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Daptomycin as Frontline Therapy for MRSA Bacteremia: Has the Time Come?

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Kevin J. Downes, MD, and Contagion® Section Editor Conan MacDougall, PharmD, MAS, BCPS, BCIDP, discuss these important topics as another season approaches.

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Laurie Saloman is a seasoned medical journalist who has written extensively about HIV, influenza, Zika, Covid-19, cancer, endocrine disorders, mental illness, and other infectious and non-infectious diseases. Her work has appeared in Contagion, The American Journal of Managed Care, Pfizer’s Breakthroughs.com, Health After 50, and the journal of the Emergency Nurses Association, among others. A member of the Association of Health Care Journalists and the American Society of Journalists and Authors, Laurie lives in New Jersey with her family. You can reach her on Twitter: @LaurieSaloman

 comes the unfortunate reality of significant numbers of orphaned children. A new study published in 

 who have lost at least 1 parent and are living either in an institutional setting, with extended family, or on the streets.

 was led by Paula Braitstein, PhD, MA, MSc, an epidemiologist and environmentalist in the division of epidemiology at the Dalla Lana School of Public Health, University of Toronto, who is currently based in Kenya. It followed 2,551 Kenyan children—1230 each in institutional and family-based settings and 91 in a street setting. The children were enrolled between 2010 and 2013 and were followed through 2019. All were 18 or younger, with a mean age at enrollment of 10.4 years.

More than 85% of those in an institutional setting had lost both parents, as had 78% of those on the streets—a significantly higher percentage than the 39.6% of children in family-based settings who were double orphaned.

When first recruited into the study, 77 children were HIV positive. This included 53 children in institutional care (4.3%), 23 children in family care (1.9%), and 1 child in a street setting (1.1%). During the course of the study, 31 children, or 1.2% of the total, became infected with HIV, and 28 (1.1%) died. Expressed in terms of cases of HIV per person-years, there were 2.2 cases per 1000 person-years (95% confidence interval, 0.5-3.8 cases per 1000 person-years) for those in institutional settings, 1.2 cases per 1000 person-years (95% confidence interval, 0.2-2.1 cases per 1,000 person-years) for children in family-based settings, and 15.5 cases per 1,000 person-years (95% confidence interval, 3.1-27.1 cases per 1000 person-years) for youths living on the streets.

The death rate was 0.3 per 1000 person-years (95% confidence interval, 0-0.9 deaths per 1000 person-years) for children in institutional settings, 2.2 deaths per 1000 person-years (95% confidence interval, 0.9-3.5 deaths per 1,000 person-years) for those in family settings, and 8.6 deaths per 1000 person-years (95% confidence interval, 0-17.9 deaths per 1000 person-years) for children living on the streets.

Children living on the streets also became infected and/or died more quickly than their peers being cared for in institutions or family settings, with the time until infection with HIV or death expressed as 3.0 cases or deaths per 1,000 person-years (95% confidence interval, 1.1-4.9 cases or deaths per 1000 person-years) in institutional settings, 3.4 cases or deaths per 1000 person-years (95% confidence interval, 1.8-5.0 cases or deaths per 1000 person-years) in family settings, and 25.7 cases or deaths per 1000 person-years (95% confidence interval, 10.1-40.1 cases or deaths per 1000 person-years) for children on the streets.

Although an earlier meta-analysis of studies of orphaned children and HIV/death status indicated worse outcomes for children in institutional care versus family-based care, this was not the case in the current study. According to Braitstein, 1 reason is the studies in the meta-analysis took place in Eastern Europe and focused on government-run orphanages notorious for poor treatment of children. The findings of the current study were, however, consistent with those of other studies that took place in sub-Saharan Africa, which found that deep poverty, family strife, and abuse in the home mean family-based settings may have inherent vulnerabilities compared with institutional ones.

“Although all the institutions in our study have their own financial struggles, on average they are better resourced materially than most of the family-based settings,” Braitstein said. “Clearly, having things like a blanket, enough food, and consistent and predictable education (i.e., payment of fees and related costs) enhances the well-being of children when measured in physical ways, like nutritional status, for example.”

