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.
Long-term Care Facility Residents: A Significant Source of Intra- and Inter-facility C. difficile Transmission
Reviewed by Jennifer Brown, MD
Clostridium difficile infection (CDI) and asymptomatic carriage of C. difficile are common in long-term care facility (LTCF) residents, and these residents often transfer between LTCFs and acute care hospitals. The extent that LTCF residents with CDI or asymptomatic carriage impact C. difficile transmission in LTCF and acute care hospitals is unclear.
In a prospective, cohort study in Infection Control & Hospital Epidemiology involving patients of a Veterans Affairs hospital and its affiliated LTCF, Donskey et al. screened the LTCF residents and their environment (at study enrollment/LTCF admission then bi-monthly for one month and monthly thereafter) for C. difficile carriage. Using restriction endonuclease analysis and whole genome sequencing (WGS), isolates from LTCF residents with asymptomatic carriage were compared to those of LTCF or hospitalized patients who developed health care-associated CDI. Isolates that differed by two or fewer single nucleotide polymorphisms (SNPs) were considered genetically related; those that differed by three to four SNPs were considered possibly genetically related. Patient movements and ward/facility contacts were also tracked.
Over the six-month study period, 29/201 (14.4 percent) LTCF residents were found to be asymptomatic carriers of C. difficile and 37 (26 hospital-associated and 11 LTCF-associated) health care-associated CDI cases occurred. Based on WGS and ward/facility contact, 4/37 health care-associated CDI cases were determined to be transmissions from LTCF residents and 3/37 were deemed to be possible transmissions. Of these seven CDI cases, five were linked to LTCF residents with asymptomatic carriage and two were linked to those with CDI. Overall, 19 percent of health care-associated CDI cases were linked to LTCF residents, including 3/26 (11.5 percent) hospital-associated cases and 4/11 (36.4 percent) LTCF-associated cases.
This small but rigorous study highlights that LTCF residents can be a significant source of CDI transmission, particularly for institutions with frequent inter-facility transfers. This underscores the importance of optimizing infection prevention and antimicrobial stewardship in LTCFs.
(Donskey et al. Infect Control Hosp Epidemiol. 2018;39:909-16.)
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Patients Living with HIV and Chronic Pain Treated with Long-Term Opioid Therapy Had Lower Rates of Virologic Failure
Reviewed by Lauren Richey, MD, MPH, FIDSA
Chronic pain is common among people living with HIV, reported in up to 80 percent of patients. Data suggests that up to 17 percent may be on long-term opioid medications to address pain. A recent study in the Journal of Acquired Immune Deficiency Syndrome was designed to determine the association of chronic pain and long-term opioid therapy with retention in HIV primary care and virologic failure.
The prospective cohort study included five HIV clinics across the country. Chronic pain was defined as at least moderate pain for at least 3 months. Long-term opioid therapy (LTOT) was defined as an opioid prescription for 90 consecutive days following the first visit in the study period. Suboptimal retention was defined as a no-show to a scheduled visit without another completed visit within 31 days. Virologic failure was defined as an HIV viral load greater than 1,000 copies/mL without a repeat in the next month that was less than 1,000 copies/mL. An adjusted analysis was performed, which controlled for age, race, sex, depressive symptoms, anxiety symptoms, substance use other than marijuana, and high-risk alcohol use.
Over 2,300 patients participated, and most were male (84 percent) and white (48 percent). Among patients with chronic pain who were not on LTOT, significantly increased odds of suboptimal retention and virologic failure were seen (adjusted odds ratio [OR]: 1.46 [95 percent confidence interval (CI) 1.1 to 1.93] and 1.97 [95 percent CI 1.39 to 2.8] respectively). Patients with chronic pain on LTOT had lower rates of virologic failure (adjusted OR 0.56 [95 percent CI 0.33 to 0.96]). The authors suggested that untreated chronic pain may result in poorer adherence to antiretroviral therapy or biological factors such as immune suppression. Given the push to limit opioid medications for chronic pain, more studies are needed to determine if chronic pain contributes to poorer HIV treatment outcomes as well as to find effective treatments that are acceptable in our current prescribing environment.
(Merlin et al. J Acquir Immune Defic Syndr. 2018;79:77-82.)
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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:
- Pulmonary Mycobacterium avium Complex (MAC): Treatment Failure or Reinfection?
- Mycobacterium leprae Infection in Asymptomatic Household Contacts
- Case Vignette: Another Cause of Culture-Negative Endocarditis—Lyme Disease