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IDCM Issue 10: Updates for All Providers: Key Studies from IDWeek 2016
November 9, 2016
This year’s IDWeek, the combined annual meeting of the Infectious Disease Society of America (IDSA), the Society of Healthcare Epidemiology of America (SHEA), the HIV Medicine Association (HIVMA), and the Pediatric Infectious Diseases Society (PIDS), convened October 26-30 in New Orleans, Louisiana. The conference features the latest science in the prevention, diagnosis, treatment, and epidemiology of ID. More information about IDWeek2016 can be found on the conference website: www.idweek.org. This issue covers a few of many key findings presented at the conference that are of relevance to providers who see patients with ID issues, either as a primary provider or in consultation.
Epidemiology of the Globally Emerging, Multidrug-Resistant Yeast, Candida auris. Candida auris is a multidrug-resistant yeast first described in Japan in 2009 that has become an emerging healthcare-associated disease globally. Associated with severe infection, C. auris often eludes diagnosis using standard laboratory techniques.1 Infections have occurred in Japan, South Korea, India, Pakistan, South Africa, Kenya, Kuwait, Israel, Venezuela, Colombia, the United Kingdom, and very recently in the United States and Canada. While limited data is available, it has been estimated that invasive infections with this organism are associated with a mortality rate of 60%, although the people who acquire C. auris infection are often already ill.
In a multinational study, authors evaluated a convenience sample of C. auris infections from India, Pakistan, South Africa, and Venezuela during 2012–2015.2 This resulted in isolates from 54 patients. The median time from admission to culture positivity was 17 days. Fluconazole resistance was seen in all isolates, while voriconazole resistance was seen in 54%, and echinocandin resistance was seen in 7%. Amphotericin B resistance testing was conducted in 21 of the 54 isolates, and 29% were found to harbor resistance. Clinical information was available for 31 of the patients; the median age was 54 years. Of these patients, 78% had a central venous catheter, 50% had undergone surgery in the prior 90 days, 47% had recent antifungal therapy, and 42% had Diabetes mellitus. Fungemia was present in 63% of the patients, and 61% died. Given the high mortality rates being seen with C. auris, providers in all fields of medicine must be aware of this emerging disease.
Antibiotics May Be as Helpful as Adjunctive Therapy for Drainage in Uncomplicated Small Skin Abscesses. Findings were presented on a multicenter, prospective, placebo-controlled, double-blind study of 786 outpatient adults and children with uncomplicated skin abscesses ≤to 5 cm in diameter (≤3 cm for ages 6-11 months and 4 cm for ages 1-8 years).3 After an I and D, the patients were randomized to clindamycin, trimethoprim-sulfamethoxazole (TMP-SMX), or placebo. Staphylococcus aureus was cultured from 67% of the patients, while 49% grew MRSA. At 10 days post-therapy, the mean cure rates among subjects receiving clindamycin and TMP-SMX were similar (83.1% and 81.7%, p=0.73), and were greater than placebo (68.9%, p = 0.0001 and p = 0.0008, respectively). Adverse events occurred in 21.9% of the clindamycin group, 11.1% of the TMP-SMX group, and 12.5% of the placebo group. Of note, the majority of these patients had S. aureus infection; whether these results hold for non-S. aureus infections is less clear. Providers must also weigh the risks of antibiotics against an 11% difference in cure at 10 days.
Efficacy and Safety Results of the Monoclonal Antibody Ibalizumab in Treatment-experienced Patients with Multidrug-resistant (MDR) HIV Infection. Ibalizumab (IBA) is a long-acting monoclonal antibody HIV-1 entry inhibitor that is currently in Phase 3 development. The goal of this single arm study was to demonstrate antiviral activity 7 days after initiation of IBA.4 The study enrolled 40 patients with MDR HIV-1 infection who were found to have failed an ARV regimen. The mean age of patients was 51 years; the mean duration of HIV infection was 21 years. Approximately 28% had previously received ≥10 antiretroviral. The mean CD4 count was 161 cells/μL (50% <100 cells/μL), and the mean viral load was 5.0 log10. Patients were given a loading dose of IBA 7 days after they were determined to have failed. After another 7 days, an optimized background regimen was initiated; 35% of the patients had an investigational agent as part of the regimen due to their resistance patterns. A ≥0.5 log10 decrease from BL to day 14 on IBA occurred in 83% of patients. No treatment-related side effects or discontinuations were reported by day 14. This study highlights one of the exciting new directions in HIV therapy: biologics.
Chronic Arthralgia Following Chikungunya Virus (CHIKV) Infection. CHIKV is a viral disease transmitted by mosquitoes. In acute infections, it may cause either mild symptoms or more severe symptoms such as fever, significant joint pain, muscle pain, headache, nausea, fatigue, and rash. Most patients recover without sequelae, but some develop persistent arthralgias.5 Rarely, infected persons may die or develop significant cardiac or neurological symptoms.
This retrospective cohort study was conducted in an area of Colombia in which CHIKV is newly endemic.6 In 171 patients with proven CHIKV between February 2015–March 2016, 45.6% reported persistent rheumatological symptoms. Of these, 100% reported joint pain, 43.9% morning stiffness, 38.6% had joint edema, and 19.9% had joint redness. The results of this study are in accordance with a prior meta-analysis that was multi-country. Providers may consider prior CHIKV as an etiology of chronic arthralgia in patients with typical symptoms from an area with active transmission.
Bottom Line: These studies highlight the breadth of clinical ID—from global emerging diseases to novel therapeutics—seen by ID and non-ID providers alike. The dynamic nature of ID makes it important for providers to stay abreast of the ID literature.
- Centers for Disease Control and Prevention. Candida auris Q&A Web page. http://www.cdc.gov/fungal/diseases/candidiasis/candida-auris-qanda.html Accessed 2016-11-07.
- Etienne K, et al. Epidemiology and whole genome sequence typing of globally emerging, multidrug-resistant Candida auris. Abstract 121 presented at: IDWeek 2016; October 26-30, 2016; New Orleans, LA. http://ofid.oxfordjournals.org/content/3/suppl_1/local/complete-issue.pdf
- Daum Roberts, et al. Clindamycin versus trimethoprim-sulfamethoxazole versus placebo for uncomplicated skin and soft tissue abscesses. Abstract 1684 presented at: IDWeek 2016; October 26-30, 2016; New Orleans, LA. http://ofid.oxfordjournals.org/content/3/suppl_1/local/complete-issue.pdf
- Lalezari J. Primary efficacy endpoint and safety results of Ibalizumab in a phase 3 study of heavily treatment-experienced patients with multidrug-resistant Human Immunodeficiency Virus-1 infection. Abstract LB-6 presented at: IDWeek 2016; October 26-30, 2016; New Orleans, LA. http://ofid.oxfordjournals.org/content/3/suppl_1/local/complete-issue.pdf
- World Health Organization. Chikungunya Fact Sheet. Updated April 2016. http://www.who.int/mediacentre/factsheets/fs327/en
- Rodriguez-Morales AJ, et al. Post-chikungunya chronic inflammatory rheumatism: results from a retrospective 12-month follow-up study of 171 cases in La Virginia, Risaralda, Colombia. Abstract 88 presented at: IDWeek 2016; October 26-30, 2016; New Orleans, LA. http://ofid.oxfordjournals.org/content/3/suppl_1/local/complete-issue.pdf
The Johns Hopkins Center for Clinical Global Health Education is a clinical research, education, and leadership development center in the Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine. We conduct clinical research, and we train, support, and empower healthcare providers and researchers working in resource-limited communities who share our commitment to improve health outcomes.