Sharon Worcester

LAS VEGAS – Patients recall only about 10% of the information imparted by physicians during an office visit, and about half of all patients don’t understand their treatment plan, according to Richard Nordstrom.

Furthermore, 90% of patients have difficulty following routine medical advice, said Mr. Nordstrom, chief executive officer for a health care communications consulting firm in Montclair, N.J.

The problem isn’t just one of low health care literacy. Patients who receive a significant, life-altering diagnosis often don’t hear much else after they hear words like, "you have rheumatoid arthritis," he said at Perspectives in Rheumatic Diseases 2013.

This is true regardless of a patient’s literacy level, and even those with high literacy may be too embarrassed to ask questions that they think might make them sound uninformed, he noted.

These factors lead to poor outcomes and less patient satisfaction. Improved communication can go a long way toward improving both, he said.

Physicians have so little time with patients; about half of those in a recent survey said that they see between 50 and 100 patients each week. The average time a health care professional spends educating a patient on conditions and treatments critical for the patient’s care is only 11 minutes, and during that time, patients ask an average of only two questions.

"Your moments with that patient are critical," Mr. Nordstrom said, stressing that for the patient, that time is the most valuable time they will spend "in their entire health care ecosystem."

Excellent communication in those brief moments will ensure that the most is made of that time, and that the patient experience is exceptional. Several steps can be taken to improve communication and to enhance the doctor-patient relationship – and to improve satisfaction and outcomes.

For one thing, talk more slowly, he said.

Eleven minutes is not a lot of time, and while slowing down may seem counterproductive, it will allow more information to sink in.

Also, use plain language. "NSAID" may seem like plain language to you, but for a patient, "anti-inflammatory" will likely make more sense. Remember that what may seem like plain language often is jargon.

"One report suggested that if you spend time on an educational intervention on something as simple as an NSAID, you’ll have a fourfold increase in efficacy in pain relief and reduction of inflammation," he said. "Assuming patients understand what they’re supposed to do is not enough."

Visual tools – pictures and "infographics" – are very helpful for improving communication and information retention among patients, as well.

Physicians often scribble information and drawings on the white examination table paper, then crumple that up and throw it away – and patients often fish that out of the trash can and take it home, he said, in explaining the value of visual learning.

"Infographics provide visual ways to communicate a lot of data," he said.

Technology, such as tablet computers, which are increasingly used in the office setting, can assist with this and can be an excellent communication tool rather than just a research tool and a tool for recording patient data.

Other tips for improving communication include using short- rather than long-form information and creating an empathic environment that makes patients feel comfortable asking questions.

Brief communications are important. Many patients get lost trying to navigate through long-form communications. It is important to filter it down to simple, small bits of information, Mr. Nordstrom said.

In addition to improving outcomes and patient satisfaction, improving communication is likely to reduce your risk of being sued for malpractice. One report suggests that at the core of 75% of malpractice cases are one or more of six factors: an inadequate explanation of the diagnosis, an inadequate explanation of the treatment, a feeling on the part of the patient of being ignored, a failure by the physician to understand the perspective of the patient or family/caregiver, a sense on the part of the patient that his or her views are devalued, and a sense by the patient that he or she was rushed.

Conversely, when communication is used to promote a more patient-centered relationship, which Mr. Nordstrom called an "exceptional patient experience," patients tend to come away feeling more engaged, activated, and empowered, he said at the meeting, which was held by Global Academy for Medical Education. GAME and this news organization are owned by Frontline Medical Communications.

Mr. Nordstrom reported having no relevant financial disclosures.

LAS VEGAS – Patients recall only about 10% of the information imparted by physicians during an office visit, and about half of all patients don’t understand their treatment plan, according to Richard Nordstrom.

Furthermore, 90% of patients have difficulty following routine medical advice, said Mr. Nordstrom, chief executive officer for a health care communications consulting firm in Montclair, N.J.

The problem isn’t just one of low health care literacy. Patients who receive a significant, life-altering diagnosis often don’t hear much else after they hear words like, "you have rheumatoid arthritis," he said at Perspectives in Rheumatic Diseases 2013.

This is true regardless of a patient’s literacy level, and even those with high literacy may be too embarrassed to ask questions that they think might make them sound uninformed, he noted.

These factors lead to poor outcomes and less patient satisfaction. Improved communication can go a long way toward improving both, he said.

Physicians have so little time with patients; about half of those in a recent survey said that they see between 50 and 100 patients each week. The average time a health care professional spends educating a patient on conditions and treatments critical for the patient’s care is only 11 minutes, and during that time, patients ask an average of only two questions.

"Your moments with that patient are critical," Mr. Nordstrom said, stressing that for the patient, that time is the most valuable time they will spend "in their entire health care ecosystem."

Excellent communication in those brief moments will ensure that the most is made of that time, and that the patient experience is exceptional. Several steps can be taken to improve communication and to enhance the doctor-patient relationship – and to improve satisfaction and outcomes.