The institutions also may keep children under closer watch than extended families do, meaning children in these facilities may be less likely to engage in sex for money or goods such as clothes and phones, or to endure the rapes and forced sexual partnerships common in street life. Institutional settings may offer “art classes, sports, and other structured activities, the opportunity to volunteer in a church or civic context, and better family/social/peer support,” Braitstein said. “We have found that many of the institutions in the study try hard to create a family atmosphere, where they are organized into households headed by a house mother and, usually, a father, plus their biological children. The whole ‘family,’ including all the orphaned children, eat together, pray together, and so on.” The mental health of orphans in institutions also may be superior to those in home settings due to the availability of social workers and other counselors trained to deal with trauma.

The study’s strengths include the incorporation of a small but significant cohort of children living on the streets as well as a follow-up period of almost a decade. Its limitations are a lack of long-term outcomes for all cohorts and a shorter follow-up period for children living in institutional settings, probably because Kenyan law means all children leave these settings by age 18.

homeless and under-housed children worldwide

 are at significantly higher risk of HIV and early death, among other negative outcomes, and how to best care for these minors is a question with which all nations must grapple. Clinicians have an opportunity to assess minors and intervene when necessary. “Do not assume that orphaned or separated children who are living with family are okay,” she stressed. “Do not assume that orphaned or separated children living in an institution are not okay. And perhaps most importantly, assume that any homeless child or youth who comes into your clinic needs your help, compassion, and support.”

Articles

Parentless youth living on the streets had the highest rates of HIV and death, but extended-family living situations were not necessarily better than institutional care.

HIV and Kenyan Orphans: Those in Institutional Care May Fare Best

. Prior to joining MJH Life Sciences in 2020, he has covered a variety of fields and markets including diabetes, oncology, ophthalmology, IT, travel, and local news. You can email him at 

With the different modes of transmission and the variability in their incidence rates, infectious disease outbreaks can be difficult to manage once they appear. 

The introduction of COVID-19 reaffirmed how quickly an infectious disease can take hold and how dangerous a viral pathogen can be to a larger, global population.

Ebola, on the other hand, has had very bad regional outbreaks in various countries within Africa. And while its mode of transmission is different (through body fluids), the fear it could spread to other areas in the world remains intense due to the disease’s harmful effects and potential mortality. Ebola’s 

 according to the World Health Organization, but there is also great variability with rates ranging from 25% to 90% from past individual outbreaks. 

is a mysterious fungal infection and not much is fully known for why outbreaks appear. It remains highly contagious in health care settings and is often multidrug resistant. Similar to Ebola, the mortality rates for 

 vary greatly according to Jeffrey Rybak, PharmD, PhD, instructor, Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital.

Outside of a smattering of cases in Europe and the US, Ebola outbreaks have remained on the African continent. Conversely, 

 has had outbreaks in several continents occurring simultaneously, according to Rybak.

In the second installment of an interview with 

Rybak discusses outbreaks across different geographic locations including one where there was a high incidence rate of COVID-19, 

 mortality rates, and whether it has enough durability that will provide it with a sense of permanency and therefore remain a concern in public health for years to come.

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The emergence of this fungal infection remains mysterious as the world experiences more outbreaks. 

Considering Candida Auris Outbreak Behavior

 Tavell, how are you supporting your patients? Obviously having HIV [human immunodeficiency virus] as a patient is becoming more complicated. How can you support these people? Some of our patients come to us and see the clinic as a big supporter in their life. They may not have family or friends supporting them. How are you supporting your patients in the clinic?

 When we meet them initially, it’s to establish that rapport with them and let them know we have a committed team of individuals who are here to help whatever it is that they’re dealing with. Because we know that whatever barriers that are there, be it housing, transportation or lack thereof, lack of finances, lack of food, all those things can significantly impact someone’s ability to become undetectable and in viral suppression. 

Our support team wraps a lot of resources around people when they initially come to see us. There’s an initial assessment that’s done. You try to uncover some things that may be there. Sometimes patients are just shocked that they’ve received the diagnosis, so we may not get all the information initially, and that’s OK. As they continue to come back to us, we can break it down so it won’t be overwhelming and then try and get those individuals’ needs addressed. Over time, we need to build that rapport and that relationship, and I’m all about relationships. My patients can text me whenever they need something. Some just stop by to say hello, and that’s when you’ve gotten to a point where you have a good relationship and you’ve broken down those stigmatizing things that patients are experiencing. 

