From the IDSA Meeting: SESSION 34. CLINICAL ISSUES IN THE PRACTICE OF INFECTIOUS DISEASES
Session 34. Clinical Issues in the Practice of Infectious Diseases. No. 127. The complexity, relative value unit (RVU), and cost estimates of curbside consultations in an academic infectious diseases unit.1
Grace et al reported the complexity, RVU, and cost estimates of curbside consultation (CC) in an academic infectious disease (ID) practice. During a 6-month period, this group prospectively evaluated each CC fielded by them. Every CC was assigned inpatient versus outpatient status, initial versus subsequent care, complexity, and a cost estimate. Based on the CPT code, a physician work RVU was given to each CC. According to the recommendations of the Center for Medicare and Medicaid Services 2005, a conversion factor of US$37.89 was used to estimate the cost.
A total of 515 CCs (86 per month) were fielded, of which 65% were outpatient. On a scale of 1 to 5 (where 5 is the highest intensity), 65% were level 4, and 24% were level 5. The following services requested CC-medicine, 42%; FP, 22%; and surgery, 12%. CC accounted for 22% of clinical ID work and generated a large RVU/CC. It resulted in a potential annual revenue loss of US$95,000.00.
To obtain a treatment plan, informal exchange of information occurs frequently in an ID practice and provides an educational benefit.2,3 However, CC may result in improper advice, inappropriate or overuse of antibiotics, and medicolegal claims. It must be recognized that this practice can lead to loss of revenues and liability for the ID consultants. In general, ID physicians should seek formal consultation because it would result in more specific, reliable advice and avoidance of an erosion of revenues.
1. Grace CJ, Kemper A, Ramundo M, et al. Session 34. No. 127 IDSA; 2005.
2. Fox BC, Siegel ML, Weinstein RA. 'Curbside' consultation and informal communication in medical practice: a medicolegal perspective. Clin Infect Dis. 1996;23(3):616-622.
3. Leblebicioglu H, Akbulut A, Ulusoy S, et al. Informal consultations in infectious diseases and clinical microbiology practice. Clin Microbiol Infect. July 2003;9(7):724-726.
From the IDSA Meeting: SESSION 59. SYMPOSIUM ON EMERGING INFECTIONS EMERGENCE OF HEPATITIS E: fsPRESENTED BY GREGORY L. ARMSTRONG1
Dr Gregory Armstrong summarized the clinical features and emergence of hepatitis E. Hepatitis E virus (HEV) is a self-limited acute viral hepatitis. HEV is an icosahedral, nonenveloped RNA virus with structural similarity to the Caliciviridae family.
The most common transmission of the virus is by fecally contaminated water or by enteric means.2 Zoonotic spread occurs occasionally. The highest incidence of HEV infection is seen in Asia, Middle East, Africa, and Central America.
The incubation period of HEV infection ranges from 15 to 60 days. Age group 15 to 40 years has the highest attack rates. The clinical picture of HEV infection is very similar to other acute viral hepatitis, especially hepatitis A. However, unlike hepatitis A, HEV is less readily transmitted, is not as widely distributed, and is less infectious. Following acute HEV infections, fulminant hepatitis occurs infrequently. However, in patients with prior liver disease, HEV infection can lead to hepatic decompensation. During pregnancy, primarily in the third trimester, hepatic failure is more common and results in a mortality of 15% to 25%. The reason for this association is not clearly understood. Acute HEV infection does not result in chronic infection.
Laboratory findings include elevated serum bilirubin, alanine aminotransferase, and aspartate aminotransferase. The diagnosis of HEV infection is based on the detection of IgM antibodies to HEV or by the detection of HEV genome in serum or feces. False-positive results can occur in patients with IgM rheumatoid factor in the serum; therefore, simultaneous detection of anti-IgA HEV can increase specificity.
Treatment and Prevention
There are no recommended treatment strategies for acute HEV infection. Treatment is primarily supportive. Vaccination or immunoglobulin has not shown to confer protection. Travelers to endemic areas should avoid exposure to unsafe food and water.
