureau for Astellas Pharma and Merck/MSD. She has received travel grants from 3M and Gilead Sciences. Another study investigator, Dr. Maria J. G. T. Vehreschild, disclosed numerous financial ties to industry.

dbrunk@frontlinemedcom.com

SAN DIEGO – Chlorhexidine-containing intravenous catheter securement dressings significantly reduced the incidence of central venous catheter–related bloodstream infections in neutropenic patients, a multicenter randomized trial showed.

“Central venous catheters impose a risk of catheter-related bloodstream infections, especially when used in neutropenic patients, and the mortality risk has been reported to be up to 36%,” Dr. Lena M. Biehl said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

One way to prevent catheter-related bloodstream infections is to use chlorhexidine-containing intravenous catheter securement dressings in an effort to decrease skin colonization, said Dr. Biehl of the department of internal medicine at University Hospital of Cologne (Germany). “A few studies have looked at this, but most of them used chlorhexidine-containing sponges. There’s only one study using a more advanced chlorhexidine-containing gel pad, and this study was done in the ICU setting. The gel pad enables you to evaluate the insertion site, so you can see if there are signs of infection without removing the dressing.”

In a multicenter, randomized trial known as the COAT study that was conducted at 10 hematology departments in Germany from February 2012 to September 2014, Dr. Biehl and her associates set out to compare the incidence of central venous catheter–related bloodstream infections in two groups of neutropenic patients: those with chlorhexidine-containing IV catheter-securement dressings that included a gel pad (the chlorhexidine group) and those with conventional IV catheter-securement dressings that lacked a gel pad (the control group). They limited the analysis to patients undergoing intensive chemotherapy with expected neutropenia for at least 5 days and expected central venous catheter use of at least 10 days. The primary endpoint was the incidence of definite catheter-related bloodstream infections within 14 days of central venous catheter placement. The secondary endpoints were overall incidence of definite or probable central venous catheter–related bloodstream infections at 14 days and the overall incidence of definite or probable central venous catheter–related bloodstream infections.

Dr. Biehl presented results from 613 patients. Of these, 307 were in the chlorhexidine group and 306 were in the control group. The median age was 58 years and 59% were male, and the distribution of causative pathogens was similar between the two groups. The incidence of definite catheter-related bloodstream infections at 14 days was 2.6% in the chlorhexidine group, compared with 3.9% in the control group, a difference that did not reach statistical significance (P = .375). However, the overall incidence of definite and probable central venous catheter–related bloodstream infections together at 14 days was 6.5% in the chlorhexidine group, compared with 11.1% in the control group, a difference that reached statistical significance (P = .047). Finally, the overall incidence of definite and probable central venous catheter–related bloodstream infections was 10.4% in the chlorhexidine group, compared with 17% in the control group, a difference that also reached statistical significance (P = .019).

“The chlorhexidine dressings were very well tolerated, and in contrast to previous studies we saw no increase in skin and soft tissue abnormalities or contact dermatitis,” Dr. Biehl said. The researchers also observed no significant difference in mortality between the chlorhexidine and control groups (6.2 % vs. 5.6%, respectively).

The study was supported by a grant from 3M. Dr. Biehl disclosed that she is a member of the speakers bureau for Astellas Pharma and Merck/MSD. She has received travel grants from 3M and Gilead Sciences. Another study investigator, Dr. Maria J. G. T. Vehreschild, disclosed numerous financial ties to industry.

dbrunk@frontlinemedcom.com

SAN DIEGO – Cases of ocular syphilis are on the upswing in 2015, and many physicians are not up to speed regarding this serious complication, experts asserted at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

“I know that at my institution there’s been a lack of education about ocular syphilis. The housestaff are unaware that you can have ocular syphilis with a normal lumbar puncture,” said Dr. Kimberly A. Workowski, professor of medicine at Emory University in Atlanta and lead author of the Centers for Disease Control and Prevention 2015 STD guidelines (MMWR Recomm Rep. 2015;64[RR-03]:1-137).

Bruce Jancin/Frontline Medical news

When she asked for a show of hands by physicians in the audience who had seen a case of ocular syphilis in the past 6 months, a lot of arms shot up.

“We’ve had a large increase in ocular syphilis at our institution, too,” Dr. Workowski noted.

Dr. Juliet Stoltey of the University of California, San Francisco, said that since the initial January 2015 report of an outbreak of ocular syphilis in the Seattle area, cases have been reported from around the country, prompting the CDC to issue a clinical advisory in April.

It remains unclear whether the increase in ocular syphilis cases is the result of a true outbreak of a more oculo/neurotrophic strain of Treponema pallidum or simply the result of greater awareness of the complication in the setting of a steep rise in syphilis overall, according to Dr. Stoltey.

Circulation of a more neurotrophic strain is biologically plausible based on animal studies. Data from the University of Washington, Seattle, point to strain type 14d/f as a potential culprit.

California surveillance data show a more than 140% increase in syphilis cases overall during 2006-2014. And while it appears that the proportion of cases with ocular or other forms of neurologic syphilis has increased to an even greater extent than the overall rise in syphilis, the significance of this observation is uncertain given that the surveillance system lacks a standard mechanism for reporting ocular syphilis.

Regardless, Dr. Stoltey continued, here’s what physicians really need to know about ocular syphilis: Syphilis can affect virtually all parts of the eye, neurosyphilis can occur at any stage of the infection, and delayed identification of ocular syphilis has been associated with visual loss.

A syphilis serology test should be ordered in patients who have visual complaints along with risk factors for syphilis, such as men who have sex with men, as well as in those who have ophthalmologic findings compatible with syphilis. Both a treponemal and nontreponemal test should be ordered since the false-negative prozone effect has been documented in patients with ocular syphilis.

Clinical characteristics of ocular syphilis include eye redness, eye pain, visual field deficits or a decline in visual acuity, and headache accompanying eye symptoms. Ophthalmologic findings can include uveitis, iritis, vitrial detachment, optic neuritis, and marked vision loss.

Any patient with visual complaints plus a positive syphilis serology should undergo ophthalmologic evaluation immediately, Dr. Stoltey emphasized. A lumbar puncture and CSF analysis is recommended for syphilis patients with eye or neurologic symptoms such as cranial nerve dysfunction, auditory disease, meningitis, loss of vibration sensation, stroke, or altered mental status.

“I see signs of potential neurosyphilis being missed all the time,” Dr. Workowski said. “And here is a really important point: Treat for neurosyphilis if a patient with syphilis has the signs or symptoms of neurologic, audiologic, or ophthalmologic involvement regardless of what the CSF shows.”