For one thing, talk more slowly, he said.

Eleven minutes is not a lot of time, and while slowing down may seem counterproductive, it will allow more information to sink in.

Also, use plain language. "NSAID" may seem like plain language to you, but for a patient, "anti-inflammatory" will likely make more sense. Remember that what may seem like plain language often is jargon.

"One report suggested that if you spend time on an educational intervention on something as simple as an NSAID, you’ll have a fourfold increase in efficacy in pain relief and reduction of inflammation," he said. "Assuming patients understand what they’re supposed to do is not enough."

Visual tools – pictures and "infographics" – are very helpful for improving communication and information retention among patients, as well.

Physicians often scribble information and drawings on the white examination table paper, then crumple that up and throw it away – and patients often fish that out of the trash can and take it home, he said, in explaining the value of visual learning.

"Infographics provide visual ways to communicate a lot of data," he said.

Technology, such as tablet computers, which are increasingly used in the office setting, can assist with this and can be an excellent communication tool rather than just a research tool and a tool for recording patient data.

Other tips for improving communication include using short- rather than long-form information and creating an empathic environment that makes patients feel comfortable asking questions.

Brief communications are important. Many patients get lost trying to navigate through long-form communications. It is important to filter it down to simple, small bits of information, Mr. Nordstrom said.

In addition to improving outcomes and patient satisfaction, improving communication is likely to reduce your risk of being sued for malpractice. One report suggests that at the core of 75% of malpractice cases are one or more of six factors: an inadequate explanation of the diagnosis, an inadequate explanation of the treatment, a feeling on the part of the patient of being ignored, a failure by the physician to understand the perspective of the patient or family/caregiver, a sense on the part of the patient that his or her views are devalued, and a sense by the patient that he or she was rushed.

Conversely, when communication is used to promote a more patient-centered relationship, which Mr. Nordstrom called an "exceptional patient experience," patients tend to come away feeling more engaged, activated, and empowered, he said at the meeting, which was held by Global Academy for Medical Education. GAME and this news organization are owned by Frontline Medical Communications.

Mr. Nordstrom reported having no relevant financial disclosures.

LAS VEGAS – Patients recall only about 10% of the information imparted by physicians during an office visit, and about half of all patients don’t understand their treatment plan, according to Richard Nordstrom.

Furthermore, 90% of patients have difficulty following routine medical advice, said Mr. Nordstrom, chief executive officer for a health care communications consulting firm in Montclair, N.J.

The problem isn’t just one of low health care literacy. Patients who receive a significant, life-altering diagnosis often don’t hear much else after they hear words like, "you have rheumatoid arthritis," he said at Perspectives in Rheumatic Diseases 2013.

This is true regardless of a patient’s literacy level, and even those with high literacy may be too embarrassed to ask questions that they think might make them sound uninformed, he noted.

These factors lead to poor outcomes and less patient satisfaction. Improved communication can go a long way toward improving both, he said.

Physicians have so little time with patients; about half of those in a recent survey said that they see between 50 and 100 patients each week. The average time a health care professional spends educating a patient on conditions and treatments critical for the patient’s care is only 11 minutes, and during that time, patients ask an average of only two questions.

"Your moments with that patient are critical," Mr. Nordstrom said, stressing that for the patient, that time is the most valuable time they will spend "in their entire health care ecosystem."

Excellent communication in those brief moments will ensure that the most is made of that time, and that the patient experience is exceptional. Several steps can be taken to improve communication and to enhance the doctor-patient relationship – and to improve satisfaction and outcomes.

For one thing, talk more slowly, he said.

Eleven minutes is not a lot of time, and while slowing down may seem counterproductive, it will allow more information to sink in.

Also, use plain language. "NSAID" may seem like plain language to you, but for a patient, "anti-inflammatory" will likely make more sense. Remember that what may seem like plain language often is jargon.

"One report suggested that if you spend time on an educational intervention on something as simple as an NSAID, you’ll have a fourfold increase in efficacy in pain relief and reduction of inflammation," he said. "Assuming patients understand what they’re supposed to do is not enough."

Visual tools – pictures and "infographics" – are very helpful for improving communication and information retention among patients, as well.

Physicians often scribble information and drawings on the white examination table paper, then crumple that up and throw it away – and patients often fish that out of the trash can and take it home, he said, in explaining the value of visual learning.

"Infographics provide visual ways to communicate a lot of data," he said.

Technology, such as tablet computers, which are increasingly used in the office setting, can assist with this and can be an excellent communication tool rather than just a research tool and a tool for recording patient data.

Other tips for improving communication include using short- rather than long-form information and creating an empathic environment that makes patients feel comfortable asking questions.

Brief communications are important. Many patients get lost trying to navigate through long-form communications. It is important to filter it down to simple, small bits of information, Mr. Nordstrom said.

