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Background: There is limited evidence of association of nirmatrelvir-ritonavir (NMV-r) and incidence of postacute sequelae of SARS-CoV-2 infection (PASC) in patients with pre-existing cardiovascular disease (CVD). Objectives: The objective of this study was to assess the association of NMV-r in nonhospitalized, vaccinated patients with pre-existing CVD and occurrence of PASC. Methods: We conducted a retrospective cohort study utilizing the TriNetX research network, including vaccinated patients with pre-existing CVD who developed COVID-19 between December 2021 and December 2022. Two cohorts were created based on NMV-r administration within 5 days of diagnosis: NMV-r and non-NMV-r cohort. The main outcome was presence of PASC, assessed between 30 to 90 days and 90 to 180 days after index COVID-19 infection. After propensity score matching, both cohorts were compared using t-test and chi-square test for continuous and categorical variables, respectively. Results: A total of 26,953 patients remained in each cohort after propensity score matching. Broadly defined PASC occurred in 6,925 patients (26%) in the NMV-r cohort vs 8,150 patients (30.6%) in the non-NMV-r cohort (OR: 0.80; 95% CI: 0.76-0.82; P < 0.001) from 30 to 90 days and in 6,692 patients (25.1%) as compared to 8,910 patients (33.5%) (OR: 0.25, 95% CI: 0.23-0.29; P < 0.001) from 90 to 180 days. Similarly, narrowly defined PASC occurred in 5,335 patients (20%) in the NMV-r cohort vs 6,271 patients (23.6%) in the non-NMV-r cohort between 30 and 90 days (OR: 0.81, 95% CI: 0.78-0.84, P < 0.001) and in 5,121 patients (19.2%) as compared to 6,964 patients (26.1%) (OR: 0.67, 95% CI: 0.64-0.70, P < 0.001) between 90 and 180 days. Conclusions: NMV-r in nonhospitalized vaccinated patients with pre-existing CVD with COVID-19 was associated with a reduction in PASC and health care utilization.
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In this article, we summarize findings from research conducted by the Johns Hopkins Center for Health Security and the Infectious Diseases Society of America to understand infectious disease (ID) workforce contributions to the coronavirus disease 2019 (COVID-19) response and their impacts. ID experts were found to have made diverse and unique contributions that went well beyond their usual responsibilities, with many spending several hours a week on these activities without additional compensation. These efforts were thought to not only build community resilience but also augment the ongoing public health response. Respondents also reported several hospital and clinical leadership roles taken on during the pandemic, such as developing protocols and leading clinical trials. We also make several policy recommendations, such as medical student debt relief and improved compensation, that will be needed to help fortify the ID workforce for future pandemics.
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COVID-19 , Enfermedades Transmisibles , Humanos , Salud Pública , PandemiasRESUMEN
BACKGROUND: Treatment of coronavirus disease 2019 (COVID-19) with nirmatrelvir plus ritonavir (NMV-r) in high-risk nonhospitalized unvaccinated patients reduced the risk of progression to severe disease. However, the potential benefits of NMV-r among vaccinated patients are unclear. METHODS: We conducted a comparative retrospective cohort study using the TriNetX research network. Patients ≥18 years of age who were vaccinated and subsequently developed COVID-19 between 1 December 2021 and 18 April 2022 were included. Cohorts were developed based on the use of NMV-r within 5 days of diagnosis. The primary composite outcome was all-cause emergency room (ER) visit, hospitalization, or death at a 30-day follow-up. Secondary outcomes included individual components of primary outcomes, multisystem symptoms, COVID-19-associated complications, and diagnostic test utilization. RESULTS: After propensity score matching, 1130 patients remained in each cohort. A primary composite outcome of all-cause ER visits, hospitalization, or death in 30 days occurred in 89 (7.87%) patients in the NMV-r cohort compared with 163 (14.4%) patients in the non-NMV-r cohort (odds ratio: .5; 95% confidence interval: .39-.67; P < .005) consistent with 45% relative risk reduction. A significant reduction in multisystem symptom burden and subsequent complications, such as lower respiratory tract infection, cardiac arrhythmia, and diagnostic radiology testing, were noted in NMV-r-treated patients. There was no apparent increase in serious complications between days 10 and 30. CONCLUSIONS: Treatment with NMV-r in nonhospitalized vaccinated patients with COVID-19 was associated with a reduced likelihood of ER visits, hospitalization, or death. Complications and overall resource utilization were also decreased.