The guideline-recommended treatment for ocular or neurosyphilis is aqueous crystalline penicillin G, 18-24 million units daily, administered as 3-4 million units IV every 4 hours for 10-14 days.

Dr. Stoltey urged physicians to store frozen pre–antibiotic therapy clinical samples from their patients with ocular syphilis and to contact the CDC, which, together with investigators at the University of Washington, Seattle, is conducting a study aimed at determining whether an oculotrophic strain of T. pallidum is circulating.

Dr. Stoltey and Dr. Workowski reported having no financial conflicts of interest.

bjancin@frontlinemedcom.com

SAN DIEGO – Cases of ocular syphilis are on the upswing in 2015, and many physicians are not up to speed regarding this serious complication, experts asserted at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

“I know that at my institution there’s been a lack of education about ocular syphilis. The housestaff are unaware that you can have ocular syphilis with a normal lumbar puncture,” said Dr. Kimberly A. Workowski, professor of medicine at Emory University in Atlanta and lead author of the Centers for Disease Control and Prevention 2015 STD guidelines (MMWR Recomm Rep. 2015;64[RR-03]:1-137).

Bruce Jancin/Frontline Medical news

When she asked for a show of hands by physicians in the audience who had seen a case of ocular syphilis in the past 6 months, a lot of arms shot up.

“We’ve had a large increase in ocular syphilis at our institution, too,” Dr. Workowski noted.

Dr. Juliet Stoltey of the University of California, San Francisco, said that since the initial January 2015 report of an outbreak of ocular syphilis in the Seattle area, cases have been reported from around the country, prompting the CDC to issue a clinical advisory in April.

It remains unclear whether the increase in ocular syphilis cases is the result of a true outbreak of a more oculo/neurotrophic strain of Treponema pallidum or simply the result of greater awareness of the complication in the setting of a steep rise in syphilis overall, according to Dr. Stoltey.

Circulation of a more neurotrophic strain is biologically plausible based on animal studies. Data from the University of Washington, Seattle, point to strain type 14d/f as a potential culprit.

California surveillance data show a more than 140% increase in syphilis cases overall during 2006-2014. And while it appears that the proportion of cases with ocular or other forms of neurologic syphilis has increased to an even greater extent than the overall rise in syphilis, the significance of this observation is uncertain given that the surveillance system lacks a standard mechanism for reporting ocular syphilis.

Regardless, Dr. Stoltey continued, here’s what physicians really need to know about ocular syphilis: Syphilis can affect virtually all parts of the eye, neurosyphilis can occur at any stage of the infection, and delayed identification of ocular syphilis has been associated with visual loss.

A syphilis serology test should be ordered in patients who have visual complaints along with risk factors for syphilis, such as men who have sex with men, as well as in those who have ophthalmologic findings compatible with syphilis. Both a treponemal and nontreponemal test should be ordered since the false-negative prozone effect has been documented in patients with ocular syphilis.

Clinical characteristics of ocular syphilis include eye redness, eye pain, visual field deficits or a decline in visual acuity, and headache accompanying eye symptoms. Ophthalmologic findings can include uveitis, iritis, vitrial detachment, optic neuritis, and marked vision loss.

Any patient with visual complaints plus a positive syphilis serology should undergo ophthalmologic evaluation immediately, Dr. Stoltey emphasized. A lumbar puncture and CSF analysis is recommended for syphilis patients with eye or neurologic symptoms such as cranial nerve dysfunction, auditory disease, meningitis, loss of vibration sensation, stroke, or altered mental status.

“I see signs of potential neurosyphilis being missed all the time,” Dr. Workowski said. “And here is a really important point: Treat for neurosyphilis if a patient with syphilis has the signs or symptoms of neurologic, audiologic, or ophthalmologic involvement regardless of what the CSF shows.”

The guideline-recommended treatment for ocular or neurosyphilis is aqueous crystalline penicillin G, 18-24 million units daily, administered as 3-4 million units IV every 4 hours for 10-14 days.

Dr. Stoltey urged physicians to store frozen pre–antibiotic therapy clinical samples from their patients with ocular syphilis and to contact the CDC, which, together with investigators at the University of Washington, Seattle, is conducting a study aimed at determining whether an oculotrophic strain of T. pallidum is circulating.

Dr. Stoltey and Dr. Workowski reported having no financial conflicts of interest.

bjancin@frontlinemedcom.com

SAN DIEGO – Cases of ocular syphilis are on the upswing in 2015, and many physicians are not up to speed regarding this serious complication, experts asserted at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

“I know that at my institution there’s been a lack of education about ocular syphilis. The housestaff are unaware that you can have ocular syphilis with a normal lumbar puncture,” said Dr. Kimberly A. Workowski, professor of medicine at Emory University in Atlanta and lead author of the Centers for Disease Control and Prevention 2015 STD guidelines (MMWR Recomm Rep. 2015;64[RR-03]:1-137).

Bruce Jancin/Frontline Medical news

When she asked for a show of hands by physicians in the audience who had seen a case of ocular syphilis in the past 6 months, a lot of arms shot up.

“We’ve had a large increase in ocular syphilis at our institution, too,” Dr. Workowski noted.

Dr. Juliet Stoltey of the University of California, San Francisco, said that since the initial January 2015 report of an outbreak of ocular syphilis in the Seattle area, cases have been reported from around the country, prompting the CDC to issue a clinical advisory in April.

It remains unclear whether the increase in ocular syphilis cases is the result of a true outbreak of a more oculo/neurotrophic strain of Treponema pallidum or simply the result of greater awareness of the complication in the setting of a steep rise in syphilis overall, according to Dr. Stoltey.

Circulation of a more neurotrophic strain is biologically plausible based on animal studies. Data from the University of Washington, Seattle, point to strain type 14d/f as a potential culprit.

California surveillance data show a more than 140% increase in syphilis cases overall during 2006-2014. And while it appears that the proportion of cases with ocular or other forms of neurologic syphilis has increased to an even greater extent than the overall rise in syphilis, the significance of this observation is uncertain given that the surveillance system lacks a standard mechanism for reporting ocular syphilis.

Regardless, Dr. Stoltey continued, here’s what physicians really need to know about ocular syphilis: Syphilis can affect virtually all parts of the eye, neurosyphilis can occur at any stage of the infection, and delayed identification of ocular syphilis has been associated with visual loss.