When they come by just to say hello and see how you’re doing, you’ve helped them to self-actualize as someone who is going to do well. Even though they have an HIV infection, they’re going to live a healthy and full life. We take it individual-by-individual. We have case managers, linkage to care coordinators, and HIV prevention coordinators. That role is interesting because not only are they educating individuals and making sure they know about PrEP [pre-exposure prophylaxis] and access to PrEP, but they’re also helping patients understand that when they are undetectable, doing all the right things, and taking their medications like they’re supposed to, they’re not going to be transmitting HIV to others. Quality of life is a true issue. Oftentimes patients will ask me, “Can I have children?” “I’m worried that I’m going to give HIV to my fiancée, or my female partner, or my wife.” Or there’s a woman living with HIV who is worried about giving HIV to her baby. We have to strategically talk to patients, making sure that we give clear, correct messages, and make sure they understand that we’re here for them along the journey as a cohesive team and as a complete team to give them everything that they need to make sure they are successful.

Yes, we do, and some individuals don’t want to participate in the larger groups, so we have individual support. I have several women who are newly diagnosed and struggling, and we’ve paired them with other women who have lived experience with HIV, and they are working closely with them. We see a lot of improvement with them. Otherwise, for individuals who want to participate in the larger groups, they can. Some individuals, for instance, a heterosexual man who is not comfortable being in an all-male group with men who have sex with other men, you carve that out to where you could have that particular support group. We’ll find resources in the community. Fortunately, being in New Orleans, [Louisiana], there are a variety of service organizations that can be helpful. I’m a big proponent of customer service. People need to receive good care and they deserve good care. I make sure that my team recognizes that we are dealing with a population that historically have likely had bad customer service or have not been treated well or fairly. We have to uncover and deal with all of that, and make sure that they understand that we’re on their side, that they can trust us, and that we’re here to support whatever they need.

John, do you have anything different at Vanderbilt [University Medical Center]? Any comments on that?

 I would second what Tavell says, particularly regarding the importance of customer service within a community clinic. The patient experience starts at the door. One thing we pride ourselves on is how long many of the clinic staff members have been in our HIV treatment clinic and the rapport that patients have at each stage of the process.

The only other thing I would add is we’re understanding that HIV is something that exists both within a larger health context and within a larger health system context. There’s a need to navigate things like insurance. There’s a need to navigate access. There’s a need to be able to call the clinic and say, “I don’t have transportation today,” or “My kid is sick, can I reschedule?” And not pushing people out 6 months to the next visit, but saying, “That’s fine, we’ll get you in next week." One of the things we have is an entire office devoted to navigating the Ryan White [HIV/AIDS] Program and commercial insurance. We also have in-house pharmacists, in-house mental health, tobacco cessation, nutrition, and all these things. As providers, we’re managing more and more cardiovascular, metabolic, and other comorbidities of aging. We know when to refer people out, but we also try to identify people to refer patients to folks that seem to be HIV-literate in our other services. At least they are going to see a specialist who may have had some interaction with our providers and understands that these individuals have received all their care frequently within our HIV clinic, and are now being asked to leave the outpatient center, perhaps, and travel to the main campus where they’re going to be in a different environment. Just to be aware of that.

That’s a huge deal. When I first came to where I’m currently practicing, I tried my best to make relationships external to where I’m currently working. I’m fortunate to have a collective of colleagues that have a variety of other specialties—internal medicine, med peds [medicine pediatrics], family medicine, all of that—within the confines of the organization. But as you said, if you must refer them out, you want to send them where you know that they’re going to be careful and nobody’s going to treat them badly. I made it a point to get out in the community and meet these other providers to make sure they understand, “Look, here’s who I’m sending you. I want to make sure that we’re both on the same page and agree that this patient deserves to be treated with respect, dignity, and those kinds of things. They can benefit from your expertise, but you need to treat them right.” That’s important.

Trust comes with time. I’ve been taking care of some patients for over 15 years, and it’s amazing. They go to a different state. They keep coming every 6 months—travel and everything—just to see me because they don’t want to deal with a new doctor. That’s part of why we attract ID [infectious diseases] fellows, because they go to our clinic and see how our patients deal with us. A lot of them say, “Wow, I love that clinic.”

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The importance of establishing strong relationships with patients with HIV and expert advice on building rapport. 

HIV: Building Rapport With Patients 

Osama, do [lifestyle changes] make a difference? Do people listen?

