Teams. Teams I.D. YEAR IN REVIEW JANUARY 2010 MARCH 2011 TEAM CHALLENGE. Playing for Team Glory: I.D. Style 6/22/2011

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1 I.D. YEAR IN REVIEW JANUARY 2010 MARCH 2011 TEAM CHALLENGE Playing for Team Glory: I.D. Style Cover subjects that are important, clinically relevant, on the news, or merely interesting Lisa Winston, MD University of California, San Francisco/ San Francisco General Hospital -At least 35% of the team must answer correctly to get credit -Each question is worth 1 point, unless otherwise noted -Have fun! Cal Teams Stanford Proud parasites Teams Mighty Mycobacteria 1

2 PP: A novel antibiotic 1 What makes ceftaroline fosamil unique among cephalosporins approved for use in the U.S.? A. It is active against extended-spectrum betalactamase (ESBL) producing organisms 38% B. It is active again methicillin-resistant Staphylococcus aureus C. It has activity against Pseudomonas 15% aeruginosa that are resistant to other cephalosporins D. The fosamil part of ceftaroline fosamil inhibits AmpC beta-lactamases 26% 21% Ceftaroline fosamil Ceftaroline fosamil is the prodrug form; converted to the active form ceftaroline in vivo Like other beta-lactam antibiotics, acts by binding to penicillin-binding proteins in the cell membrane Unlike other beta-lactams, binds to and inhibits the modified penicillin-binding protein PBP 2a found in MRSA Not active against ESBL producing Gram negatives; limited against Pseudomonas aeruginosa and Acintobacter baumanii FDA approved skin and soft tissue infections, CAP MM: Pertussis 2 Which of the following statements is NOT true? A. In the 2010 outbreak in California, there were 10 infant deaths reported B. In 2010 in the U.S., the increase in pertussis cases was largely limited to California C. In California in 2010, 9,477 cases of pertussis were reported, the most since 1945 D. The highest age-specific rates have been in Hispanic infants < 6 months of age 6% 59% 9% 26% 2

3 PP: Clostridium difficile 3 Which of the following statements is true? A. Stool culture is the most commonly used method for diagnosing C. difficile infection B. Oral metronidazole and oral vancomycin are thought to be equal for treating severe disease C. Diarrhea is the most predictive sign or symptom of C. difficile infection 21% 26% 40% D. The relapse rate after responding to initial therapy approaches 50% 12% 3

4 Clostridium difficile Infection (CDI) Clostridium difficile Infection (CDI) Diagnosis is made by toxin detection: most commonly by enzyme immunoassay (EIA), 2- step tests using glutamate dehydrogenase for screening, or polymerase chain reaction (PCR) Toxigenic stool culture is the gold standard Most patients with CDI have diarrhea at least 3 loose stools in 24 hours Relapse rate after first episode about 20% Oral vancomycin considered drug of choice for severe disease Prevalence has increased in North America Evidence of increased virulence/worse outcomes NAP1/BI/027 strain may be implicated high levels of toxin A and B production Exposure to antibiotics remains most important risk factor Increased attention to community cases MM: Another new antibiotic 4 Results of a trial of oral fidaxomicin versus oral vancomycin for treatment of C. difficile infection were recently reported. The main advantage of fidaxomicin appeared to be Infect Control Hosp Epidemiol 2010;31(5): A. Higher rates of initial clinical cure B. Fewer adverse effects C. Improved clinical cure rates in female patients D. Lower relapse rates in those without the NAP1/BI/027 strain 29% 12% 3% 56% 4

5 PP: Catheter-associated urinary tract infection 5 Per guidelines published in March 2010, catheterassociated urinary tract infection is defined by the presence of signs or symptoms compatible with UTI with no other identified source and at least how many colony forming units/ml of bacteria N Engl Med 2011;364: A % Macrocyclic antibiotic (new class): inhibits RNA polymerase Narrow spectrum, high stool levels, high levels in vitro C. difficile activity Just approved by the FDA B C D % 20% 6% Catheter-Associated UTI: Potpourri Catheter-Associated UTI: Potpourri CA-UTI defined as at least 1,000 cfu/ml in catheterized urine specimen plus compatible symptoms with no other identified source Symptoms include fever, rigors, altered mental status, malaise, flank pain, CVA tenderness, hematuria, pelvic pain Presence and degree of pyuria cannot be used to diagnose UTI Absence of pyuria in a symptomatic patient suggests an alternate source of symptoms Condom catheterization should be considered as an alternative to reduce catheter-associated bacteriuria (data not sufficient for recommendation re UTI) For catheters in place at least 2 weeks, decreased bacteriuria and faster resolution of symptoms when replaced at time of treating for UTI (one small study) Seven days of therapy for most patients (limited data) 5

6 Finally Catheter-Associated UTI: Guidelines Remember to remove urinary catheters and to place them judiciously Catheter-associated UTI is a CMS never event Clinical Infectious Diseases 2010;50: MM: Just for fun 6 Which of the following conditions is NOT caused by a virus? A. Kennel cough B. Canine distemper C. Proventricular dilatation disease D. Feline leukemia 12% 26% 56% 6% Proventricular Dilatation Disease Often fatal disease of psittacine birds (parrots) Affects the autonomic nerves of the upper and middle digestive tract Birds develop gastrointestinal tract dysfunction and/or neurological symptoms Dilated and non-motile proventriculus Now, evidence that avian bornavirus infection is causal May be analogous to the human disease achalasia 6