A syphilis serology test should be ordered in patients who have visual complaints along with risk factors for syphilis, such as men who have sex with men, as well as in those who have ophthalmologic findings compatible with syphilis. Both a treponemal and nontreponemal test should be ordered since the false-negative prozone effect has been documented in patients with ocular syphilis.

Clinical characteristics of ocular syphilis include eye redness, eye pain, visual field deficits or a decline in visual acuity, and headache accompanying eye symptoms. Ophthalmologic findings can include uveitis, iritis, vitrial detachment, optic neuritis, and marked vision loss.

Any patient with visual complaints plus a positive syphilis serology should undergo ophthalmologic evaluation immediately, Dr. Stoltey emphasized. A lumbar puncture and CSF analysis is recommended for syphilis patients with eye or neurologic symptoms such as cranial nerve dysfunction, auditory disease, meningitis, loss of vibration sensation, stroke, or altered mental status.

“I see signs of potential neurosyphilis being missed all the time,” Dr. Workowski said. “And here is a really important point: Treat for neurosyphilis if a patient with syphilis has the signs or symptoms of neurologic, audiologic, or ophthalmologic involvement regardless of what the CSF shows.”

The guideline-recommended treatment for ocular or neurosyphilis is aqueous crystalline penicillin G, 18-24 million units daily, administered as 3-4 million units IV every 4 hours for 10-14 days.

Dr. Stoltey urged physicians to store frozen pre–antibiotic therapy clinical samples from their patients with ocular syphilis and to contact the CDC, which, together with investigators at the University of Washington, Seattle, is conducting a study aimed at determining whether an oculotrophic strain of T. pallidum is circulating.

Dr. Stoltey and Dr. Workowski reported having no financial conflicts of interest.

bjancin@frontlinemedcom.com

SAN DIEGO – Among patients with MRSA bacteremia, age, markers of severity of acute treatment, and duration of treatment are predictive of mortality risk at 90 days and 1 year, a long-term single-center study showed.

At the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, Renee-Claude Mercier, Pharm.D., presented results from an analysis which set out to describe the trajectory and long-term outcomes of patients with MRSA bacteremia, including the influence of bacterial, treatment, and host factors on outcomes.

Dr. Mercier and her associates identified 273 patients who were diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia during admission to the University of New Mexico Hospital between 2003 and 2013. The main outcomes were mortality at 90 days and 1 year, while secondary outcomes were hospital readmission, nursing home placement, and continued need for hemodialysis. Dr. Mercier, professor of pharmacy and medicine at the University of New Mexico, Albuquerque, and her associates used multivariable logistic regression and survival analysis to evaluate predictors of outcomes.

The mean age of the 273 patients was 52 years, 71% were male, and USA300 accounted for more than half of the strains (57%). A total of 66 patients (24%) died. “Importantly, we do not know the [mortality] status of 30% of our [study] population,” said Dr. Mercier. “We’re working right now with the [Centers for Disease Control and Prevention] to determine the cause or whether or not some of our patients that were included died in the 365 days following their infection with MRSA.”

At 30 days, the mortality rate was 17.7%, most commonly because of MRSA infection (75% of cases), followed by cancer (6.8% of cases) and secondary infection (2.3% of cases). The researchers followed the patients for a median of 237 days. Nearly half (44.8%) were discharged to home, 40.6% were discharged to a skilled nursing facility, and 2.9% returned to prison. “If patients were to die, they died in the first 30 days after infection with MRSA,” Dr. Mercier said. Independent predictors of mortality at 30 days included older age, the presence of liver disease, an ICU stay, a higher Pitt bacteremia score, and unresolved fever.

When the researchers excluded mortality that occurred in the first 30 days, the mortality rate at 90 days was 5.8%, mainly because of MRSA infection (in 46% of the cases), followed by other infection and unspecified sepsis (9%). On multivariable analysis, independent predictors of mortality at 90 days were use of mechanical ventilation (hazard ratio, 4.8; P = .02) and duration of treatment in days (HR .97; P = .078). “Treatment duration was an important determinant of survival in our study,” Dr. Mercier said. “Whether used as a continuous variable or as a dichotomous variable, using 4 weeks as our cutoff showed that the longer the treatment, the [greater the] decrease in mortality.”

After excluding mortality that occurred in the first 30 days, the researchers found that the mortality rate at 1 year was 17.8%, mainly because of MRSA infection (in 28% of the cases), followed by cancer (in 16% of cases) and secondary infections and unspecified sepsis (in 4% of cases). On multivariable analysis, independent predictors of mortality at 90 days were use of mechanical ventilation (HR 1.04; P = .005) and duration of treatment in days (HR .98; P = .05).

The majority of patients (64%) were not readmitted to the hospital within 1 year, while 16% were readmitted for other types of infections not related to S. aureus. In addition, 4% were readmitted because of cardiovascular causes, and 3% were readmitted because of a S. aureus infection.

Finally, Dr. Mercier and her colleagues performed a competing risk regression analysis examining different factors and their impact on mortality. Having an ICU stay as well as the presence of liver disease and receiving antibiotics for less than 4 weeks were significant predictors of mortality.

The researchers reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Among patients with MRSA bacteremia, age, markers of severity of acute treatment, and duration of treatment are predictive of mortality risk at 90 days and 1 year, a long-term single-center study showed.

At the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, Renee-Claude Mercier, Pharm.D., presented results from an analysis which set out to describe the trajectory and long-term outcomes of patients with MRSA bacteremia, including the influence of bacterial, treatment, and host factors on outcomes.

Dr. Mercier and her associates identified 273 patients who were diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia during admission to the University of New Mexico Hospital between 2003 and 2013. The main outcomes were mortality at 90 days and 1 year, while secondary outcomes were hospital readmission, nursing home placement, and continued need for hemodialysis. Dr. Mercier, professor of pharmacy and medicine at the University of New Mexico, Albuquerque, and her associates used multivariable logistic regression and survival analysis to evaluate predictors of outcomes.

The mean age of the 273 patients was 52 years, 71% were male, and USA300 accounted for more than half of the strains (57%). A total of 66 patients (24%) died. “Importantly, we do not know the [mortality] status of 30% of our [study] population,” said Dr. Mercier. “We’re working right now with the [Centers for Disease Control and Prevention] to determine the cause or whether or not some of our patients that were included died in the 365 days following their infection with MRSA.”