Definitely. People who are already contemplating and would like to lose weight, they usually can lose weight. But most importantly, we must understand the fundamentals of weight loss, because when people just go on a dietary plan, like in a commercial, they may lose weight and gain weight back because they lose muscle mass. One of the major points in weight loss is to maintain as much of the muscle mass as you can. I’m glad I heard John saying that they are evaluating body composition and know exactly what’s going on. In general, people beyond the age of 40 lose around 8% of their muscle mass every decade. By the age of 70, they lose around 15% of their muscle mass every decade. Between 40 and 70, people already lost 24% of their muscle mass. When they lose muscle mass, energy expenditure goes down, basic metabolic goes down, and they gain the weight back again. If you would like to implement an efficient weight management program, you’ll need to keep an eye on maintaining muscle mass.

One approach for weight management is not enough. You need dietary intervention, exercise intervention, behavior modification, and an adjustment of medications. For example, with diabetes medications, if you have someone with HIV [human immunodeficiency virus] on a medication that causes weight gain, and that person is also on pioglitazone, insulin, or a sulfonylurea, the weight gain will be doubled. Sometimes we adjust the medications that cause weight gain, like a SGLT2 [sodium-glucose cotransporter-2] inhibitor and GLP-1 [glucagon-like peptide 1] receptor agonist. Now GLP-1 receptor agonists are approved to be used for obesity, even without diabetes. But dietary intervention is important. We now know that the most modifying factor in weight gain and help in weight control is to cut down carbohydrates. We usually tell people to cut their carbohydrates lower than 40%, increase the amount of protein, and more strength exercise. That’s important to keep muscle mass up. A multidisciplinary program works well. District programs are working well. Coaching during weight management is efficient because we always love to see someone that is accountable and observe and encourage them. There are many other tips for weight management we can discuss in detail, if you would like.

 One thing I want to add—and this is something that I talk to patients about in the clinic—patients who are, say, 40 lbs overweight, let them know that they don’t have to lose 40 lbs in order to realize metabolic benefit. If they were to lose 5 lbs to 10 lbs, or 5% to 10%, they will start to see some of the metabolic benefit. That is an important message to tell patients because it’s less overwhelming. They think, “I can lose 10 lbs. That’s not a problem.” Whereas if its 40 lbs, they may feel overwhelmed.

Almost 20 year ago, our research showed that when people lose just 7%, insulin sensitivity improves by 57%. Every 5% weight loss will reduce blood pressure by 5 mm Hg. The risks for development of diabetes significantly lowers, and improves the dyslipidemia, which is also common in patients with HIV.

You mentioned GLP-1 receptor agonists. I want to point out, for the audience, we have 2 ongoing studies in HIV looking at GLP-1 receptor agonists, but we don’t have any data yet. I would think about waiting for these studies before broad use in HIV, but they look good in the general population.

Lifestyle management interventions that can help patients with HIV on antiretroviral therapy manage their weight. 

HIV and Lifestyle Management 

Though a vaccine against the SARS-CoV-2 virus has been widely available for months and millions of Americans have 

, a new report suggests that overall population-level immunity in the United States may still be too low to contain the virus.

, is based on publicly reported statistics and epidemiological simulation modeling. It warns that, at least as of this summer, the US was in no position to let its guard down.

Corresponding author Alison P. Galvani, PhD, of the Yale School of Public Health, and colleagues, noted that as of the end of July, the country had reported 34 million cases of COVID-19, and about 6 in 10 adult Americans had been fully vaccinated.

 At the same time, they noted the Delta variant of SARS-CoV-2 was spreading rapidly, and many Americans were ignoring public health recommendations like masking and social distancing.

“The lack of adherence to nonpharmaceutical interventions before attainment of sufficient population immunity carries a significant risk for another wave of COVID-19 cases and deaths,” they wrote.

Yet, Galvani and colleagues also suggested that the official count of people who were immune due to previous infection might not be accurate, in part because of the presence of asymptomatic cases, in which individuals may not have been tested for the virus because they never experienced symptoms. 

Given the uncertainty about the actual level of population immunity, the investigators embarked to use statistical and simulation modeling, as well as publicly reported COVID-19 death data to extrapolate age-stratified estimates of actual immunity. The study’s primary outcome was population immunity, a metric that accounts for the impact of vaccination as well as those who would have immunity based on previous infections.