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COVID-19 , Ritonavir , Humanos , Tratamiento Farmacológico de COVID-19 , Estudios RetrospectivosRESUMEN
Nirmatrelvir-ritonavir (NMVr) is used to treat symptomatic, nonhospitalized patients with coronavirus disease-2019 (COVID-19) who are at high risk of progression to severe disease. Patients with cardiovascular risk factors and cardiovascular disease are at a high risk of developing adverse events from COVID-19 and as a result have a higher likelihood of receiving NMVr. Ritonavir, the pharmaceutical enhancer used in NMVr, is an inhibitor of the enzymes of CYP450 pathway, particularly CYP3A4 and to a lesser degree CYP2D6, and affects the P-glycoprotein pump. Co-administration of NMVr with medications commonly used to manage cardiovascular conditions can potentially cause significant drug-drug interactions and may lead to severe adverse effects. It is crucial to be aware of such interactions and take appropriate measures to avoid them. In this review, we discuss potential drug-drug interactions between NMVr and commonly used cardiovascular medications based on their pharmacokinetics and pharmacodynamic properties.
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COVID-19 , Fármacos Cardiovasculares , Humanos , Ritonavir/uso terapéutico , Pandemias , Interacciones Farmacológicas , Fármacos Cardiovasculares/uso terapéutico , Tratamiento Farmacológico de COVID-19RESUMEN
We describe a case of acute liver failure in a woman in whom a diagnosis was initially unable to be established. The patient rapidly deteriorated, requiring admission to the intensive care unit, and was placed under consideration for liver transplantation. On consultation with the infectious disease service, thorough history taking was performed that uncovered salient epidemiologic information pointing toward the eventual diagnosis of disseminated histoplasmosis. We discuss aspects of diagnosis and management, including the management of immune reconstitution syndrome which complicated treatment.
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Jamestown Canyon virus (JCV) is a neuroinvasive arbovirus that is found throughout North America and increasingly recognized as a public health concern. From 2004 to 2012, an average of 1.7 confirmed cases were reported annually in the United States, whereas from 2013 to 2018 this figure increased over seventeen-fold to 29.2 cases per year. The rising number of reported human infections highlights the need for better understanding of the clinical manifestations and epidemiology of JCV. Here, we describe nine patients diagnosed with neuroinvasive JCV infection in Massachusetts from 2013, the year of the first reported case in the state, to 2017. Because current diagnostic testing relies on serology, which is complicated by cross-reactivity with related orthobunyaviruses and can be negative in immunosuppressed patients, we developed and evaluated an RT-qPCR assay for detection of JCV RNA. We tested this on the available archived serum from two patients, but did not detect viral RNA. JCV is transmitted by multiple mosquito species and its primary vector in Massachusetts is unknown, so we additionally applied the RT-qPCR assay and confirmatory RNA sequencing to assess JCV prevalence in a vector candidate, Ochlerotatus canadensis. We identified JCV in 0.6% of mosquito pools, a similar prevalence to neighboring Connecticut. We assembled the first Massachusetts JCV genome directly from a mosquito sample, finding high identity to JCV isolates collected over a 60-year period. Further studies are needed to reconcile the low vector prevalence and low rate of viral evolutionary change with the increasing number of reported cases.