At 30 days, the mortality rate was 17.7%, most commonly because of MRSA infection (75% of cases), followed by cancer (6.8% of cases) and secondary infection (2.3% of cases). The researchers followed the patients for a median of 237 days. Nearly half (44.8%) were discharged to home, 40.6% were discharged to a skilled nursing facility, and 2.9% returned to prison. “If patients were to die, they died in the first 30 days after infection with MRSA,” Dr. Mercier said. Independent predictors of mortality at 30 days included older age, the presence of liver disease, an ICU stay, a higher Pitt bacteremia score, and unresolved fever.

When the researchers excluded mortality that occurred in the first 30 days, the mortality rate at 90 days was 5.8%, mainly because of MRSA infection (in 46% of the cases), followed by other infection and unspecified sepsis (9%). On multivariable analysis, independent predictors of mortality at 90 days were use of mechanical ventilation (hazard ratio, 4.8; P = .02) and duration of treatment in days (HR .97; P = .078). “Treatment duration was an important determinant of survival in our study,” Dr. Mercier said. “Whether used as a continuous variable or as a dichotomous variable, using 4 weeks as our cutoff showed that the longer the treatment, the [greater the] decrease in mortality.”

After excluding mortality that occurred in the first 30 days, the researchers found that the mortality rate at 1 year was 17.8%, mainly because of MRSA infection (in 28% of the cases), followed by cancer (in 16% of cases) and secondary infections and unspecified sepsis (in 4% of cases). On multivariable analysis, independent predictors of mortality at 90 days were use of mechanical ventilation (HR 1.04; P = .005) and duration of treatment in days (HR .98; P = .05).

The majority of patients (64%) were not readmitted to the hospital within 1 year, while 16% were readmitted for other types of infections not related to S. aureus. In addition, 4% were readmitted because of cardiovascular causes, and 3% were readmitted because of a S. aureus infection.

Finally, Dr. Mercier and her colleagues performed a competing risk regression analysis examining different factors and their impact on mortality. Having an ICU stay as well as the presence of liver disease and receiving antibiotics for less than 4 weeks were significant predictors of mortality.

The researchers reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Among patients with MRSA bacteremia, age, markers of severity of acute treatment, and duration of treatment are predictive of mortality risk at 90 days and 1 year, a long-term single-center study showed.

At the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, Renee-Claude Mercier, Pharm.D., presented results from an analysis which set out to describe the trajectory and long-term outcomes of patients with MRSA bacteremia, including the influence of bacterial, treatment, and host factors on outcomes.

Dr. Mercier and her associates identified 273 patients who were diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia during admission to the University of New Mexico Hospital between 2003 and 2013. The main outcomes were mortality at 90 days and 1 year, while secondary outcomes were hospital readmission, nursing home placement, and continued need for hemodialysis. Dr. Mercier, professor of pharmacy and medicine at the University of New Mexico, Albuquerque, and her associates used multivariable logistic regression and survival analysis to evaluate predictors of outcomes.

The mean age of the 273 patients was 52 years, 71% were male, and USA300 accounted for more than half of the strains (57%). A total of 66 patients (24%) died. “Importantly, we do not know the [mortality] status of 30% of our [study] population,” said Dr. Mercier. “We’re working right now with the [Centers for Disease Control and Prevention] to determine the cause or whether or not some of our patients that were included died in the 365 days following their infection with MRSA.”

At 30 days, the mortality rate was 17.7%, most commonly because of MRSA infection (75% of cases), followed by cancer (6.8% of cases) and secondary infection (2.3% of cases). The researchers followed the patients for a median of 237 days. Nearly half (44.8%) were discharged to home, 40.6% were discharged to a skilled nursing facility, and 2.9% returned to prison. “If patients were to die, they died in the first 30 days after infection with MRSA,” Dr. Mercier said. Independent predictors of mortality at 30 days included older age, the presence of liver disease, an ICU stay, a higher Pitt bacteremia score, and unresolved fever.

When the researchers excluded mortality that occurred in the first 30 days, the mortality rate at 90 days was 5.8%, mainly because of MRSA infection (in 46% of the cases), followed by other infection and unspecified sepsis (9%). On multivariable analysis, independent predictors of mortality at 90 days were use of mechanical ventilation (hazard ratio, 4.8; P = .02) and duration of treatment in days (HR .97; P = .078). “Treatment duration was an important determinant of survival in our study,” Dr. Mercier said. “Whether used as a continuous variable or as a dichotomous variable, using 4 weeks as our cutoff showed that the longer the treatment, the [greater the] decrease in mortality.”

After excluding mortality that occurred in the first 30 days, the researchers found that the mortality rate at 1 year was 17.8%, mainly because of MRSA infection (in 28% of the cases), followed by cancer (in 16% of cases) and secondary infections and unspecified sepsis (in 4% of cases). On multivariable analysis, independent predictors of mortality at 90 days were use of mechanical ventilation (HR 1.04; P = .005) and duration of treatment in days (HR .98; P = .05).

The majority of patients (64%) were not readmitted to the hospital within 1 year, while 16% were readmitted for other types of infections not related to S. aureus. In addition, 4% were readmitted because of cardiovascular causes, and 3% were readmitted because of a S. aureus infection.

Finally, Dr. Mercier and her colleagues performed a competing risk regression analysis examining different factors and their impact on mortality. Having an ICU stay as well as the presence of liver disease and receiving antibiotics for less than 4 weeks were significant predictors of mortality.

The researchers reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Use of antibiotics was cut by one-third among 3- to 5-year-olds attending child care centers that used enhanced hard surface disinfection practices in a multicenter randomized trial.

The intervention involved the use of commercially available wipes and sprays containing quaternary ammonium chloride compounds as well as a combined cleaner plus 1.9% sodium hypochlorite.

“Our intervention involved providing easier-to-use products that are more likely to provide an effective dose of the disinfectant, and the disinfection intervention appeared to reduce antibiotic use,” Charles P. Gerba, Ph.D., observed at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The 10-week study included 402 children at a dozen Arizona day care centers. Six centers were randomized to serve as controls, with the staff continuing to follow standard disinfection protocols recommended by the Arizona state health department: namely, a two-step process entailing the use of soapy water followed by bleach.

The other six centers were provided with the commercial hard surface disinfectants and instructed in using them effectively to kill germs. For example, the disinfecting wipes were to be used daily on refrigerator door handles and after every use of diaper-changing areas and high chairs. The one-step cleanser/dilute bleach product was to be applied daily to the sink, toilet, and countertops.

“These quat ammonium-containing wipes and sprays typically require 2-10 minutes of contact time in order to disinfect,” explained Dr. Gerba, professor of microbiology and environmental sciences at the University of Arizona, Tucson.

