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.

• PrEP, MSM, Sexual Risk Behavior, and STIs: Making Sense of the Emerging Impacts
• It’s Not Easy When You’re Teensy: Antimicrobial Stewardship Strategies in Small Hospitals

PrEP, MSM, Sexual Risk Behavior, and STIs: Making Sense of the Emerging Impacts

Reviewed by Erica Kaufman West, MD

Pre-exposure prophylaxis (PrEP) for HIV prevention has been adopted into the mainstream of medicine as an effective tool in the fight to eliminate HIV. Its uptake within the men who have sex with men (MSM) community started slowly but has gained steam. Studies looking at PrEP and sexually transmitted infection (STI) rates initially used data from early PrEP studies, ones that were blinded. Blinded studies would not necessarily reveal changes in sexual behaviors as participants would not be aware of whether they were on placebo or an active drug.

In a recent analysis in Clinical Infectious Diseases, researchers looked at unblinded clinical trials only and extracted rates of newly diagnosed STIs and details of self-reported condomless anal sexual intercourse. They found 17 studies that met their criteria, including 6,671 participants with a median follow-up of 6 months and a mean age of 34 years. In looking at STIs, eight studies of 4,388 participants reported STI positivity at baseline and at follow-up, and PrEP use was associated with significantly increased odds of any rectal STI and rectal chlamydia diagnosis. Thirteen studies of 5,008 participants measured change in self-reported sexual behavior, and none found a significant increase in the proportion of MSM reporting any condomless sex from baseline to follow-up. However, there was an increase in the proportion of participants reporting condomless receptive anal sex with ≥ 10 partners, condomless sex with an HIV+ or HIV-unknown partner, and never using condoms during anal sex.

The authors concluded that the increase in STIs may be due to an increase in risky behavior but that the frequent STI checks that PrEP patients undergo may be uncovering more infections than previously reported. In addition, they stressed that the proportion of men engaging in condomless sex stayed constant—those who were consistent in condom use before PrEP continued to use condoms after. Those who had inconsistent use, however, had less use and more partners after starting PrEP. This brings to light a concern that many HIV practitioners had when PrEP came to market. While further and more specific studies are needed, this analysis shows that many of those at risk for HIV—and thus eligible for PrEP—remain at risk for other STIs and are in need of continued counseling and screening.

(Traeger et al. Clin Infect Dis. Published online: 2 March 2018.)

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It’s Not Easy When You’re Teensy: Antimicrobial Stewardship Strategies in Small Hospitals

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

While antimicrobial stewardship programs have been widely adopted to promote appropriateness in antimicrobial use and reduce adverse effects of antimicrobial therapy, high-quality data to support the efficacy of specific antimicrobial stewardship interventions have been sparse. This is particularly true for smaller hospitals that have limited resources.

Authors of a recent study published in Clinical Infectious Diseases addressed this gap by randomizing 15 small hospitals (bed range 14 to 146, median 25) in the Intermountain system in Utah and Idaho that did not have routine ID consultation available or a pre-existing antimicrobial stewardship program to one of three interventions. Program 1 included basic stewardship education and tools, a “hotline” where providers could speak to an ID physician at any time, and receipt of an antibiotic utilization report by pharmacy managers and hospital leadership. Program 2 added on advanced stewardship education, limited prospective audit and feedback for vancomycin and common antipseudomonals, and local antibiotic restriction for several agents. Program 3 differed from Program 2 by expanding audit and feedback to ertapenem, aminoglycosides, ceftriaxone, and fluoroquinolones, restricting antibiotics to ID centrally, and adding central ID review of designated cultures. Antibiotic use was determined for the 12 months pre-intervention and 14 months post-intervention.

Overall antibiotic usage (rate ratio 0.89; confidence interval 0.80-0.99) and usage of broad-spectrum antimicrobial therapy (0.76; 0.63-0.91) was only significantly reduced for the Program 3 hospitals; no difference was seen between Program 1 and Program 2. Use of restricted antibiotics declined 81 percent in Program 3 hospitals, 52 percent in Program 2, and 41 percent in Program 1. No differences in mortality, 30-day readmission, or hospital length of stay were observed.

This study highlights the difficulty of performing antimicrobial stewardship in small hospitals. A significant investment in personnel with ID expertise is likely required to achieve meaningful change, and the sustainability and cost-effectiveness of this degree of investment requires ongoing study.

(Stenehjem et al. Clin Infect Dis. Published online: 23 February 2018.)

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