In addition to improving outcomes and patient satisfaction, improving communication is likely to reduce your risk of being sued for malpractice. One report suggests that at the core of 75% of malpractice cases are one or more of six factors: an inadequate explanation of the diagnosis, an inadequate explanation of the treatment, a feeling on the part of the patient of being ignored, a failure by the physician to understand the perspective of the patient or family/caregiver, a sense on the part of the patient that his or her views are devalued, and a sense by the patient that he or she was rushed.

Conversely, when communication is used to promote a more patient-centered relationship, which Mr. Nordstrom called an "exceptional patient experience," patients tend to come away feeling more engaged, activated, and empowered, he said at the meeting, which was held by Global Academy for Medical Education. GAME and this news organization are owned by Frontline Medical Communications.

Mr. Nordstrom reported having no relevant financial disclosures.

SAN FRANCISCO – Influenza vaccination during pregnancy was associated with significantly lower odds of delivering a preterm or small for gestational age infant during a period of widespread influenza activity, but the effects varied based on maternal characteristics, according to findings from a large retrospective cohort study.

A highly significant overall association was seen between maternal vaccination with trivalent inactivated influenza vaccine and reduced odds of preterm birth among all 8,393 women with live births between Jan. 1, 2005, and Dec. 31, 2008, who were included in the study (odds ratio, 0.39). However, vaccination was most protective against preterm birth among white women (OR, 0.34) and women of higher socioeconomic status (OR, 0.30), Dr. Saad Omer of Emory University, Atlanta, reported an annual scientific meeting on infectious diseases.

©AvailableLight/istockphoto.com

Vaccination protected against small for gestational age birth only among those at higher risk for influenza-related morbidity, including those enrolled in the WIC (Women, Infant, and Children) program (OR, 0.20) and black women (OR, 0.15), Dr. Omer said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

Data for this study were derived from the Georgia pregnancy risk assessment and monitoring system, as well as from hospital discharges and birth certificates. A number of prior studies have demonstrated beneficial effects of maternal immunization on maternal outcomes, and a 2011 study by Dr. Omer was the first to demonstrate overall beneficial effects on fetal outcomes following maternal influenza vaccine.

In that study, maternal vaccination was associated with reduced odds of preterm birth during local, regional, and widespread periods of influenza activity (OR, 0.44, 0.41, and 0.28, respectively), and with reduced odds of delivering a small for gestational age infant during the widespread activity period (OR, 0.31), he said (PLoS Med. 2011;8:e1000441). These findings have been replicated in subsequent studies.

But this is a complex process, and there is increasing recognition that inflammation and other factors play a role in preterm birth, he explained, noting: "There is substantial epidemiological and biological evidence that maternal characteristics are associated with adverse birth outcomes."

The current study is the first to look at fetal outcomes stratified by some of these maternal characteristics, he noted.

The outcomes were similar in magnitude to those in his 2011 study – but were restricted to the period of widespread influenza activity.

"And essentially, we had restriction of effect by race," he added, noting that there also was heterogeneity among the two outcomes (preterm birth and small for gestational age birth).

"So the bottom line is, yes, we saw – especially during the period of widespread influenza activity – that there was reduction of odds in both preterm birth and small for gestational age, but there’s more to this story. There is heterogeneity, perhaps based on underlying risk factors and mechanisms through which these extraneous factors have an impact on birth outcome," he said.

Currently, three international trials looking at some of these outcomes are underway, he said, adding: One hopes that from these trials "we’ll have a little bit more clarity both in terms of the actual clinical effect of these interventions, but also in terms of biologic pathways that are involved."

Dr. Omer reported having no disclosures.

SAN FRANCISCO – Influenza vaccination during pregnancy was associated with significantly lower odds of delivering a preterm or small for gestational age infant during a period of widespread influenza activity, but the effects varied based on maternal characteristics, according to findings from a large retrospective cohort study.

A highly significant overall association was seen between maternal vaccination with trivalent inactivated influenza vaccine and reduced odds of preterm birth among all 8,393 women with live births between Jan. 1, 2005, and Dec. 31, 2008, who were included in the study (odds ratio, 0.39). However, vaccination was most protective against preterm birth among white women (OR, 0.34) and women of higher socioeconomic status (OR, 0.30), Dr. Saad Omer of Emory University, Atlanta, reported an annual scientific meeting on infectious diseases.

©AvailableLight/istockphoto.com

Vaccination protected against small for gestational age birth only among those at higher risk for influenza-related morbidity, including those enrolled in the WIC (Women, Infant, and Children) program (OR, 0.20) and black women (OR, 0.15), Dr. Omer said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

Data for this study were derived from the Georgia pregnancy risk assessment and monitoring system, as well as from hospital discharges and birth certificates. A number of prior studies have demonstrated beneficial effects of maternal immunization on maternal outcomes, and a 2011 study by Dr. Omer was the first to demonstrate overall beneficial effects on fetal outcomes following maternal influenza vaccine.