Hand-washing practices continued as usual throughout the study.

Every time a child missed school during the 10-week study, Dr. Gerba or a coinvestigator phoned the parents to learn if the child was sick, had sought medical attention, or was taking antibiotics.

The key finding: In a multivariate Poisson regression analysis, the use of antibiotics was 32% lower in the intervention arm than in controls.

Children attending the day care centers in the intervention arm also had fewer medical visits. Moreover, microbiologic sampling of hard surfaces at the participating centers documented that fewer antibiotic-resistant bacteria were present at the centers using enhanced disinfection practices.

Asked if he expects his study findings to result in a widespread change in cleaning practices at child care centers, Dr. Gerba noted that the commercially available enhanced disinfectant products are costlier than a bucket of soapy water and another bucket of dilute bleach.

“Child care centers are sensitive to cost,” he said. “Our current studies are examining the economic benefit of using products that are more convenient and contain the right doses for disinfection.”

He dismissed audience concerns that microbes might develop resistance to the disinfectants used in this study.

“In 120 years, no one has ever seen resistance to chlorine bleach by any microorganisms in continuous exposure. The same can be said for quat compounds. The literature shows that if they are used properly for disinfection, microorganisms don’t develop resistance because basically you’re using a stick of dynamite to kill a cockroach,” Dr. Gerba said.

The study was partially funded by a research grant provided by the Clorox Company to the University of Arizona, Tucson.

bjancin@frontlinemedcom.com

SAN DIEGO – Use of antibiotics was cut by one-third among 3- to 5-year-olds attending child care centers that used enhanced hard surface disinfection practices in a multicenter randomized trial.

The intervention involved the use of commercially available wipes and sprays containing quaternary ammonium chloride compounds as well as a combined cleaner plus 1.9% sodium hypochlorite.

“Our intervention involved providing easier-to-use products that are more likely to provide an effective dose of the disinfectant, and the disinfection intervention appeared to reduce antibiotic use,” Charles P. Gerba, Ph.D., observed at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The 10-week study included 402 children at a dozen Arizona day care centers. Six centers were randomized to serve as controls, with the staff continuing to follow standard disinfection protocols recommended by the Arizona state health department: namely, a two-step process entailing the use of soapy water followed by bleach.

The other six centers were provided with the commercial hard surface disinfectants and instructed in using them effectively to kill germs. For example, the disinfecting wipes were to be used daily on refrigerator door handles and after every use of diaper-changing areas and high chairs. The one-step cleanser/dilute bleach product was to be applied daily to the sink, toilet, and countertops.

“These quat ammonium-containing wipes and sprays typically require 2-10 minutes of contact time in order to disinfect,” explained Dr. Gerba, professor of microbiology and environmental sciences at the University of Arizona, Tucson.

Hand-washing practices continued as usual throughout the study.

Every time a child missed school during the 10-week study, Dr. Gerba or a coinvestigator phoned the parents to learn if the child was sick, had sought medical attention, or was taking antibiotics.

The key finding: In a multivariate Poisson regression analysis, the use of antibiotics was 32% lower in the intervention arm than in controls.

Children attending the day care centers in the intervention arm also had fewer medical visits. Moreover, microbiologic sampling of hard surfaces at the participating centers documented that fewer antibiotic-resistant bacteria were present at the centers using enhanced disinfection practices.

Asked if he expects his study findings to result in a widespread change in cleaning practices at child care centers, Dr. Gerba noted that the commercially available enhanced disinfectant products are costlier than a bucket of soapy water and another bucket of dilute bleach.

“Child care centers are sensitive to cost,” he said. “Our current studies are examining the economic benefit of using products that are more convenient and contain the right doses for disinfection.”

He dismissed audience concerns that microbes might develop resistance to the disinfectants used in this study.

“In 120 years, no one has ever seen resistance to chlorine bleach by any microorganisms in continuous exposure. The same can be said for quat compounds. The literature shows that if they are used properly for disinfection, microorganisms don’t develop resistance because basically you’re using a stick of dynamite to kill a cockroach,” Dr. Gerba said.

The study was partially funded by a research grant provided by the Clorox Company to the University of Arizona, Tucson.

bjancin@frontlinemedcom.com

SAN DIEGO – Use of antibiotics was cut by one-third among 3- to 5-year-olds attending child care centers that used enhanced hard surface disinfection practices in a multicenter randomized trial.

The intervention involved the use of commercially available wipes and sprays containing quaternary ammonium chloride compounds as well as a combined cleaner plus 1.9% sodium hypochlorite.

“Our intervention involved providing easier-to-use products that are more likely to provide an effective dose of the disinfectant, and the disinfection intervention appeared to reduce antibiotic use,” Charles P. Gerba, Ph.D., observed at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The 10-week study included 402 children at a dozen Arizona day care centers. Six centers were randomized to serve as controls, with the staff continuing to follow standard disinfection protocols recommended by the Arizona state health department: namely, a two-step process entailing the use of soapy water followed by bleach.

The other six centers were provided with the commercial hard surface disinfectants and instructed in using them effectively to kill germs. For example, the disinfecting wipes were to be used daily on refrigerator door handles and after every use of diaper-changing areas and high chairs. The one-step cleanser/dilute bleach product was to be applied daily to the sink, toilet, and countertops.

“These quat ammonium-containing wipes and sprays typically require 2-10 minutes of contact time in order to disinfect,” explained Dr. Gerba, professor of microbiology and environmental sciences at the University of Arizona, Tucson.

Hand-washing practices continued as usual throughout the study.

Every time a child missed school during the 10-week study, Dr. Gerba or a coinvestigator phoned the parents to learn if the child was sick, had sought medical attention, or was taking antibiotics.

The key finding: In a multivariate Poisson regression analysis, the use of antibiotics was 32% lower in the intervention arm than in controls.

Children attending the day care centers in the intervention arm also had fewer medical visits. Moreover, microbiologic sampling of hard surfaces at the participating centers documented that fewer antibiotic-resistant bacteria were present at the centers using enhanced disinfection practices.

Asked if he expects his study findings to result in a widespread change in cleaning practices at child care centers, Dr. Gerba noted that the commercially available enhanced disinfectant products are costlier than a bucket of soapy water and another bucket of dilute bleach.

“Child care centers are sensitive to cost,” he said. “Our current studies are examining the economic benefit of using products that are more convenient and contain the right doses for disinfection.”

He dismissed audience concerns that microbes might develop resistance to the disinfectants used in this study.