1. Armstrong G. Emergence of Hepatitis E, Symposium 59, Emerging Infections. San Francisco, CA: IDSA; 2005.
2. Khuroo MS. Study of an epidemic of non-A, non-B hepatitis: possibility of another human hepatitis virus distinct from post-transfusion non-A, non-B type. Am J Med. 1980;68:818.
From the IDSA Meeting: SESSION 11. VACCINES INCREASE IN NONVACCINE-TYPE PNEUMOCOCCAL DISEASE
Session 11. No. 66. Replacement pneumococcal disease: increase in nonvaccine type disease in the era of widespread pneumococcal conjugate vaccination.
Introduction of the pneumococcal conjugate vaccine for infants in 2000 has dramatically reduced disease caused by the 7 serotypes in the vaccine. New information indicates that some types not in the vaccine are increasing in incidence, causing so-called "replacement disease."1 Disease caused by nonvaccine types increased 18% in children younger than 5 years and 13% in adults 65 years or older (both P < 0.05), although the increase in rates of nonvaccine-type disease was small in comparison to the drop seen in rates of vaccine-type disease. Among nonvaccine strains, serotype 19A has increased the most. Genetic analysis suggests that traditional 19A clones are now more frequently isolated from patients with pneumococcal disease and that pneumococci are switching their capsule type from vaccine types to 19A.2
Overall, the pneumococcal conjugate vaccine remains a real public health success story, but the increase in particular nonvaccine-type strains is worrisome and suggests that next-generation vaccines will have to combat additional types. Serotype 19A is often resistant to antibiotics, giving it a selective advantage over most of the other nonvaccine pneumococcal types. The genetic analysis suggests that pneumococci are once again adapting to their environment. In the past, pneumococci have shown their ability to acquire resistance to antibiotics; now, pneumococci are switching capsule structure to avoid the effects of the new conjugate vaccine.
1. Hicks LA, Flannery BL, Beall BW, et al. Paper no. 978. Replacement pneumococcal disease: increase in non-vaccine type disease in the era of widespread pneumococcal conjugate vaccination. In: 43rd Annual Meeting of the Infectious Diseases Society of America, 2006. San Francisco, CA; 2006:215.
2. Pai R, Moore MR, Pilishvili T, et al. Postvaccine genetic structure of Streptococcus pneumoniae serotype 19A from children in the United States. J Infect Dis. 2005;192:1988-1995.
From the Literature: INCREASE IN PNEUMONIA HOSPITALIZATIONS IN THE U.S.
Rates of hospitalization for pneumonia have increased among older adults in the last decade. Investigators from the CDC analyzed data from 1988 to 1990 and 2000 to 2002 from the National Hospital Discharge Survey.1 According to this analysis, pneumonia hospitalizations increased 20% for adults aged 65 to 74 years and 75 to 84 years, but did not increase for adults aged 85 years. Disease rates were high in this oldest age group, however; each year, at least 1 in 20 was hospitalized for pneumonia. The proportion of pneumonia patients with heart or lung disease or diabetes increased from 66% to 77% between the 2 periods.
Despite all the advances in the battle against infectious diseases, pneumonia remains a common problem and is becoming increasingly common with the aging of the US population. In addition, pneumonia patients are more likely to have comorbidities that may complicate their treatment course. Efforts to prevent and optimally treat chronic conditions such as chronic obstructive pulmonary disease and diabetes may lessen the risk for pneumonia or for developing complications from pneumonia. Increasing use of influenza and pneumococcal vaccines may also help.
1. Fry AM, Shay DK, Holman RC, et al. Trends in hospitalizations for pneumonia among persons aged 65 years or older in the United States, 1988-2002. JAMA. 2005;294:2712-2719.