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Culicidae/virología , Virus de la Encefalitis de California , Encefalitis/virología , Meningitis/virología , Ochlerotatus/virología , Adulto , Anciano , Animales , Vectores de Enfermedades , Encefalitis/diagnóstico , Virus de la Encefalitis de California/genética , Virus de la Encefalitis de California/inmunología , Virus de la Encefalitis de California/aislamiento & purificación , Femenino , Genoma Viral , Humanos , Masculino , Massachusetts/epidemiología , Meningitis/diagnóstico , Persona de Mediana Edad , Mosquitos Vectores/virología , Filogenia , Prevalencia , ARN ViralRESUMEN
In October 2018, the Infectious Diseases Society of America (IDSA) Board of Directors (BOD) decided to develop a 2019 IDSA Strategic Plan. The IDSA BOD has invested in strategic planning at regular intervals as part of an ongoing process to review and to renew the vision and direction of IDSA. Herein, the 2018-2019 strategic planning process and outcomes are described. The 2019 IDSA Strategic Plan presents 4 key initiatives: (1) optimize the development, dissemination, and adoption of timely and relevant ID guidance and guidelines that improve the outcomes of clinical care; (2) quantify, communicate, and advocate for the value of ID physicians to increase professional fulfillment and compensation; (3) facilitate the growth and development of the ID workforce to meet emerging scientific, clinical, and leadership needs; and (4) develop and position a new tool to serve as the leading US benchmark to measure and drive national progress on antimicrobial resistance. The BOD looks forward to developing, implementing, assessing, and advancing the 2019 IDSA Strategic Plan working with member volunteers, Society partners, and IDSA staff.
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Control de Enfermedades Transmisibles , Enfermedades Transmisibles/epidemiología , Planificación en Salud , Enfermedades Transmisibles/historia , Prioridades en Salud , Historia del Siglo XXI , Humanos , Vigilancia en Salud Pública , Estados Unidos/epidemiologíaRESUMEN
Background: Intervention by infectious diseases (ID) physicians improves outcomes for inpatients in Medicare, but patients with other insurance types could fare differently. We assessed whether ID involvement leads to better outcomes among privately insured patients under age 65 years hospitalized with common infections. Methods: We performed a retrospective analysis of administrative claims data from community hospital and postdischarge ambulatory care. Patients were privately insured individuals less than 65 years old with an acute-care stay in 2014 for selected infections, classed as having early (by day 3) or late (after day 3) ID intervention, or none. Key outcomes were mortality, cost, length of the index stay, readmission rate, mortality, and total cost of care over the first 30 days after discharge. Results: Patients managed with early ID involvement had shorter length of stay, lower spending, and lower mortality in the index stay than those patients managed without ID involvement. Relative to late, early ID involvement was associated with shorter length of stay and lower cost. Individuals with early ID intervention during hospitalization had fewer readmissions and lower healthcare payments after discharge. Relative to late, those with early ID intervention experienced lower readmission, lower spending, and lower mortality. Conclusions: Among privately insured patients less than 65 years old, treated in a hospital, early intervention with an ID physician was associated with lower mortality rate and shorter length of stay. Patients who received early ID intervention during their hospital stay were less likely to be readmitted after discharge and had lower total healthcare spending.
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Costos de la Atención en Salud , Infectología , Readmisión del Paciente , Estudios de Cohortes , Femenino , Hospitales , Humanos , Control de Infecciones/métodos , Masculino , Alta del Paciente , Estudios Retrospectivos , Estados UnidosAsunto(s)
Anticuerpos Monoclonales Humanizados/efectos adversos , Inactivadores del Complemento/efectos adversos , Infecciones por Neisseriaceae/etiología , Anticuerpos Monoclonales Humanizados/uso terapéutico , Inactivadores del Complemento/uso terapéutico , Hemoglobinuria Paroxística/tratamiento farmacológico , HumanosRESUMEN
While a career in infectious diseases (ID) has always been challenging and exciting, recognition of the value that ID physicians provide to the healthcare system as a whole, over and above the value they provide to individual patients, has been poor in this system. In response to this disparity, the Infectious Diseases Society of America Clinical Affairs Committee has long endeavored to quantify the value of ID physicians to the system, which is challenging in part because of the many avenues through which they influence healthcare. We discuss data showing that ID physicians improve clinical outcomes, positively impact transitions of care, and direct system-level improvements through infection prevention and antimicrobial stewardship. We identify areas where value-based care provides additional future opportunities for ID physicians. A Clinical Affairs Committee-sponsored study of ID physicians' positive impact on patient outcomes shows that few medical specialties are better positioned to positively impact the Triple Aim approach-better health, better care, and lower per capita cost-that is the principle tenet of healthcare system reform.