“In 120 years, no one has ever seen resistance to chlorine bleach by any microorganisms in continuous exposure. The same can be said for quat compounds. The literature shows that if they are used properly for disinfection, microorganisms don’t develop resistance because basically you’re using a stick of dynamite to kill a cockroach,” Dr. Gerba said.

The study was partially funded by a research grant provided by the Clorox Company to the University of Arizona, Tucson.

bjancin@frontlinemedcom.com

SAN DIEGO – The potent synergistic benefits of coadministration of rotavirus vaccine and pneumococcal conjugate vaccine in young children are uniquely highlighted by a natural experiment conducted in southern Israel as described by Dr. Ron Dagan at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Dr. Dagan is professor of pediatrics and infectious diseases at Soroka University Medical Center in Beersheba, Israel. It’s the sole hospital in a large, well-defined area of southern Israel. All children in that part of Israel are born in the hospital and receive their health care there, making it possible to generate highly reliable disease incidence data.

At any given time, physicians at the hospital are responsible for the care of roughly 30,000 children less than 2 years of age. So there’s a huge study population, comprehensive follow-up, and – the final element in this prospective, population-based study – the rotavirus and pneumococcal conjugate vaccines were introduced in Israel just a few years ago and at roughly the same time. This enabled Dr. Dagan and his coinvestigators to compare hospitalization rates and pediatric emergency department outpatient visits for diarrheal and lower respiratory viral illnesses among children less than 2 years old during the prevaccine period of April 2006-March 2009 with rates during April 2013-March 2014, when uptake of the two vaccines in that age group exceeded 90%.

This was an unusual study in that it looked at the global impact of two major vaccines. In contrast, vaccine clinical trials and postmarketing studies typically evaluate only those outcomes directly related to that particular vaccine.

The results of the Israeli study were startling: in the 3 years prior to introduction of the vaccines, one in five children under age 2 years admitted to the hospital had as an admitting diagnosis either rotavirus gastroenteritis confirmed by a positive stool ELISA test or pneumococcal pneumonia as evidenced by alveolar pneumonia on chest x-ray. After the vaccines became available, the hospitalization rates for rotavirus gastroenteritis and alveolar pneumonia plummeted by 78% and 46%, respectively. Moreover, outpatient pediatric emergency department visits for rotavirus gastroenteritis dropped by 71% and visits for alveolar pneumonia fell by 67%.

But that’s not all. Smaller yet clinically meaningful reductions were also documented in nonrotavirus gastroenteritis and nonalveolar lower respiratory tract infections. Specifically, the hospitalization rate for nonrotavirus diarrheal illnesses and nonalveolar pneumonia lower respiratory infections dropped by 21% and 7%, respectively, while outpatient emergency visits for those disorders fell by 16% and 14%.

This translates to an estimated 1,890 fewer hospitalizations and 4,030 fewer outpatient emergency department visits for diarrheal disease or lower respiratory infection per 100,000 children under age 2 per year, Dr. Dagan reported.

Michael Schmidt, Ph.D., who chaired a press conference highlighting the Israeli study, declared, “These data are absolutely phenomenal. It really shows the global value of these vaccines for society.”

Dr. Schmidt, professor and vice chairman of microbiology and immunology at the Medical University of South Carolina, Charleston, posed a question: What’s the explanation for the reductions in diseases not directly addressed by those two vaccines?

“We believe that one success can favorably affect the other. If you are weakened by diarrhea, you may be more likely to get pneumonia, and vice versa,” according to Dr. Dagan.

He added that the results actually pack a significantly greater wallop than is apparent at first look because rotavirus gastroenteritis and pneumococcal pneumonia in young children are seasonal diseases. They occur chiefly during October-March. So those 5,920 fewer hospitalizations and outpatient visits/100,000 per young children per year are concentrated during pediatricians’ busiest half of the year.

“In most places in the world, winter is a time of so much illness that pediatricians can’t deliver appropriate care. We knew that in our hospital we couldn’t deliver appropriate care to children in the winter because there were so many sick children piled on top of each other. But now, because of these two vaccines, we are less crowded in the winter, we have more time for children, we make fewer mistakes,” he said.

The study was funded by vaccine manufacturers and the Israel Ministry of Health. Dr. Dagan reported serving as a consultant, adviser to, and/or recipient of research grants from GlaxoSmithKline, Merck Sharp & Dohme, Pfizer, and Genocea.

bjancin@frontlinemedcom.com

SAN DIEGO – The potent synergistic benefits of coadministration of rotavirus vaccine and pneumococcal conjugate vaccine in young children are uniquely highlighted by a natural experiment conducted in southern Israel as described by Dr. Ron Dagan at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Dr. Dagan is professor of pediatrics and infectious diseases at Soroka University Medical Center in Beersheba, Israel. It’s the sole hospital in a large, well-defined area of southern Israel. All children in that part of Israel are born in the hospital and receive their health care there, making it possible to generate highly reliable disease incidence data.

At any given time, physicians at the hospital are responsible for the care of roughly 30,000 children less than 2 years of age. So there’s a huge study population, comprehensive follow-up, and – the final element in this prospective, population-based study – the rotavirus and pneumococcal conjugate vaccines were introduced in Israel just a few years ago and at roughly the same time. This enabled Dr. Dagan and his coinvestigators to compare hospitalization rates and pediatric emergency department outpatient visits for diarrheal and lower respiratory viral illnesses among children less than 2 years old during the prevaccine period of April 2006-March 2009 with rates during April 2013-March 2014, when uptake of the two vaccines in that age group exceeded 90%.

This was an unusual study in that it looked at the global impact of two major vaccines. In contrast, vaccine clinical trials and postmarketing studies typically evaluate only those outcomes directly related to that particular vaccine.

The results of the Israeli study were startling: in the 3 years prior to introduction of the vaccines, one in five children under age 2 years admitted to the hospital had as an admitting diagnosis either rotavirus gastroenteritis confirmed by a positive stool ELISA test or pneumococcal pneumonia as evidenced by alveolar pneumonia on chest x-ray. After the vaccines became available, the hospitalization rates for rotavirus gastroenteritis and alveolar pneumonia plummeted by 78% and 46%, respectively. Moreover, outpatient pediatric emergency department visits for rotavirus gastroenteritis dropped by 71% and visits for alveolar pneumonia fell by 67%.

But that’s not all. Smaller yet clinically meaningful reductions were also documented in nonrotavirus gastroenteritis and nonalveolar lower respiratory tract infections. Specifically, the hospitalization rate for nonrotavirus diarrheal illnesses and nonalveolar pneumonia lower respiratory infections dropped by 21% and 7%, respectively, while outpatient emergency visits for those disorders fell by 16% and 14%.