In that study, maternal vaccination was associated with reduced odds of preterm birth during local, regional, and widespread periods of influenza activity (OR, 0.44, 0.41, and 0.28, respectively), and with reduced odds of delivering a small for gestational age infant during the widespread activity period (OR, 0.31), he said (PLoS Med. 2011;8:e1000441). These findings have been replicated in subsequent studies.

But this is a complex process, and there is increasing recognition that inflammation and other factors play a role in preterm birth, he explained, noting: "There is substantial epidemiological and biological evidence that maternal characteristics are associated with adverse birth outcomes."

The current study is the first to look at fetal outcomes stratified by some of these maternal characteristics, he noted.

The outcomes were similar in magnitude to those in his 2011 study – but were restricted to the period of widespread influenza activity.

"And essentially, we had restriction of effect by race," he added, noting that there also was heterogeneity among the two outcomes (preterm birth and small for gestational age birth).

"So the bottom line is, yes, we saw – especially during the period of widespread influenza activity – that there was reduction of odds in both preterm birth and small for gestational age, but there’s more to this story. There is heterogeneity, perhaps based on underlying risk factors and mechanisms through which these extraneous factors have an impact on birth outcome," he said.

Currently, three international trials looking at some of these outcomes are underway, he said, adding: One hopes that from these trials "we’ll have a little bit more clarity both in terms of the actual clinical effect of these interventions, but also in terms of biologic pathways that are involved."

Dr. Omer reported having no disclosures.

SAN FRANCISCO – Influenza vaccination during pregnancy was associated with significantly lower odds of delivering a preterm or small for gestational age infant during a period of widespread influenza activity, but the effects varied based on maternal characteristics, according to findings from a large retrospective cohort study.

A highly significant overall association was seen between maternal vaccination with trivalent inactivated influenza vaccine and reduced odds of preterm birth among all 8,393 women with live births between Jan. 1, 2005, and Dec. 31, 2008, who were included in the study (odds ratio, 0.39). However, vaccination was most protective against preterm birth among white women (OR, 0.34) and women of higher socioeconomic status (OR, 0.30), Dr. Saad Omer of Emory University, Atlanta, reported an annual scientific meeting on infectious diseases.

©AvailableLight/istockphoto.com

Vaccination protected against small for gestational age birth only among those at higher risk for influenza-related morbidity, including those enrolled in the WIC (Women, Infant, and Children) program (OR, 0.20) and black women (OR, 0.15), Dr. Omer said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

Data for this study were derived from the Georgia pregnancy risk assessment and monitoring system, as well as from hospital discharges and birth certificates. A number of prior studies have demonstrated beneficial effects of maternal immunization on maternal outcomes, and a 2011 study by Dr. Omer was the first to demonstrate overall beneficial effects on fetal outcomes following maternal influenza vaccine.

In that study, maternal vaccination was associated with reduced odds of preterm birth during local, regional, and widespread periods of influenza activity (OR, 0.44, 0.41, and 0.28, respectively), and with reduced odds of delivering a small for gestational age infant during the widespread activity period (OR, 0.31), he said (PLoS Med. 2011;8:e1000441). These findings have been replicated in subsequent studies.

But this is a complex process, and there is increasing recognition that inflammation and other factors play a role in preterm birth, he explained, noting: "There is substantial epidemiological and biological evidence that maternal characteristics are associated with adverse birth outcomes."

The current study is the first to look at fetal outcomes stratified by some of these maternal characteristics, he noted.

The outcomes were similar in magnitude to those in his 2011 study – but were restricted to the period of widespread influenza activity.

"And essentially, we had restriction of effect by race," he added, noting that there also was heterogeneity among the two outcomes (preterm birth and small for gestational age birth).

"So the bottom line is, yes, we saw – especially during the period of widespread influenza activity – that there was reduction of odds in both preterm birth and small for gestational age, but there’s more to this story. There is heterogeneity, perhaps based on underlying risk factors and mechanisms through which these extraneous factors have an impact on birth outcome," he said.

Currently, three international trials looking at some of these outcomes are underway, he said, adding: One hopes that from these trials "we’ll have a little bit more clarity both in terms of the actual clinical effect of these interventions, but also in terms of biologic pathways that are involved."

Dr. Omer reported having no disclosures.

SAN FRANCISCO – Colonization with a methicillin-resistant Staphylococcus aureus strain carrying the gene for staphylococcal enterotoxin P was highly correlated with development of MRSA bacteremia among intensive care unit patients in a nested case-control study.

From among 8,203 adults with 11,528 intensive care unit admissions, staff collected 1,578 MRSA isolates from 492 patients – either at ICU admission or readmission, ICU discharge, or during weekly MRSA surveillance screening. Case subjects were 33 colonized patients who developed MRSA bacteremia; controls were 132 colonized patients (four controls for each case patient) who did not develop bacteremia, Dr. Michael S. Calderwood, an infectious disease specialist at Brigham and Women’s Hospital, Boston, reported at an annual scientific meeting on infectious diseases.