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Atención a la Salud/organización & administración , Infectología/organización & administración , Rol del Médico , Médicos , Humanos , Infectología/estadística & datos numéricos , Resultado del Tratamiento , Recursos HumanosRESUMEN
BACKGROUND: Powassan virus (POWV) is a rarely diagnosed cause of encephalitis in the United States. In the Northeast, it is transmitted by Ixodes scapularis, the same vector that transmits Lyme disease. The prevalence of POWV among animal hosts and vectors has been increasing. We present 8 cases of POWV encephalitis from Massachusetts and New Hampshire in 2013-2015. METHODS: We abstracted clinical and epidemiological information for patients with POWV encephalitis diagnosed at 2 hospitals in Massachusetts from 2013 to 2015. We compared their brain imaging with those in published findings from Powassan and other viral encephalitides. RESULTS: The patients ranged in age from 21 to 82 years, were, for the most part, previously healthy, and presented with syndromes of fever, headache, and altered consciousness. Infections occurred from May to September and were often associated with known tick exposures. In all patients, cerebrospinal fluid analyses showed pleocytosis with elevated protein. In 7 of 8 patients, brain magnetic resonance imaging demonstrated deep foci of increased T2/fluid-attenuation inversion recovery signal intensity. CONCLUSIONS: We describe 8 cases of POWV encephalitis in Massachusetts and New Hampshire in 2013-2015. Prior to this, there had been only 2 cases of POWV encephalitis identified in Massachusetts. These cases may represent emergence of this virus in a region where its vector, I. scapularis, is known to be prevalent or may represent the emerging diagnosis of an underappreciated pathogen. We recommend testing for POWV in patients who present with encephalitis in the spring to fall in New England.
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Virus de la Encefalitis Transmitidos por Garrapatas , Encefalitis Transmitida por Garrapatas/diagnóstico por imagen , Encefalitis Transmitida por Garrapatas/epidemiología , Flavivirus , Aciclovir/uso terapéutico , Adulto , Anciano , Anciano de 80 o más Años , Animales , Anticuerpos Antivirales/líquido cefalorraquídeo , Antivirales/uso terapéutico , Encéfalo/diagnóstico por imagen , Encéfalo/patología , Encéfalo/virología , Virus de la Encefalitis Transmitidos por Garrapatas/efectos de los fármacos , Virus de la Encefalitis Transmitidos por Garrapatas/inmunología , Virus de la Encefalitis Transmitidos por Garrapatas/patogenicidad , Encefalitis Transmitida por Garrapatas/diagnóstico , Encefalitis Transmitida por Garrapatas/virología , Femenino , Flavivirus/efectos de los fármacos , Flavivirus/inmunología , Flavivirus/patogenicidad , Humanos , Ixodes/virología , Imagen por Resonancia Magnética , Masculino , Massachusetts/epidemiología , Meningitis Bacterianas/tratamiento farmacológico , Persona de Mediana Edad , New Hampshire/epidemiología , Prevalencia , Estaciones del Año , Estados Unidos/epidemiología , Adulto JovenRESUMEN
OBJECTIVES: Patients who are immunocompromised (IC) are at increased risk of Clostridium difficile infection (CDI), which has increased to epidemic proportions over the past decade. Fecal microbiota transplantation (FMT) appears effective for the treatment of CDI, although there is concern that IC patients may be at increased risk of having adverse events (AEs) related to FMT. This study describes the multicenter experience of FMT in IC patients. METHODS: A multicenter retrospective series was performed on the use of FMT in IC patients with CDI that was recurrent, refractory, or severe. We aimed to describe rates of CDI cure after FMT as well as AEs experienced by IC patients after FMT. A 32-item questionnaire soliciting demographic and pre- and post-FMT data was completed for 99 patients at 16 centers, of whom 80 were eligible for inclusion. Outcomes included (i) rates of CDI cure after FMT, (ii) serious adverse events (SAEs) such as death or hospitalization within 12 weeks of FMT, (iii) infection within 12 weeks of FMT, and (iv) AEs (related and unrelated) to FMT. RESULTS: Cases included adult (75) and pediatric (5) patients treated with FMT for recurrent (55%), refractory (11%), and severe and/or overlap of recurrent/refractory and severe CDI (34%). In all, 79% were outpatients at the time of FMT. The mean follow-up period between FMT and data collection was 11 months (range 3-46 months). Reasons for IC included: HIV/AIDS (3), solid organ transplant (19), oncologic condition (7), immunosuppressive therapy for inflammatory bowel disease (IBD; 36), and other medical conditions/medications (15). The CDI cure rate after a single FMT was 78%, with 62 patients suffering no recurrence at least 12 weeks post FMT. Twelve patients underwent repeat FMT, of whom eight had no further CDI. Thus, the overall cure rate was 89%. Twelve (15%) had any SAE within 12 weeks post FMT, of which 10 were hospitalizations. Two deaths occurred within 12 weeks of FMT, one of which was the result of aspiration during sedation for FMT administered via colonoscopy; the other was unrelated to FMT. None suffered infections definitely related to FMT, but two patients developed unrelated infections and five had self-limited diarrheal illness in which no causal organism was identified. One patient had a superficial mucosal tear caused by the colonoscopy performed for the FMT, and three patients reported mild, self-limited abdominal discomfort post FMT. Five (14% of IBD patients) experienced disease flare post FMT. Three ulcerative colitis (UC) patients underwent colectomy related to course of UC >100 days after FMT. CONCLUSIONS: This series demonstrates the effective use of FMT for CDI in IC patients with few SAEs or related AEs. Importantly, there were no related infectious complications in these high-risk patients.
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Clostridioides difficile , Enterocolitis Seudomembranosa/microbiología , Enterocolitis Seudomembranosa/terapia , Heces/microbiología , Huésped Inmunocomprometido , Microbiota , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Encuestas y Cuestionarios , Resultado del TratamientoRESUMEN
BACKGROUND: Previous studies, largely based on chart reviews with small sample sizes, have demonstrated that infectious diseases (ID) specialists positively impact patient outcomes. We investigated how ID specialists impact mortality, utilization, and costs using a large claims dataset. METHODS: We used administrative fee-for-service Medicare claims to identify beneficiaries hospitalized from 2008 to 2009 with at least 1 of 11 infections. There were 101 991 stays with and 170 336 stays without ID interventions. Cohorts were propensity score matched for patient demographics, comorbidities, and hospital characteristics. Regression models compared ID versus non-ID intervention and early versus late ID intervention. Risk-adjusted outcomes included hospital and intensive care unit (ICU) length of stay (LOS), mortality, readmissions, hospital charges, and Medicare payments. RESULTS: The ID intervention cohort demonstrated significantly lower mortality (odds ratio [OR], 0.87; 95% confidence interval [CI], .83 to .91) and readmissions (OR, 0.96; 95% CI, .93 to .99) than the non-ID intervention cohort. Medicare charges and payments were not significantly different; the ID intervention cohort ICU LOS was 3.7% shorter (95% CI, -5.5% to -1.9%). Patients receiving ID intervention within 2 days of admission had significantly lower 30-day mortality and readmission, hospital and ICU length of stay, and Medicare charges and payments compared with patients receiving later ID interventions. CONCLUSIONS: ID interventions are associated with improved patient outcomes. Early ID interventions are also associated with reduced costs for Medicare beneficiaries with select infections.