This translates to an estimated 1,890 fewer hospitalizations and 4,030 fewer outpatient emergency department visits for diarrheal disease or lower respiratory infection per 100,000 children under age 2 per year, Dr. Dagan reported.

Michael Schmidt, Ph.D., who chaired a press conference highlighting the Israeli study, declared, “These data are absolutely phenomenal. It really shows the global value of these vaccines for society.”

Dr. Schmidt, professor and vice chairman of microbiology and immunology at the Medical University of South Carolina, Charleston, posed a question: What’s the explanation for the reductions in diseases not directly addressed by those two vaccines?

“We believe that one success can favorably affect the other. If you are weakened by diarrhea, you may be more likely to get pneumonia, and vice versa,” according to Dr. Dagan.

He added that the results actually pack a significantly greater wallop than is apparent at first look because rotavirus gastroenteritis and pneumococcal pneumonia in young children are seasonal diseases. They occur chiefly during October-March. So those 5,920 fewer hospitalizations and outpatient visits/100,000 per young children per year are concentrated during pediatricians’ busiest half of the year.

“In most places in the world, winter is a time of so much illness that pediatricians can’t deliver appropriate care. We knew that in our hospital we couldn’t deliver appropriate care to children in the winter because there were so many sick children piled on top of each other. But now, because of these two vaccines, we are less crowded in the winter, we have more time for children, we make fewer mistakes,” he said.

The study was funded by vaccine manufacturers and the Israel Ministry of Health. Dr. Dagan reported serving as a consultant, adviser to, and/or recipient of research grants from GlaxoSmithKline, Merck Sharp & Dohme, Pfizer, and Genocea.

bjancin@frontlinemedcom.com

SAN DIEGO – The potent synergistic benefits of coadministration of rotavirus vaccine and pneumococcal conjugate vaccine in young children are uniquely highlighted by a natural experiment conducted in southern Israel as described by Dr. Ron Dagan at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Dr. Dagan is professor of pediatrics and infectious diseases at Soroka University Medical Center in Beersheba, Israel. It’s the sole hospital in a large, well-defined area of southern Israel. All children in that part of Israel are born in the hospital and receive their health care there, making it possible to generate highly reliable disease incidence data.

At any given time, physicians at the hospital are responsible for the care of roughly 30,000 children less than 2 years of age. So there’s a huge study population, comprehensive follow-up, and – the final element in this prospective, population-based study – the rotavirus and pneumococcal conjugate vaccines were introduced in Israel just a few years ago and at roughly the same time. This enabled Dr. Dagan and his coinvestigators to compare hospitalization rates and pediatric emergency department outpatient visits for diarrheal and lower respiratory viral illnesses among children less than 2 years old during the prevaccine period of April 2006-March 2009 with rates during April 2013-March 2014, when uptake of the two vaccines in that age group exceeded 90%.

This was an unusual study in that it looked at the global impact of two major vaccines. In contrast, vaccine clinical trials and postmarketing studies typically evaluate only those outcomes directly related to that particular vaccine.

The results of the Israeli study were startling: in the 3 years prior to introduction of the vaccines, one in five children under age 2 years admitted to the hospital had as an admitting diagnosis either rotavirus gastroenteritis confirmed by a positive stool ELISA test or pneumococcal pneumonia as evidenced by alveolar pneumonia on chest x-ray. After the vaccines became available, the hospitalization rates for rotavirus gastroenteritis and alveolar pneumonia plummeted by 78% and 46%, respectively. Moreover, outpatient pediatric emergency department visits for rotavirus gastroenteritis dropped by 71% and visits for alveolar pneumonia fell by 67%.

But that’s not all. Smaller yet clinically meaningful reductions were also documented in nonrotavirus gastroenteritis and nonalveolar lower respiratory tract infections. Specifically, the hospitalization rate for nonrotavirus diarrheal illnesses and nonalveolar pneumonia lower respiratory infections dropped by 21% and 7%, respectively, while outpatient emergency visits for those disorders fell by 16% and 14%.

This translates to an estimated 1,890 fewer hospitalizations and 4,030 fewer outpatient emergency department visits for diarrheal disease or lower respiratory infection per 100,000 children under age 2 per year, Dr. Dagan reported.

Michael Schmidt, Ph.D., who chaired a press conference highlighting the Israeli study, declared, “These data are absolutely phenomenal. It really shows the global value of these vaccines for society.”

Dr. Schmidt, professor and vice chairman of microbiology and immunology at the Medical University of South Carolina, Charleston, posed a question: What’s the explanation for the reductions in diseases not directly addressed by those two vaccines?

“We believe that one success can favorably affect the other. If you are weakened by diarrhea, you may be more likely to get pneumonia, and vice versa,” according to Dr. Dagan.

He added that the results actually pack a significantly greater wallop than is apparent at first look because rotavirus gastroenteritis and pneumococcal pneumonia in young children are seasonal diseases. They occur chiefly during October-March. So those 5,920 fewer hospitalizations and outpatient visits/100,000 per young children per year are concentrated during pediatricians’ busiest half of the year.

“In most places in the world, winter is a time of so much illness that pediatricians can’t deliver appropriate care. We knew that in our hospital we couldn’t deliver appropriate care to children in the winter because there were so many sick children piled on top of each other. But now, because of these two vaccines, we are less crowded in the winter, we have more time for children, we make fewer mistakes,” he said.

The study was funded by vaccine manufacturers and the Israel Ministry of Health. Dr. Dagan reported serving as a consultant, adviser to, and/or recipient of research grants from GlaxoSmithKline, Merck Sharp & Dohme, Pfizer, and Genocea.

bjancin@frontlinemedcom.com

SAN DIEGO – Using a multiplex gastrointestinal PCR test known as the GI FilmArray enabled clinicians to rapidly diagnose infective diarrhea at a children’s hospital, allowing them to free up single rooms for patients presenting with other conditions.

“We have shown that this test can be used for infection control purposes,” Dr. Mitul Patel, a consultant microbiologist at Birmingham (England) Children’s Hospital, said in an interview at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. “People may want to look at this test not just purely from a diagnostic point of view, but as an adjunct to their infection control efforts.”