Full genome sequencing of collected MRSA strains was performed for all cases and for 127 controls. In particular, the investigators evaluated the isolates for the presence of 30 MRSA genes potentially associated with virulence and invasion. After controlling for host factors, they assessed the association between these genes and the development of bacteremia, Dr. Calderwood said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

"We all know that MRSA colonization is increasing in U.S. hospitals, and that colonization with MRSA is a predictor of later infection," Dr. Calderwood said, noting that more than 80% of bacteremia cases involve an identical strain in the patient’s nares and blood.

While both host and pathogen factors play a role in MRSA infection, the two are typically looked at separately; their interaction hasn’t been assessed, he said.

"We looked at combined host-pathogen risk factors in a prospective cohort with the hope of successfully identifying genomic determinants of virulence," he said, noting that identifying risk-adjusted genomic determinant of virulence may improve the ability to predict invasive disease and suggest new targets for therapeutic intervention.

Cases and controls for the current study were identified from samples from eight ICUs, banked between Sept. 1, 2003 and April 30, 2005.

Host factors considered in this study included comorbidities, wounds or recent surgeries, device use (such as a central venous catheter or intubation), recent health care exposures, antibiotic use, and lab values. Pathogen factors included Panton-Valentine leukocidin (LukS and LukF), other leukocidins (LukD and LukE), staphylococcal enterotoxins A-U, chemotaxis inhibitory protein of S. aureus, staphylococcal complement inhibitor protein family, staphylokinase, toxic shock syndrome toxin, staphylococcal cassette chromosome mec type, accessory gene regulator locus group, single-nucleotide polymorphisms (SNPs) in gene for phenol-soluble modulins, and SNPs in gene for alpha-hemolysin.

Hazard ratios were calculated for each of these factors, and those with a P value of 0.2 or less were entered into a multivariable model.

On multivariate analysis, significant risk factors for bacteremia among colonized patients included staphylococcal enterotoxin P, known as SEP (HR, 26.7), cancer (HR, 3.1), presence of a central venous catheter (HR, 2.9), and hyperglycemia (HR, 0.9). Treatment with an anti-MRSA antibiotic had a protective effect (HR, 0.5). An interaction effect was found for SEP and treatment with an anti-MRSA antibiotic (HR, 1.5), Dr. Calderwood said.

The presence of SEP – which is carried by a bacteriophage along with other genes encoding proteins that help S. aureus evade the host’s innate immune response – has been linked previously to higher mortality in S. aureus bacteremia, and lower antibody levels of S. aureus enterotoxins have been linked to bacteremia, he said, adding that the findings have potential implications for predicting and preventing MRSA bacteremia; they suggest SEP as a possible target for immunotherapeutics or vaccine development, he said.

This study was supported by the Centers for Disease Control and Prevention and the National Institute of Allergy and Infectious Diseases/National Institutes of Health. Dr. Calderwood reported having no disclosures.

SAN FRANCISCO – Colonization with a methicillin-resistant Staphylococcus aureus strain carrying the gene for staphylococcal enterotoxin P was highly correlated with development of MRSA bacteremia among intensive care unit patients in a nested case-control study.

From among 8,203 adults with 11,528 intensive care unit admissions, staff collected 1,578 MRSA isolates from 492 patients – either at ICU admission or readmission, ICU discharge, or during weekly MRSA surveillance screening. Case subjects were 33 colonized patients who developed MRSA bacteremia; controls were 132 colonized patients (four controls for each case patient) who did not develop bacteremia, Dr. Michael S. Calderwood, an infectious disease specialist at Brigham and Women’s Hospital, Boston, reported at an annual scientific meeting on infectious diseases.

Full genome sequencing of collected MRSA strains was performed for all cases and for 127 controls. In particular, the investigators evaluated the isolates for the presence of 30 MRSA genes potentially associated with virulence and invasion. After controlling for host factors, they assessed the association between these genes and the development of bacteremia, Dr. Calderwood said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

"We all know that MRSA colonization is increasing in U.S. hospitals, and that colonization with MRSA is a predictor of later infection," Dr. Calderwood said, noting that more than 80% of bacteremia cases involve an identical strain in the patient’s nares and blood.

While both host and pathogen factors play a role in MRSA infection, the two are typically looked at separately; their interaction hasn’t been assessed, he said.

"We looked at combined host-pathogen risk factors in a prospective cohort with the hope of successfully identifying genomic determinants of virulence," he said, noting that identifying risk-adjusted genomic determinant of virulence may improve the ability to predict invasive disease and suggest new targets for therapeutic intervention.

Cases and controls for the current study were identified from samples from eight ICUs, banked between Sept. 1, 2003 and April 30, 2005.

