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August 7, 2019

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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.

Click here for the previous edition of Journal Club. For a review of other recent research in the infectious diseases literature, see “In the Literature,” by Stanley Deresinski, MD, FIDSA, in each issue of Clinical Infectious Diseases.

 

Zeina A. Kanafani, MD, MS, FIDSA.jpgChlorhexidine Use in Meatal Cleaning to Reduce Catheter-Associated Urinary Tract Infections

Reviewed by Zeina A. Kanafani, MD, MS, FIDSA

The use of urinary catheters is associated with the development of asymptomatic bacteriuria as well as symptomatic urinary tract infection in a considerable proportion of hospitalized patients. This occurs despite efforts to implement the urinary care bundle advocated by infection control programs. Therefore, there has been interest in evaluating the efficacy of a variety of agents for meatal cleaning before catheter insertion.

In a recent stepped-wedge, randomized controlled trial reported in Lancet Infectious Diseases, the investigators examined whether the use of chlorhexidine for meatal cleaning was effective and safe in reducing catheter-associated urinary tract infections (CAUTIs) in three hospitals in Australia. A total of 945 patients received the intervention (0.1 percent chlorhexidine solution) and were compared to 697 controls in whom meatal cleaning was performed using 0.9 percent normal saline.

Over the entire study duration, 16 cases of asymptomatic bacteriuria were detected during the intervention period (0.68 per 100 catheter-days) compared to 29 cases during the control period (1.00 per 100 catheter-days). This amounted to a 74 percent reduction in the incidence of asymptomatic bacteriuria (P = 0.026). Similarly, the number of CAUTI episodes was also reduced during the intervention period (4; 0.17 per 100 catheter-days) compared to the control period (13; 0.45 per 100 catheter-days), with a 94 percent reduction in the incidence of CAUTI (P = 0.0008). This effect was uniformly observed across all three participating hospitals. Chlorhexidine was well tolerated and no adverse events were recorded in either study arm.

The investigators, therefore, concluded that 0.1 percent chlorhexidine solution can be used effectively and safely for meatal cleaning prior to catheter placement in order to reduce the incidence of asymptomatic bacteriuria and CAUTI.

(Fasugba et al. Lancet ID. 2019;19(6):P611-619.)

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Christopher J. Graber, MD, MPH, FIDSA.jpgUsing Point-of-Care C-Reactive Protein to Guide Antibiotic Use in COPD Exacerbations

Reviewed by Christopher J. Graber, MD, MPH, FIDSA

The role of antimicrobial therapy in managing exacerbations of chronic obstructive lung disease (COPD) has long been controversial. The Global Initiative for Chronic Obstructive Lung Disease guidelines currently recommend antibiotics for patients with increased dyspnea, increased sputum volume, and increased sputum purulence (or increased sputum purulence with only one other criterion), but these criteria may not be particularly specific in predicting a bacterial trigger of the exacerbation.

C-reactive protein (CRP) has been found to have some predictive value in response to antibiotic therapy in COPD exacerbation, so investigators (in a recent report in The New England Journal of Medicine) randomized patients presenting with COPD exacerbations at any of 86 general practices in Great Britain to have CRP checked at the point-of-care with recommendations to prescribe antibiotics based on its result versus usual care. Antibiotics were discouraged for CRP less than 20 mg/L, noted to be potentially beneficial for CRP 20-40 mg/L (especially if purulent sputum was present), and encouraged for CRP greater than 40 mg/L.

In the 653 patients that underwent randomization, the CRP group had significantly less antibiotics prescribed (57 percent vs. 77 percent) with a slightly lower total score on the Clinical COPD Questionnaire (favorable, though not deemed clinically important) and no evidence of increased adverse outcomes. While this study cannot be interpreted to prove that a low CRP level indicates no role for antibiotics (33 percent of patients with CRP less than 20 mg/L still received antibiotics, compared to 84 percent for CRP 20-40 mg/L and 95 percent for CRP > 40 mg/L), it does serve as validation of a potential strategy to give providers point-of-care data that can help them withhold antimicrobial therapy in some exacerbations that may be lower-risk.

(Butler et al. N Engl J Med. 2019;381(2):111-120.)

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Erica Kaufman West, MD.jpgWhen Bactrim Isn’t an Option: An Alternative Treatment for Pneumocystis Pneumonia

Reviewed by Erica Kaufman West, MD

While the incidence of Pneumocystis jirovecii pneumonia (PJP) has gone down, it remains the most common opportunistic infection in HIV-infected patients not on antiretroviral therapy, mostly in those who do not know they are positive. Trimethoprim-sulfamethoxazole (TMP-SMX) is the drug of choice for the treatment of PJP. However, it is contraindicated in those with severe sulfa allergy and glucose-6-phosphate dehydrogenase deficiency, and has known toxicities that some patients cannot tolerate. Second-line options, such as pentamidine, clindamycin and primaquine, atovaquone, or dapsone and trimethoprim carry their own toxicities or are only indicated for mild-to-moderate disease.

Pneumocystis species utilize 1,3-beta-D-glucan in its cyst’s cell wall, making echinocandins (an inhibitor of 1,3-beta-D glucan) a logical option. A recent retrospective AIDS study from Taiwan looked at adult HIV+ patients with PJP who could not take TMP-SMX or who had no response to it. They found 34 patients who took echinocandins: The majority (32) received TMP-SMX first, and 21 switched to echinocandin monotherapy. Seven patients died (five related to PJP). Overall, nine patients had TMP-SMX failure, and their in-hospital mortality rate was 44 percent (4/9). Patients who switched because of side effects had a smaller 12 percent in-hospital mortality rate (3/25).

The authors point out that data regarding echinocandin use in PJP is very small, and more data is needed, but their experience gives hope for those patients for whom TMP-SMX and even second-line therapies are not options. It would be great to see studies looking at combination therapies (e.g., TMP-SMX + echinocandins), the use of steroids with echinocandins, and whether one echinocandin is superior in efficacy.

(Huang et al. AIDS. 2019;33(8):1345–1351.)

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For a review of other recent research in the infectious diseases literature, see “In the Literature,” by Stanley Deresinski, MD, FIDSA, in each issue of Clinical Infectious Diseases:

August 15

  • Every Day of Antipseudomonal β-Lactam Antibiotic Administration Is Associated With a Risk of Selection of Resistant Pathogens
  • Not All Sepsis Deaths Are Preventable
  • Case Vignette: Parvovirus B19 and Acute Hepatic Failure

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