Manufactured by BioFire Diagnostics, GI FilmArray is a qualitative multiplex gastrointestinal polymerase chain reaction (PCR) which can detect 22 common gastrointestinal pathogens in about 1 hour. Dr. Patel and his associates set out to determine whether diagnosis with the device would facilitate infection control management of pediatric inpatients with diarrhea. “We postulated that if this test is negative, then we have reasonably excluded a pathogenic cause for their diarrhea,” he said. “If the test is negative, then that patient can [safely] be taken out of the isolation and kept on a general ward. In that case, the room can now be used for other patients.”

During a 3-week period in early 2015, the researchers identified 22 patients with a median age of 2 years who were isolated in a single hospital room because of diarrhea. Stool samples obtained from these patients were tested with the GI FilmArray as well as with routine culture for enteric pathogens and testing for Clostridium difficile, rotavirus, and adenovirus by enzyme immunoassay (EIA). Of the 22 patients, 11% (50%) were negative. The GI FilmArray detected a range of pathogens in the remaining 11 patients, including five cases of norovirus, four cases of rotavirus, two cases of Astrovirus, two cases of Sapovirus, and one case of enteroaggregative Escherichia coli. (More than one pathogen was detected in three patients.)

On the other hand, routine culture was negative in all cases, while EIA detected two of the four rotavirus cases that were positive on the GI FilmArray. “By conventional culture and PCR tests, we would have detected only two patients,” Dr. Patel said. “There were nine more patients [for whom] we had an etiological agent known.”

As a result of using the GI FilmArray, two patients were moved out of a single room. “The remaining nine, in spite of having a negative test, still remained in isolation for other reasons,” he said. These included imminent discharge home, protective isolation, and clinician preference.

The researchers acknowledged limitations of the study, including its small sample size, difficulty obtaining stool samples from all symptomatic patients, and the inability of a negative result to fully exclude infection.

They reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Using a multiplex gastrointestinal PCR test known as the GI FilmArray enabled clinicians to rapidly diagnose infective diarrhea at a children’s hospital, allowing them to free up single rooms for patients presenting with other conditions.

“We have shown that this test can be used for infection control purposes,” Dr. Mitul Patel, a consultant microbiologist at Birmingham (England) Children’s Hospital, said in an interview at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. “People may want to look at this test not just purely from a diagnostic point of view, but as an adjunct to their infection control efforts.”

Manufactured by BioFire Diagnostics, GI FilmArray is a qualitative multiplex gastrointestinal polymerase chain reaction (PCR) which can detect 22 common gastrointestinal pathogens in about 1 hour. Dr. Patel and his associates set out to determine whether diagnosis with the device would facilitate infection control management of pediatric inpatients with diarrhea. “We postulated that if this test is negative, then we have reasonably excluded a pathogenic cause for their diarrhea,” he said. “If the test is negative, then that patient can [safely] be taken out of the isolation and kept on a general ward. In that case, the room can now be used for other patients.”

During a 3-week period in early 2015, the researchers identified 22 patients with a median age of 2 years who were isolated in a single hospital room because of diarrhea. Stool samples obtained from these patients were tested with the GI FilmArray as well as with routine culture for enteric pathogens and testing for Clostridium difficile, rotavirus, and adenovirus by enzyme immunoassay (EIA). Of the 22 patients, 11% (50%) were negative. The GI FilmArray detected a range of pathogens in the remaining 11 patients, including five cases of norovirus, four cases of rotavirus, two cases of Astrovirus, two cases of Sapovirus, and one case of enteroaggregative Escherichia coli. (More than one pathogen was detected in three patients.)

On the other hand, routine culture was negative in all cases, while EIA detected two of the four rotavirus cases that were positive on the GI FilmArray. “By conventional culture and PCR tests, we would have detected only two patients,” Dr. Patel said. “There were nine more patients [for whom] we had an etiological agent known.”

As a result of using the GI FilmArray, two patients were moved out of a single room. “The remaining nine, in spite of having a negative test, still remained in isolation for other reasons,” he said. These included imminent discharge home, protective isolation, and clinician preference.

The researchers acknowledged limitations of the study, including its small sample size, difficulty obtaining stool samples from all symptomatic patients, and the inability of a negative result to fully exclude infection.

They reported having no financial disclosures.

dbrunk@frontlinemedcom.com

SAN DIEGO – Using a multiplex gastrointestinal PCR test known as the GI FilmArray enabled clinicians to rapidly diagnose infective diarrhea at a children’s hospital, allowing them to free up single rooms for patients presenting with other conditions.

“We have shown that this test can be used for infection control purposes,” Dr. Mitul Patel, a consultant microbiologist at Birmingham (England) Children’s Hospital, said in an interview at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. “People may want to look at this test not just purely from a diagnostic point of view, but as an adjunct to their infection control efforts.”

Manufactured by BioFire Diagnostics, GI FilmArray is a qualitative multiplex gastrointestinal polymerase chain reaction (PCR) which can detect 22 common gastrointestinal pathogens in about 1 hour. Dr. Patel and his associates set out to determine whether diagnosis with the device would facilitate infection control management of pediatric inpatients with diarrhea. “We postulated that if this test is negative, then we have reasonably excluded a pathogenic cause for their diarrhea,” he said. “If the test is negative, then that patient can [safely] be taken out of the isolation and kept on a general ward. In that case, the room can now be used for other patients.”

During a 3-week period in early 2015, the researchers identified 22 patients with a median age of 2 years who were isolated in a single hospital room because of diarrhea. Stool samples obtained from these patients were tested with the GI FilmArray as well as with routine culture for enteric pathogens and testing for Clostridium difficile, rotavirus, and adenovirus by enzyme immunoassay (EIA). Of the 22 patients, 11% (50%) were negative. The GI FilmArray detected a range of pathogens in the remaining 11 patients, including five cases of norovirus, four cases of rotavirus, two cases of Astrovirus, two cases of Sapovirus, and one case of enteroaggregative Escherichia coli. (More than one pathogen was detected in three patients.)

On the other hand, routine culture was negative in all cases, while EIA detected two of the four rotavirus cases that were positive on the GI FilmArray. “By conventional culture and PCR tests, we would have detected only two patients,” Dr. Patel said. “There were nine more patients [for whom] we had an etiological agent known.”

As a result of using the GI FilmArray, two patients were moved out of a single room. “The remaining nine, in spite of having a negative test, still remained in isolation for other reasons,” he said. These included imminent discharge home, protective isolation, and clinician preference.

The researchers acknowledged limitations of the study, including its small sample size, difficulty obtaining stool samples from all symptomatic patients, and the inability of a negative result to fully exclude infection.

They reported having no financial disclosures.

dbrunk@frontlinemedcom.com