Host factors considered in this study included comorbidities, wounds or recent surgeries, device use (such as a central venous catheter or intubation), recent health care exposures, antibiotic use, and lab values. Pathogen factors included Panton-Valentine leukocidin (LukS and LukF), other leukocidins (LukD and LukE), staphylococcal enterotoxins A-U, chemotaxis inhibitory protein of S. aureus, staphylococcal complement inhibitor protein family, staphylokinase, toxic shock syndrome toxin, staphylococcal cassette chromosome mec type, accessory gene regulator locus group, single-nucleotide polymorphisms (SNPs) in gene for phenol-soluble modulins, and SNPs in gene for alpha-hemolysin.

Hazard ratios were calculated for each of these factors, and those with a P value of 0.2 or less were entered into a multivariable model.

On multivariate analysis, significant risk factors for bacteremia among colonized patients included staphylococcal enterotoxin P, known as SEP (HR, 26.7), cancer (HR, 3.1), presence of a central venous catheter (HR, 2.9), and hyperglycemia (HR, 0.9). Treatment with an anti-MRSA antibiotic had a protective effect (HR, 0.5). An interaction effect was found for SEP and treatment with an anti-MRSA antibiotic (HR, 1.5), Dr. Calderwood said.

The presence of SEP – which is carried by a bacteriophage along with other genes encoding proteins that help S. aureus evade the host’s innate immune response – has been linked previously to higher mortality in S. aureus bacteremia, and lower antibody levels of S. aureus enterotoxins have been linked to bacteremia, he said, adding that the findings have potential implications for predicting and preventing MRSA bacteremia; they suggest SEP as a possible target for immunotherapeutics or vaccine development, he said.

This study was supported by the Centers for Disease Control and Prevention and the National Institute of Allergy and Infectious Diseases/National Institutes of Health. Dr. Calderwood reported having no disclosures.

SAN FRANCISCO – Colonization with a methicillin-resistant Staphylococcus aureus strain carrying the gene for staphylococcal enterotoxin P was highly correlated with development of MRSA bacteremia among intensive care unit patients in a nested case-control study.

From among 8,203 adults with 11,528 intensive care unit admissions, staff collected 1,578 MRSA isolates from 492 patients – either at ICU admission or readmission, ICU discharge, or during weekly MRSA surveillance screening. Case subjects were 33 colonized patients who developed MRSA bacteremia; controls were 132 colonized patients (four controls for each case patient) who did not develop bacteremia, Dr. Michael S. Calderwood, an infectious disease specialist at Brigham and Women’s Hospital, Boston, reported at an annual scientific meeting on infectious diseases.

Full genome sequencing of collected MRSA strains was performed for all cases and for 127 controls. In particular, the investigators evaluated the isolates for the presence of 30 MRSA genes potentially associated with virulence and invasion. After controlling for host factors, they assessed the association between these genes and the development of bacteremia, Dr. Calderwood said at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

"We all know that MRSA colonization is increasing in U.S. hospitals, and that colonization with MRSA is a predictor of later infection," Dr. Calderwood said, noting that more than 80% of bacteremia cases involve an identical strain in the patient’s nares and blood.

While both host and pathogen factors play a role in MRSA infection, the two are typically looked at separately; their interaction hasn’t been assessed, he said.

"We looked at combined host-pathogen risk factors in a prospective cohort with the hope of successfully identifying genomic determinants of virulence," he said, noting that identifying risk-adjusted genomic determinant of virulence may improve the ability to predict invasive disease and suggest new targets for therapeutic intervention.

Cases and controls for the current study were identified from samples from eight ICUs, banked between Sept. 1, 2003 and April 30, 2005.

Host factors considered in this study included comorbidities, wounds or recent surgeries, device use (such as a central venous catheter or intubation), recent health care exposures, antibiotic use, and lab values. Pathogen factors included Panton-Valentine leukocidin (LukS and LukF), other leukocidins (LukD and LukE), staphylococcal enterotoxins A-U, chemotaxis inhibitory protein of S. aureus, staphylococcal complement inhibitor protein family, staphylokinase, toxic shock syndrome toxin, staphylococcal cassette chromosome mec type, accessory gene regulator locus group, single-nucleotide polymorphisms (SNPs) in gene for phenol-soluble modulins, and SNPs in gene for alpha-hemolysin.

Hazard ratios were calculated for each of these factors, and those with a P value of 0.2 or less were entered into a multivariable model.

On multivariate analysis, significant risk factors for bacteremia among colonized patients included staphylococcal enterotoxin P, known as SEP (HR, 26.7), cancer (HR, 3.1), presence of a central venous catheter (HR, 2.9), and hyperglycemia (HR, 0.9). Treatment with an anti-MRSA antibiotic had a protective effect (HR, 0.5). An interaction effect was found for SEP and treatment with an anti-MRSA antibiotic (HR, 1.5), Dr. Calderwood said.

