May 360: Trending Infectious Disease News of the Month

During the month of May, the editorial team traveled down to Orlando, Florida, to provide live coverage of the Making a Difference in Infectious Diseases (MAD-ID 2019) meeting. In addition to interviewing poster presenters from around the country, Contagion® also sat down with editor-in-chief Jason Gallagher, PharmD, FCCP, FIDSA, BCPS; and section editors Monica Mahoney, PharmD, BCPS AQID, BCIDP; and Ryan K. Shields, PharmD, MS.

Following the conference, Contagion® launched its #WhyID series on the web, which features testimonials from clinicians on the driving factors behind their decisions to pursue careers in infectious disease.

In HIV news, the final publication of the PARTNER results were announced, supporting that achieving and maintaining viral suppression with antiretroviral therapy renders individuals unable to sexually transmit HIV, and providing more evidence to support U=U. In the Contagion® Peer Exchange program, panelists Joseph Eron, MD; Paul Sax, MD; W. David Hardy, MD; Eric S. Daar, MD; and Ian Frank, MD, tackled important topics in HIV management, including rapid initiation of antiretrovirals, the use of boosted protease inhibitors in women who are pregnant, and the efficacy of the 2-drug regimen of dolutegravir/rilpivirine. Also, be sure to check out Contagion®’s annual update on the search for an HIV cure.

May also saw a stable increase in measles cases across the United States with 940 cases reported as of May 24, 2019.The US Centers for Disease Control and Prevention announced outbreaks of Salmonella linked to Karawan brand tahini, gastrointestinal illnesses linked to raw oysters, Salmonella linked to contact with live poultry, Salmonella linked to Del Monte vegetable trays, and E coli linked to flour sold at some Aldi stores. A list of affected states and case counts for all of these outbreaks can be found on the Contagion® Outbreak Monitor.

News from the US Food and Drug Administration (FDA) included the limited approval of the vaccine Dengvaxia for individuals with a documented laboratory-confirmed case of previous dengue infection who live in dengue-endemic regions. Later in the month, the FDA cleared extragenital tests for chlamydia and gonorrhea and granted marketing authorization of a diagnostic test for Zika antibodies.

With June on the horizon, check out a list of the top 5 articles from the month of May below.

#5: How About Letting Nurses Provide PrEP to Patients?

Because it’s so important to make sure that pre-exposure prophylaxis (PrEP) is available to people at risk of acquiring HIV, a team of investigators at the University of Ottawa in Ontario, Canada, has proposed that nurses be on the front lines of providing PrEP. Most current guidelines for PrEP are not written for non-prescribing clinicians such as nurses, even though they may be uniquely positioned to assess patients and recommend PrEP.

The team, led by Patrick O’Byrne, RN-EC, PhD, associate professor of nursing at the University of Ottawa, published a research paper citing several studies demonstrating that a dearth of medical providers—including providers who are aware of PrEP and its specific requirements for dosing and follow-up visits—is 1 reason not enough people have access to the medication. Another reason is that physicians don’t necessarily discuss sexual orientation or sexual history with their patients. These barriers can be surmounted, the investigators posit, by allowing nurses to dispense PrEP. A nurse practitioner can prepare prescriptions for PrEP that can then be handed out by nurses as necessary.

The investigators specifically recommend that registered nurses provide PrEP in the setting of sexually transmitted infection (STI) and HIV testing clinics, an approach they refer to as “Pre-Exposure Prophylaxis-Registered Nurse (PrEP-RN).” “We suggest that medical directives and established pathways to interpret laboratory findings be created to allow RNs to provide PrEP, thereby increasing the number of health care professionals who provide this intervention,” the research team writes.

Read about allowing nurses to provide PrEP.

#4: AUC/MIC-Guided Vancomycin Dosing in Patients With MRSA Bacteremia Results in Decreased Troughs

Vancomycin dosing has remained a controversial topic in the management of infectious diseases as many medical centers move away from trough-guided and toward area under the curve/minimum inhibitory concentration (AUC/MIC)-guided dosing.

Investigators at Boston Medical Center, a large academic facility, implemented a change to their primary targets for vancomycin dosing in January 2018 for patients with methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections (BSI). The goal was to move from troughs to AUC/MIC to reduce the cumulative exposure of vancomycin by 10% and decrease average troughs by 20%.