7 PP: Infestations 7 Spinosad is a new treatment for A. Head lice B. Bed bugs C. Scabies 23% 31% 31% Bed bug Sarcoptes scabiei D. Body lice 14% Head louse 7

8 Spinosad and head lice Estimated 6-12 million infestations with head lice yearly Combined annual direct and indirect costs about $1 billion Permethrin is not ovicidal, and many lice are resistant Spinosad is produced by the soil bacterium Saccharopolyspora spinosa Appears non-toxic to mammals Spinosad and head lice Spinosad was more effective than permethrin in two combined phase 3 trials 85% versus 44% lice free after treatment Nit combing not required Usually only one application FDA approved January 2011 for persons 4 years and older MM: New and scary beta-lactamases 8 Stough et al. Pediatrics 2009;124:e The Verona integron-encoded metallo-betalactamase (VIM) and the New Delhi metallobeta-lactamase (NDM-1) have both recently been reported in the United States in which type of organism A. Staphylococcus aureus B. Enterococci C. Enterobacteriaceae D. Candida tropicalis 22% 33% 36% 8% 8

9 Metallo-beta-lactamases Production of beta-lactamases is a primary mechanism of resistance among Gram negative bacteria Metallo-beta-lactamases (MBL) hydrolyze almost all beta-lactams, including carbapenems In recent years, MBL have been found on mobile genetic elements and have spread to Enterobacteriaceae NDM-1 has been linked to medical care in India A VIM-producing Klebsiella pneumoniae has been linked to medical care in Greece MMWR 2010;59:1212 MMWR 2010;59:750 PP: Fungus in the news 9 Which of the following fungi made the news in 2010 due to cases detected in the Pacific Northwest? A. Cryptococcus gattii B. Cryptococcus seattlei C. Cryptococcus vancouverii D. Cryptococcus neoformans var. grubii 19% 17% 11% 53% Cryptococcus gattii Before 1999, C. gattii thought to cause disease in immunocompetent hosts in tropics and subtropics 1999 outbreak in animals and humans on Vancouver Island; in 2004 among mainland British Columbia residents Several hundred cases Case reported in Oregon 2004 From 2004 July 1, 2010: 60 human cases in U.S. Cases in patients with and without immunocompromise Respiratory and CNS disease 9

10 MM: Infection control lapses 10 MMWR 2010;59: What infection was transmitted at a Las Vegas endoscopy clinic due to unsafe injection practices? A. HIV B. HBV C. Syphilis D. HCV 7% 29% 5% 60% Unsafe injection practices Eight patients acquired hepatitis C after undergoing endoscopy at a clinic in Las Vegas, Nevada Two clusters of disease were identified Transmissions linked to use of single-use propofol vials for multiple patients and re-entry of the vial with used syringes ~50,000 people exposed to unsafe practices were notified, the largest public health notification of this kind Lawsuits are settling in 2010 Clin Infect Dis 2010;51:

11 PP: Surgical site antisepsis 11 In 2010, a multicenter study reported results regarding surgical site antisepsis and risk of surgical site infection (SSI) in clean-contaminated surgery. The study results favored which of the following 38% A. Povidone-iodine B. Chlorhexidine-alcohol C. Povidone-iodine plus chlorhexidinealcohol D. Isopropyl alcohol alone 29% 24% 9% 849 subjects at 6 sites randomized Overall rate of SSI: 9.5% chlorhexidine-alcohol group vs. 16.1% povidone-iodine group MM: More on infection prevention 12 In a study published in 2010, the relative risk of Staphylococcus aureus infection in S. aureus nasal carriers undergoing surgery who were treated with intranasal mupirocin and chlorhexidine soap vs. placebos was A B C D % 33% 21% 10% 808 S. aureus nasal carriers underwent surgery and were randomized to intranasal mupirocin + chlorhexidine soap or placebos The rate of S. aureus infection was 3.4% in the treatment group vs. 7.7% in the placebo group (RR=0.42, 95% CI ) 11

12 PP: Antivirals for influenza 13 Which of the following statements regarding oseltamivir is false? 1. Should be given intravenously to severely ill patients, e.g. those in the ICU 45% 2. When given to healthy persons with influenza within 48 hrs. of symptom onset, shortens duration of symptoms by about 1 day 15% 3. Probably decreases mortality in inpatients 4. Should be given to pregnant women with influenza 13% 28% Influenza treatment with oseltamivir or zanamivir Groups recommended for treatment Age < 5 years (especially age < 2 years) Age > 65 years Chronic diseases: pulmonary, cardiovascular, renal, hepatic, neurologic, metabolic (including DM) Immunosuppressed, including HIV Pregnant or post partum (within 2 weeks) Children receiving long-term aspirin American Indians/Alaskan Natives Morbid obesity, BMI > 40 Residents of nursing homes and chronic care facilities MMWR, January 21, 2011/60(RR01):

13 MM: Tuberculosis 14 Extensively drug-resistant tuberculosis (XDR TB) is defined as resistance to A. INH + rifampin B. INH + riframpin + any fluoroquinolone C. INH + riframpin + any fluoroquinolone + an injectable drug (amikacin or kanamycin or capreomycin) D. INH + riframpin + any fluoroquinolone + an injectable drug (amikacin or kanamycin or capreomycin) + ethambutol 14% 31% 25% 31% Xpert MTB/RIF is an automated molecular test for tuberculosis and rifampin resistance performed on sputum samples Developed in public-private partnership Encouraging results: test is both sensitive and rapid (< 2 hours) 13