Several meta-analyses have shown that short-course antibiotic therapy (ie, 5 to 7 days) is as effective as longer-course therapy for patients with community-acquired pneumonia (CAP). Despite these findings, CAP is one of the most diagnoses associated with antibiotic overuse. In a cohort study evaluating >6400 patients hospitalized with pneumonia in the United States from 2017 to 2018, approximately two-thirds received antibiotics for an excess duration. Among patients with CAP, the median overall antibiotic duration was 8 days and the median excess duration was 2 days. Antibiotics prescribed at the transition from hospital to outpatient care accounted for most of the excess use. Longer courses of therapy were not associated with greater treatment success; however, patient-reported adverse events (primarily diarrhea and rash) were 5 percent higher for each excess day of antibiotic use. This study further confirms that a longer course of antibiotics for CAP are more likely to cause harm than benefit.
Vaughn VM, Flanders SA, Snyder A, Conlon A, Rogers MAM, Malani AN, et al. Excess Antibiotic Treatment Duration and Adverse Events in Patients Hospitalized With Pneumonia: A Multihospital Cohort Study. Ann Intern Med. 2019 Aug 6;171(3):153-163. doi: 10.7326/M18-3640.
Given the impact of antiretroviral therapy (ART) in eliminating HIV transmission between serodiscordant couples, there has been substantial interest in a “test and treat” strategy of early ART initiation upon diagnosis as a way to reduce community HIV incidence. In three recent, large trials in different areas in Africa, interventions to enhance HIV testing, linkage to care, and immediate ART initiation resulted in higher rates of viral suppression among people with HIV but resulted in no or relatively modest reductions in population HIV incidence compared with standard of care. Reasons for these findings are uncertain; improvements in the standard of care (ie, earlier ART availability) likely attenuated differences between the intervention and control groups. Untreated acute and early HIV transmission and migration of people off ART would also be expected to compromise the population benefit of a test and treat strategy.
Havlir DV, Balzer LB, Charlebois ED, Clark TD, Kwarisiima D, Ayieko J, et al. HIV Testing and Treatment with the Use of a Community Health Approach in Rural Africa. N Engl J Med. 2019 Jul 18;381(3):219-229. doi: 10.1056/NEJMoa1809866.
Hayes RJ, Donnell D, Floyd S, Mandla N, Bwalya J, Sabapathy K, et al. HPTN 071 (PopART) Study Team. Effect of Universal Testing and Treatment on HIV Incidence – HPTN 071 (PopART). N Engl J Med. 2019 Jul 18;381(3):207-218. doi: 10.1056/NEJMoa1814556.
Makhema J, Wirth KE, Pretorius Holme M, Gaolathe T, Mmalane M, Kadima E, et al. Universal Testing, Expanded Treatment, and Incidence of HIV Infection in Botswana. N Engl J Med. 2019 Jul 18;381(3):230-242. doi: 10.1056/NEJMoa1812281.
Pre-exposure prophylaxis (PrEP) with daily tenofovir disoproxil fumarate paired with emtricitabine (TDF-FTC) for prevention of HIV has been shown to be effective and well-tolerated in several individual trials. In a recent systematic review of randomized trials and observational studies with over 18,000 participants, PrEP was associated with reduced risk of HIV infection compared with placebo or no PrEP (2.37 versus 4.18 percent) . We continue to offer PrEP with TDF-FTC to HIV-uninfected patients who are at high risk for HIV, have normal kidney function, and are committed to daily medication adherence and close follow-up.
Chou R, Evans C, Hoverman A, Sun C, Dana T, Bougatsos C, Grusing S, Korthuis PT. Preexposure Prophylaxis for the Prevention of HIV Infection: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2019 Jun 11;321(22):2214-2230. doi:10.1001/jama.2019.2591.
