Journal Club
In this feature, a panel of IDSA members identifies and critiques important new studies in the current literature that have a significant impact on the practice of infectious diseases medicine.
- ID and OB: Encouraging Our Colleagues to Do What’s Right on HCV Testing
- ID Consultation and Outcomes of Patients with Candida Bloodstream Infections
- Shorter Is Better, Except When Maybe It Isn’t
- Don’t Forget Syphilis Screening for Cisgender Women with HIV
Did you miss the previous edition of Journal Club? You can find it and other past installments in the IDSA News archives. For a review of other recent research in the infectious diseases literature, see “In the Literature,” by Stanley Deresinski, M.D., FIDSA, in each issue of Clinical Infectious Diseases.
ID and OB: Encouraging Our Colleagues to Do What’s Right on HCV Testing
Reviewed by Erica Kaufman West, M.D.
Almost every young woman I see with hepatitis C virus (HCV) infection is incredulous when I explain that their obstetrician did not, in fact, test them for HCV when they were pregnant. This conversation is occurring more frequently with the incidence of chronic HCV in pregnant women doubling from 2009 to 2014. Guidelines from IDSA and the American Association for the Study of Liver Diseases, and recent editorials in Clinical Infectious Diseases and Hepatology, stand in contrast to recommendations from the Society for Maternal-Fetal Medicine and the Centers for Disease Control and Prevention for “risk-based testing.”
While the historical inadequacy of risk-based testing for hepatitis B virus and HIV should be enough to justify universal screening for HCV in pregnant women, the authors of a recent article in Clinical Infectious Diseases looked at the ever-present question of cost-effectiveness. It is estimated that about 42,000 pregnancies and 29,000 births occur to HCV+ women each year. The authors compared risk-based versus universal HCV screening among pregnant women in the U.S., tying treatment into their cost equation. Utilizing national and state-supplied data on pregnancy rates, birth rates, HCV prevalence, and HCV treatment costs, they found that universal HCV screening was associated with an incremental cost of $53.20. They also found that screening for pregnant women, even in scenarios with treatment reimbursement restrictions, was cost-effective compared to risk-based screening, with mean incremental cost effectiveness ratios of < $3,000 per quality-adjusted life-year gained, well below the willingness-to-pay threshold of $50,000 per quality-adjusted life-year.
Most importantly, screening could additionally result in the detection and treatment of an estimated 300 children born to mothers infected by HCV, and many more if the rate of 18-month HCV testing of children born to HCV-infected mothers increases from the current dismal rate of 16%. A 2019 CROI abstract showed promising phase 1 data from treating pregnant women for HCV, yet another reason to implement universal screening. We, as ID physicians, need to take this opportunity to encourage our OB colleagues to change their practices. If not us, then who? If not now, then when?
(Chaillon et al. Clin Infect Dis. 2019;69(11):1888–1895.)
ID Consultation and Outcomes of Patients with Candida Bloodstream Infections
Reviewed by Zeina Kanafani, M.D., M.S., FIDSA
Candida bloodstream infections (BSIs) are common and associated with considerable mortality. Since worse outcomes have been linked to delayed antifungal therapy, efforts should always focus on prompt initiation of treatment, according to evidence-based guidelines. Several studies have found that an infectious diseases (ID) consultation results in better quality of care and treatment outcomes in various infection syndromes.
In this latest study, published in Lancet Infectious Diseases, the investigators undertook a retrospective, single-center cohort analysis of all patients with Candida BSI between 2002 and 2015. The management of Candida BSI was evaluated based on choice of antifungal agents, length of therapy, central venous catheter removal, performance of echocardiography, ophthalmology consultation, ID consultation, and timing of ID consultation.
A total of 1,691 patients were included in the analysis, 776 (45.9%) of which had an ID consultation. Antifungal therapy was initiated in 1,550 cases (91.6%), with azoles being the most used (46.9%). Of the 141 patients who did not receive antifungal therapy, only 13 (2%) had an ID consultation compared to 128 (14%) in the non-consultation arm (P < 0.0001). In addition, patients in the ID consultation group received longer duration of therapy and were more likely to have central venous catheter removal, echocardiography, and ophthalmological evaluation. Hence, more cases of endocarditis and endophthalmitis were diagnosed in the consultation group.
The mortality rate was lower in the ID consultation arm at 42 days (22% vs. 47%; P < 0.0001) and 90 days (29% vs. 51%; P < 0.0001). Further analysis found that ID consultation resulted in a 19% survival benefit. The investigators conclude that an ID consultation provides substantial benefit in various treatment aspects and in the survival of patients with Candida BSI, and they advocate for ID consultation to be an integral part of these patients’ care.