The presence of SEP – which is carried by a bacteriophage along with other genes encoding proteins that help S. aureus evade the host’s innate immune response – has been linked previously to higher mortality in S. aureus bacteremia, and lower antibody levels of S. aureus enterotoxins have been linked to bacteremia, he said, adding that the findings have potential implications for predicting and preventing MRSA bacteremia; they suggest SEP as a possible target for immunotherapeutics or vaccine development, he said.

This study was supported by the Centers for Disease Control and Prevention and the National Institute of Allergy and Infectious Diseases/National Institutes of Health. Dr. Calderwood reported having no disclosures.

SAN FRANCISCO – Black children were less likely than nonblack children to receive an otitis media diagnosis and, when treated for otitis media, were less likely to receive a broad-spectrum antibiotic, national survey data showed.

Overall, there were no significant differences in the rate of outpatient visits for respiratory illness and otitis media (OM) between black children and nonblack children aged 0-14 years who participated in the National Ambulatory Care Survey and the National Hospital Ambulatory Medical Care Survey during 2008-2010 (1,175 vs. 1,150 per 1,000 population for respiratory visits; 253 vs. 324 per 1,000 population for OM visits), but the percentage of all visits resulting in an OM diagnosis was significantly lower among black children (7% vs. 10%), Dr. Katherine E. Fleming-Dutra of Emory University and the Centers for Disease Control and Prevention, Atlanta, reported in a poster at an annual scientific meeting on infectious diseases.

Furthermore, while the percentage of OM visits leading to an antibiotic prescription did not differ significantly between black and nonblack children, (81% vs. 76%), among those who did receive antibiotics, black children were significantly less likely than nonblack children to receive broad-spectrum antibiotics (42% vs. 52%), Dr. Fleming-Dutra reported at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

After adjustment for potential confounders, black race remained a significant protective factor against prescription of a broad-spectrum antibiotic (adjusted odds ratio, 0.59), she noted.

The findings support those from a prior regional study that also showed a lower rate of OM diagnosis and lower broad-spectrum antibiotic use in black children, and suggest these racial differences in diagnosis and prescribing also occur at the national level, Dr. Fleming-Dutra said, noting that race-based differences in physician and parental preferences may contribute to inappropriate antibiotic prescribing for nonblack children.

"Reducing antibiotic prescriptions and broad-spectrum antibiotic prescribing is a major public health goal. ... National guidelines recommend that not all patients with OM require antibiotics, and when they do, amoxicillin is recommended for most children with OM," she said.

Providers may be tailoring the diagnosis to justify an antibiotic prescription in nonblack children, she added.

"Provider education campaigns should target appropriate communication with parents regarding the need for and use of antibiotics, and how to determine and manage parental expectations," she concluded.

Dr. Fleming-Dutra reported having no relevant financial conflicts.

SAN FRANCISCO – Black children were less likely than nonblack children to receive an otitis media diagnosis and, when treated for otitis media, were less likely to receive a broad-spectrum antibiotic, national survey data showed.

Overall, there were no significant differences in the rate of outpatient visits for respiratory illness and otitis media (OM) between black children and nonblack children aged 0-14 years who participated in the National Ambulatory Care Survey and the National Hospital Ambulatory Medical Care Survey during 2008-2010 (1,175 vs. 1,150 per 1,000 population for respiratory visits; 253 vs. 324 per 1,000 population for OM visits), but the percentage of all visits resulting in an OM diagnosis was significantly lower among black children (7% vs. 10%), Dr. Katherine E. Fleming-Dutra of Emory University and the Centers for Disease Control and Prevention, Atlanta, reported in a poster at an annual scientific meeting on infectious diseases.

Furthermore, while the percentage of OM visits leading to an antibiotic prescription did not differ significantly between black and nonblack children, (81% vs. 76%), among those who did receive antibiotics, black children were significantly less likely than nonblack children to receive broad-spectrum antibiotics (42% vs. 52%), Dr. Fleming-Dutra reported at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

After adjustment for potential confounders, black race remained a significant protective factor against prescription of a broad-spectrum antibiotic (adjusted odds ratio, 0.59), she noted.

The findings support those from a prior regional study that also showed a lower rate of OM diagnosis and lower broad-spectrum antibiotic use in black children, and suggest these racial differences in diagnosis and prescribing also occur at the national level, Dr. Fleming-Dutra said, noting that race-based differences in physician and parental preferences may contribute to inappropriate antibiotic prescribing for nonblack children.

"Reducing antibiotic prescriptions and broad-spectrum antibiotic prescribing is a major public health goal. ... National guidelines recommend that not all patients with OM require antibiotics, and when they do, amoxicillin is recommended for most children with OM," she said.

Providers may be tailoring the diagnosis to justify an antibiotic prescription in nonblack children, she added.