Guidelines from the United States Advisory Committee on Immunization Practices (ACIP) for the 2019 to 2020 influenza season include updated age and dosing recommendations for some vaccines. For children age 6 through 35 months, the appropriate dose for quadrivalent inactivated influenza vaccines (IIV4) varies with the vaccine formulation. As in previous years, annual influenza immunization is recommended for all persons ≥6 months of age, and any licensed vaccine that is appropriate for age and health status may be administered to individuals with egg allergy. Although the ACIP makes no preferential recommendation for individuals ≥65 years of age, when it is available, we recommend the high-dose trivalent inactivated influenza vaccine (HD-IIV3) rather than a standard-dose inactivated vaccine, because HD-IIV3 is more immunogenic and effective.
Grohskopf LA, Alyanak E, Broder KR, Walter EB, Fry AM, Jernigan DB. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory
Committee on Immunization Practices – United States, 2019-20 Influenza Season. MMWR Recomm Rep. 2019 Aug 23;68(3):1-21. doi: 10.15585/mmwr.rr6803a1.
In the United States, the Advisory Committee on Immunization Practices (ACIP) recently updated its recommendations on human papillomavirus (HPV) vaccination to recommend catch-up vaccination for all individuals up to age 26 years (previously, the ACIP recommended catch-up vaccination for males only up to age 21 with certain exceptions, while UpToDate had supported vaccination for all up to age 26 and for select older patients). The ACIP did not recommend routine catch-up vaccination for adults 27 to 45 years old but noted that the decision to vaccinate such adults should be made individually with shared decision making. We suggest vaccination for individuals in this age group who have a low likelihood of prior HPV exposure (eg, no prior sexual experience or a limited number of prior sexual partners) but are deemed to have a future risk (eg, expected new sexual partners). However, clinicians and patients should be aware that HPV vaccination of individuals older than 26 years may not be covered by insurance providers or other payers.
Meites E, Szilagyi PG, Chesson HW, Unger ER, Romero JR, Markowitz LE. Human Papillomavirus Vaccination for Adults: Updated Recommendations of the Advisory
Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2019 Aug 16;68(32):698-702. doi: 10.15585/mmwr.mm6832a3.
Recombinant zoster vaccine in autologous hematopoietic cell transplant recipients
The recombinant zoster vaccine (RZV) is recommended for immunocompetent patients, but data on its efficacy and safety in immunocompromised patients have been limited. In a large randomized trial of adult autologous hematopoietic cell transplant (HCT) recipients, two doses of RZV reduced herpes zoster episodes, postherpetic neuralgia, and other herpes zoster-associated complications compared with placebo. Injection site reactions were more common in vaccine recipients than placebo recipients, but the incidence of serious adverse effects was similar between groups. Based on the results of this trial, we suggest vaccination with RZV in adult autologous HCT recipients. The United States Advisory Committee on Immunization Practices (ACIP) has not yet issued recommendations regarding the use of RZV in this population.
Bastidas A, de la Serna J, El Idrissi M, Oostvogels L, Quittet P, López-Jiménez J, et al. ZOE-HSCT Study Group Collaborators. Effect of Recombinant Zoster Vaccine on Incidence of Herpes Zoster After Autologous Stem Cell Transplantation: A Randomized Clinical Trial. JAMA. 2019 Jul 9;322(2):123-133. doi: 10.1001/jama.2019.9053. Erratum in: JAMA. 2019. Aug 27;322(8):785.
Respiratory protection is important for the prevention of influenza transmission in health care settings. Most but not all studies have shown no difference in efficacy between facemasks and N95 respirators for preventing influenza or other respiratory virus infections among health care workers (HCWs). In a large trial of HCWs in outpatient settings who were randomly assigned to use a facemask or an N95 respirator when coming within 6 feet of patients with respiratory illness, there were a similar number of laboratory-confirmed influenza infection events in both groups. There were also no differences between the groups in the incidence of acute respiratory illness events, laboratory-detected respiratory infections, laboratory-confirmed respiratory illness events, or influenza-like illness events. These data support the recommendation to use facemasks for routine care of patients with suspected or confirmed influenza.
Radonovich LJ Jr, Simberkoff MS, Bessesen MT, Brown AC, Cummings DAT, Gaydos CA, et al. ResPECT investigators. N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial. JAMA. 2019 Sep 3;322(9):824-833. doi: 10.1001/jama.2019.11645.
Source: Uptodate, August/September 2019.