That analysis suggested that, as of July 15, 2021, about 114.9 million Americans had been infected with SARS-CoV-2, leading to a mean overall population immunity of 62.0%. On an age-cohort basis, the estimates ranged from 77.2% among Americans 65 and older down to just 17.9% of children under the age of 12.

Galvani and colleagues said those immunity rates may not be good enough to fight off new variants of the disease.

“Variants of SARS-CoV-2 with higher transmissibility, such as the Delta variant, will inevitably increase levels of naturally acquired immunity, but at the cost of potentially increased severe health outcomes,” they noted.

 would help accelerate population immunity, they noted, even if the vaccine is not equally effective against all variants of the virus.

“Our study highlights the need to accelerate vaccination to prevent additional waves of COVID-19 and the evolution of novel variants and to shorten timelines for pandemic control in the United States,” the authors concluded.

Galvani and colleagues also reported on the significant regional variance in population-level immunity.

“For example, many states in the northeast have achieved high vaccination coverage and low infection rates, whereas certain areas of the South and Midwest have relatively low vaccination and high infection rates,” they wrote.

With such wide variation in immunity status, and with the potential for newer, more contagious variants, the authors said non-pharmaceutical interventions like masking and proactive testing ought to continue “at least until population immunity is sufficiently high to contain the pandemic.”

1. Moghadas SM, Sah P, Shoukat A, Meyers LA, Galvani AP. Population Immunity Against COVID-19 in the United States [published online ahead of print, 2021 Sep 14]. 

Only about 60% of Americans have immunity, a number too low to protect the country through “herd immunity,” according to a new report.

US Immunity Not High Enough to Contain COVID-19

Nina Cosdon is the assistant editor for Contagion. Before joining MJH Life Sciences, she graduated magna cum laude from Denison University in 2021 with a degree in Communication. You can find her reading, hiking, or antiquing, or by emailing her at ncosdon@mjhlifesciences.com.

The therapy, known as EBT-101, works by eliminating HIV-infected DNA from the genome.

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A CDC examination of a Delta outbreak in a Texas prison showed unvaccinated persons have higher attack rates, hospitalizations, and deaths, but vaccinated persons can still contract and spread the virus.

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In a departure from the independent APIC advisors, CDC Director Rochelle Walensky, MD, has decided to recommend boosters for people in high-risk occupations. 

CDC Director: Recommending Booster Doses for At-Risk Occupations

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CDC ACIP Votes to Recommend Boosters for Seniors, Some Immunocompromised, But Not High Risk Occupations

Ken reports on medical innovations and advances in practice and edits presentations for news and professional education publications. He previously taught and mentored pharmacy and medical students, and provided and managed pharmacy care and drug information services. He regularly contributes to Contagion Live, HCP Live, Neurology Live, and Pain Medicine News.

A third dose booster vaccination given to persons 60 years of age or over in Israel was confirmed to lower their rate of COVID-19 infection compared to a 2-dose regimen.

Booster Vaccinations in Israel Increased Protection against COVID-19

New research shows COVID-19 mortality risk to be more nuanced than previous studies.

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The federal agency will grant an Emergency Use Authorization (EUA) for the third dose for seniors, those deemed high risk, and those with jobs that put them at risk of infection.

FDA Amends EUA for Pfizer-BioNTech Booster Dose in Certain Populations

Kevin Kunzmann is the managing editor for 

. Prior to joining parent company MJH Life Sciences in 2017, he worked as a health care and government reporter for The Pocono Record, and as a freelance writer for NJ Advance Media, The Express-Times, The Daily Journal, and more. He graduated from Rowan University with a degree in journalism in 2015. In his spare time, he enjoys reading, cooking, running his dog, and complaining about the Mets. Follow him on Twitter 

A presentation of available third-dose data suggest the adverse event rate is consistent with that observed with second doses.

CDC Panel Reviews COVID-19 mRNA Vaccine Booster Dose Safety Data

With fecal microbiota transplants (FMT) becoming a potential emerging therapy for these patients, here are some aspects to consider when treating.

Clinical Considerations for FMT for Recurrent Clostridioides Difficile 

Saskia v. Popescu, PhD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in Biodefense from George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in Infection Control and has worked in both pediatric and adult acute care facilities.

To address PrEP implementation in Kenya, a team of researchers evaluated practices and contextual modifications across public HIV clinics. 

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