Matthew Girgis, PharmD, PGY-2 Pharmacy Resident at Boston Medical Center and an investigator on the study, shared the outcomes at the 22^nd annual Making a Difference in Infectious Diseases (MAD-ID 2019) meeting (see video).

Read about AUC/MIC-guided vancomycin dosing.

#3: Candida and C Diff: Rise in Coinfections Could Be the Next Big Health Care-Associated Concern

Coinfection with Clostridium difficile (C diff) and Candida species represents an intersection of 2 of the most concerning health care-associated infections, and now a new paper by investigators in Italy explores these coinciding bacterial and fungal infections.

A 2017 survey found that nearly 10% of Americans hospitalized for candidemia—a fungal infection of the bloodstream—were coinfected with C diff, a bacterium which causes nearly half a million intestinal infections in the United States each year. According to the US Centers for Disease Control and Prevention (CDC), there are about 25,000 cases of candidemia in the US each year. A review paper published in the journal Expert Review of Anti-infective Therapy analyzes the physio-pathological mechanisms underlying the Candida and C diff coinfection, as well as its management, including in cases where candidemia occurs both before and following C diff infection (CDI).

In the new paper, investigators from the University of Pisa and Sapienza University of Rome note that, since the first-reported association between CDI and subsequent candidemia in 2013, newer research has identified Candida-C diff coinfection as a clinical entity. “The sharing of similar risk factors partially explains this mutual association. However, the observation that the sequence CDI-candidemia is more frequent than candidemia-CDI led scientific community to research a specific pathophysiological explanation of this finding,” the investigators write. “The alteration in the gut microbiome and the loss of intestinal barrier are the crucial processes favoring the development of candidemia in patients with CDI.”

Read about increased prevalence of these coinfections.

#2: Health Officials Confirm Presence of "Kissing Bug" in Delaware

A recent article published in the US Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report details the first detection of a Triatoma sanguisuga, an insect also nicknamed a “kissing bug,” in Delaware.

Triatomines are a type of blood-sucking insect that feeds on humans and animals and is known for biting the face of humans. These vectors can transmit the parasite Trypanosoma cruzi, which causes Chagas disease, a serious infection that can lead to serious cardiac and gastrointestinal complications.

Triatomine insects are more commonly encountered in Latin America, although they have been previously detected in the United States. The CDC estimates that approximately 300,000 individuals in the United States are living with Chagas disease, yet very few of these cases are connected with contact with the bug within the United States.

Read about the Triatoma sanguisuga in Delaware.

#1: Working Toward a Cure for HIV: Where Are We?

The landscape of HIV treatment continues to shift and grow, with new and streamlined therapies introduced on a regular basis. People living with HIV today can lead very different lives than those of people who were diagnosed in the ’90s and early 2000s. Antiretroviral therapy (ART) makes it possible for a person living with HIV to experience complete viral suppression, even engaging in condomless sexual intercourse, or gestating a baby without fear of passing on the virus (Undetectable=Untransmittable). Investigators, however, are still in pursuit of the holy grail—total eradication of HIV from the body. Is there a cure? How long until we find it? And will it work for the majority of people living with HIV?

It’s important to understand that the definition of “cure” differs from investigator to investigator, and some disdain the term altogether. “I don’t even use the word ‘cure’ anymore,” Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, told Contagion®. “I refer to it as different pathways to a sustained remission.”

Although ART has been considered a gamechanger for people living with HIV, allowing them to be completely virally suppressed for long periods, it’s not the right option for certain patients. “People psychologically don’t like to be reminded every day that they have to take ART to suppress their virus,” Fauci said. “It reminds you every single day that you’ve got a virus and you have to do something to suppress it.” Complicating things is the fact that some patients are quite sensitive to the potentially toxic side effects of ART. Other patients are simply resistant to ART. The goal, he said, is to offer people something that lasts longer than a daily pill.

In March at the Annual Conference on Retroviruses and Opportunistic Infections (CROI 2019), investigators revealed results from the FLAIR and ATLAS studies, which showed that monthly long-acting injections of cabotegravir and rilpivirine were non-inferior to oral ART for adults with virologically suppressed HIV-1 infections.

Read the annual update on a cure for HIV.