(Mejia-Chew et al. Lancet Infect Dis. 2019;19(12):1336–44.)
Shorter Is Better, Except When Maybe It Isn’t
Reviewed by Christopher J. Graber, M.D., MPH, FIDSA
Antibiotics are frequently given for longer durations than necessary with untoward effect. Many studies have shown therapeutic equivalence in prescribing shorter regimens than what has been traditionally prescribed for many infectious conditions such as pneumonia, urinary tract infection, and bacteremia. However, a complementary effort must be made in antimicrobial stewardship to identify situations where the “shorter is better” mantra may not necessarily hold true.
A brief report recently published in Clinical Infectious Diseases summarizes a subgroup analysis of data from a randomized controlled trial of clindamycin versus trimethoprim-sulfamethoxazole versus placebo in conjunction with incision and drainage for skin abscess < 5 cm in which the 10-day cure rate with either antibiotic was higher than with placebo. Adherence with a 10-day course was assessed by pharmacist assessment of blister packs and patient report; 77% were compliant with their entire course. Patients who completed greater than 5 days of their antibiotic course had a 97% cure rate at early follow-up, versus 48% for those completing 5 days or less (odds ratio 41, 95% confidence interval 15-112). Similar findings were seen for those completing greater than 7 days versus 7 days or less (98% versus 63%, odds ratio 25). At one month after treatment completion, differences in cure rate remained significant for both the 5- and 7-day cutoffs (odds ratios 19 and 8.8, respectively). Abscess size was not associated with cure at either timepoint.
While this report was limited by an intention to treat for 10 days in all patients (i.e., confounding may exist for treatment failure in patients not fully compliant with their antibiotic course), it suggests that shortening antibiotic treatment for skin abscess to 7 days or less may be associated with decreased rate of cure. While, in general, efforts to promote shorter durations of antibiotic therapy remain in order for many infectious conditions, the management of skin and soft tissue infection may require more individualization.
(Lake et al. Clin Infect Dis. Published online: Nov. 18, 2019.)
Don’t Forget Syphilis Screening for Cisgender Women with HIV
Reviewed by Brian R. Wood, M.D.
Clinicians across the country can attest to recent surges in new syphilis infections. In HIV clinical practice, screening often focuses on men who have sex with men, who, from 2000 to about 2013, contracted syphilis more frequently than other demographic groups. However, the epidemic has shifted, with escalating rates in heterosexual individuals, women (including pregnant women), people who inject drugs or use methamphetamine, and homeless individuals. Investigators recently assessed incidence of new infections and risk factors in a large, diverse cohort of cisgender women with HIV in the United States. The results provide informative reminders for practitioners.
In the analysis, published in Clinical Infectious Diseases, researchers retrospectively assessed data from the CNICS cohort, which includes eight urban HIV clinics, from 2005 to 2016. They identified 4,416 cisgender women tested for syphilis (64% black, 18% with reported injection drug use as their risk factor for HIV, and 23% with hepatitis C coinfection). The annual syphilis testing rate ranged from 55% to 69%. Of women tested, 9.4% had syphilis, for an annual incidence of 760 per 100,000 person-years (nearly 1 in 10). The rate was similar when limited to women aged 18 to 49 years.
Importantly, the multivariate analysis identified predictors of syphilis for cisgender women with HIV. These include injection drug use as the reported HIV risk factor, black race, hepatitis C coinfection, and more recent enrollment in HIV care (2011-2016 compared to 1994-2004). Additionally, detectable HIV RNA emerged as a risk factor for syphilis for women age 18 to 49, and younger women (age 18 to 29) were more likely to contract syphilis as compared to women over age 50, though this association did not reach statistical significance.
As the authors note, national guidelines recommend annual syphilis screening for all sexually active adults with HIV, with more frequent screening (every 3 to 6 months) indicated for those with increased sexual risk. The results of this study underscore the importance of regularly asking women in HIV clinics about drug use and sexual practices, screening for syphilis routinely, and updating guidelines to reflect all predictors of infection. While this analysis was limited to cisgender women, the authors highlight that an evaluation for transgender women is ongoing. Finally, the overlap between recent epidemics of injection drug use and syphilis is striking, and targeted efforts and resources are needed to quell both.
(Dionne-Odom et al. Clin Infect Dis. Published online: Nov. 12, 2019.)