From the Literature: CEPHALOSPORINS ARE USEFUL IN SHORT-COURSE THERAPY FOR GAS TONSILLOPHARYNGITIS
Twenty-two clinical trials involving 7470 patients treated for culture-proven GAS tonsillopharyngitis with either cephalosporins (14 trials) or macrolides (6) were compared to the traditional 10 days of penicillin.1 Short-course cephalosporin therapy was superior for bacterial eradication when compared to 10 days of penicillin. Short-course therapy with macrolides showed no advantage over 10 days of penicillin, and short courses of penicillin were not as effective as the traditional 10 days of therapy. Clinical symptoms were reported to mimic the bacteriologic eradication results.
Like so many other diseases such as bronchitis, sinusitis, community-acquired pneumonia, ventilator-associated pneumonia, and others, it now appears that shorter courses of pharmacodynamically advantageous drugs such as the multitude of oral cephalosporins are effective in the treatment of GAS tonsillopharyngitis. It is not surprising that the macrolides which do not attain high serum or tissue levels were not as effective. It seems likely that clinical pathways will likely adapt these therapies as they will be associated with equal clinical outcomes, less chance for antibiotic overuse and the development of selective resistance, potentially fewer adverse events, and better patient compliance and also be more cost-effective.
1. Casey J, Pichichero M. Metaanalysis of short course antibiotic treatment for GAS tonsillopharyngitis. J Pediatr Infect Dis. October 2005;24(10):909-917.
From the Literature: PARENTS DO WANT ANTIBIOTICS FOR THEIR CHILDREN WITH COUGH AND COLD SYMPTOMS
Fifty-five percent of 539 parents surveyed after their children were evaluated for a cough and common cold symptoms at a university-affiliated pediatric clinic were more satisfied if their child received a prescription for an antibiotic.1 Thirty-seven percent of the parents claimed incomes between US$25,000 and US$75,000 per year, and 30% reported incomes greater than US$75,000 per year.
Despite all the efforts of most medical professional societies including direct-to-consumer advertising concerning the overuse of antibiotics, it appears that more education is necessary. It is more interesting that the more economically advantaged population with access to all forms of education and advertising seemed especially oblivious to the message.
1. Christakis DA, Wright JA, Taylor JA, et al. Association between parental satisfaction and antibiotic prescription for children with cough and cold symptoms. J Pediatr Infect Dis. September 2005;24(9):774-777.
From the Literature: YET ANOTHER POTENTIAL USE FOR MACROLIDES?
It has long been known that some macrolides possess anti-inflammatory properties and some pulmonary diseases such as asthma, panbronchiolitis, cystic fibrosis, and bronchiectasis are thought to respond to the immunomodulatory properties of this class of antibiotics.1 Three cases of idiopathic bronchiolitis obliterans organizing pneumonia and 3 cases of radiation-induced bronchiolitis obliterans organizing pneumonia were treated with macrolides and improved clinically and radiographically. It is postulated that the macrolides anti-inflammatory effect is caused by their effect on phagocytes and their cytokines. The authors suggest that bronchiolitis obliterans organizing pneumonia may be added to the list of pulmonary diseases that benefit from macrolide therapy, not for the antibiotic effect but for the anti-inflammatory effect. They specifically identify 3 groups of patients who are most likely to benefit: (1) patients with minimal symptoms and or minimal physiological impairment, (2) those who use it as an adjuvant to steroid therapy allowing steroids to be rapidly tapered, and (3) patients who cannot tolerate steroids. They also suggest that macrolide therapy be continued for 3 to 6 months.
This is a very small series, but the concept is interesting. Ideally, a study with 3 arms, (1) steroids alone, (2) macrolides alone, and (3) steroids plus macrolides, should be done to accurately evaluate the usefulness of macrolides in bronchiolitis obliterans organizing pneumonia. I would not be surprised to see the practice accepted by pulmonologists and intensivists.
1. Stover D, Mangino D. Macrolides: a treatment alternative for bronchiolitis obliterans organizing pneumonia. Chest. November 2005;128(5):3611-3617.
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