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Enfermedades Transmisibles/epidemiología , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/prevención & control , Costos de la Atención en Salud , Control de Infecciones/métodos , Anciano , Anciano de 80 o más Años , Enfermedades Transmisibles/mortalidad , Infección Hospitalaria/mortalidad , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Análisis de SupervivenciaRESUMEN
The Centers for Medicare and Medicaid Services (CMS) has proposed to eliminate payments for the Inpatient and Outpatient Consultation codes beginning on 1 January 2010. The intent appears to be to promote an increase in the supply of primary physicians by increasing payments for other Evaluation and Management services. This will worsen an already inequitable disparity in the payments for complex cognitive services in comparison to procedure-based specialties, to the detriment of infectious diseases physicians. Infectious diseases as a specialty is committed to health care reform that makes sense for both patients and providers. An unintended consequence of the CMS proposal may be that few infectious diseases physicians remain to confront current or future infectious diseases challenges.
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Planes de Aranceles por Servicios/normas , Derivación y Consulta/economía , Centers for Medicare and Medicaid Services, U.S. , Enfermedades Transmisibles/diagnóstico , Enfermedades Transmisibles/terapia , Reforma de la Atención de Salud/economía , Humanos , Sistema de Pago Prospectivo/economía , Estados UnidosRESUMEN
Recent developments in health care have focused efforts on both the national and local levels to reduce unnecessary health care costs and the number of hospital stays while increasing the quality of care, particularly in the context of hospital-associated infections. Infectious diseases specialists who contract to oversee infection-control and antibiotic-stewardship programs are uniquely positioned to play a pivotal role in helping hospitals to prosper in this new environment. This article will detail the available data supporting the value of infectious diseases specialists in their roles of directing antimicrobial-management and infection-control programs, maintaining health care workers' well-being, and minimizing exposure. The evidence in support of the influence of infectious diseases specialists to achieve cost-savings, decrease the length of hospital stays, and improve outcomes is robust and can be used as the framework for negotiating appropriate compensation from hospital management for these activities. Presenting this information in an amicable but definitive framework may be the linchpin to the overall success of the movement to improve quality of care while minimizing hospital costs and antimicrobial use. Developing this ability is critical to infectious diseases specialists' success as they redefine their role in the quality-of-care and risk-management arenas.
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Antibacterianos/uso terapéutico , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/prevención & control , Personal de Salud , Control de Infecciones/métodos , Especialización , HumanosRESUMEN
Guidelines for Management of HAP were developed jointly by the ATS and IDSA in 2004. These guidelines were designed to improve patient outcomes and to decrease the emergence of MDR pathogens (see Fig. 1).Principles include early initiation of appropriate and adequate antibiotic therapy after cultures of blood and sputum are obtained. Quantitative distal airway sampling by bronchoscopy provides greater diagnostic specificity for VAP: in one randomized study, improved outcomes were noted, compared with clinical diagnosis with qualitative endotracheal aspirates. Higher doses of initial, empiric antibiotics also are recommended. Assessment of the patient's clinical response to empiric antibiotics should be correlated with microbiologic results to streamline, de-escalate, or stop unnecessary anti-biotic treatment. Duration of therapy for uncomplicated HAP should be limited to 7 days followed by close monitoring for relapse after cessation of antibiotics. The authors suggest that prevention strategies target modifiable short- and long-term risk factors. They also advocate the use of a multidisciplinary team that is dedicated to the treatment and prevention of HCAP and the basic principle of the modern Hippocratic Oath: "I will prevent disease whenever I can, for prevention is preferable to cure."