"Provider education campaigns should target appropriate communication with parents regarding the need for and use of antibiotics, and how to determine and manage parental expectations," she concluded.

Dr. Fleming-Dutra reported having no relevant financial conflicts.

SAN FRANCISCO – Black children were less likely than nonblack children to receive an otitis media diagnosis and, when treated for otitis media, were less likely to receive a broad-spectrum antibiotic, national survey data showed.

Overall, there were no significant differences in the rate of outpatient visits for respiratory illness and otitis media (OM) between black children and nonblack children aged 0-14 years who participated in the National Ambulatory Care Survey and the National Hospital Ambulatory Medical Care Survey during 2008-2010 (1,175 vs. 1,150 per 1,000 population for respiratory visits; 253 vs. 324 per 1,000 population for OM visits), but the percentage of all visits resulting in an OM diagnosis was significantly lower among black children (7% vs. 10%), Dr. Katherine E. Fleming-Dutra of Emory University and the Centers for Disease Control and Prevention, Atlanta, reported in a poster at an annual scientific meeting on infectious diseases.

Furthermore, while the percentage of OM visits leading to an antibiotic prescription did not differ significantly between black and nonblack children, (81% vs. 76%), among those who did receive antibiotics, black children were significantly less likely than nonblack children to receive broad-spectrum antibiotics (42% vs. 52%), Dr. Fleming-Dutra reported at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

After adjustment for potential confounders, black race remained a significant protective factor against prescription of a broad-spectrum antibiotic (adjusted odds ratio, 0.59), she noted.

The findings support those from a prior regional study that also showed a lower rate of OM diagnosis and lower broad-spectrum antibiotic use in black children, and suggest these racial differences in diagnosis and prescribing also occur at the national level, Dr. Fleming-Dutra said, noting that race-based differences in physician and parental preferences may contribute to inappropriate antibiotic prescribing for nonblack children.

"Reducing antibiotic prescriptions and broad-spectrum antibiotic prescribing is a major public health goal. ... National guidelines recommend that not all patients with OM require antibiotics, and when they do, amoxicillin is recommended for most children with OM," she said.

Providers may be tailoring the diagnosis to justify an antibiotic prescription in nonblack children, she added.

"Provider education campaigns should target appropriate communication with parents regarding the need for and use of antibiotics, and how to determine and manage parental expectations," she concluded.

Dr. Fleming-Dutra reported having no relevant financial conflicts.

SAN FRANCISCO – Treatment of Shiga toxin–producing Escherichia coli 0157 infection with beta-lactams is associated with increased risk for postdiarrheal hemolytic uremic syndrome in both children and adults, according to findings from a population-based study.

Beta-lactam antibiotics are particularly troublesome in this setting, the findings suggest.

Among 1,308 patients with the infection, known as STEC 0157 – the leading cause of postdiarrheal hemolytic uremic syndrome (HUS) in the United States – 137 had HUS, and 44 had partial HUS, Dr. Melissa Tobin-D’Angelo reported at an annual scientific meeting on infectious diseases.

Up to 15% of patients with STEC 0157 diarrhea develop HUS, which comprises microangiopathic hemolytic anemia, acute azotemia, and thrombocytopenia, said Dr. Tobin-D’Angelo of the Georgia Department of Public Health, Atlanta.

Generally in this observational study, antibiotic treatment was used more commonly and HUS occurred less frequently with increasing age quartile. Among those under age 5 years, 12% received antibiotics and 22% had HUS; among those aged 5-14 years, 11% received antibiotics and 11% had HUS; among those aged 15-39 years, 45% received antibiotics and 5% had HUS; and among those aged 40 years or older, 52% received antibiotics and 4% had HUS.

Adults aged 40 and older were more likely than were those in all other age groups to receive beta-lactam antibiotics (8% vs. 4%) or metronidazole (31% vs. 11%), while children under age 15 years were more likely than were others to receive sulfonamides (5% vs. 1%), Dr. Tobin-D’Angelo reported at the conference, the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

No overall association was seen between antibiotic treatment and HUS, but among children aged 5-14 years, treatment with any antibiotic and treatment with metronidazole were significantly associated with HUS (odds ratios, 2.6 and 4.0, respectively). Also, among all subjects, beta-lactam antibiotics and sulfonamides were associated with at least partial HUS (odds ratios, 2.9 and 2.2, respectively), she noted.

Study subjects were patients with STEC 0157 identified through active, population-based surveillance in 10 states during 2006-2010. Patients or caregivers were interviewed, and data were extracted from medical records. Only antibiotic exposures during the first 7 days of illness or before HUS onset were included in the analysis.

"Controversy remains regarding antibiotic treatment of STEC 0157 and its possible association with an increased risk of HUS; antibiotics increase Shiga toxin production and release in vitro, but this varies by antibiotic class and dose, and it has varied by study," Dr. Tobin-D’Angelo said. Although observational studies have suggested that antibiotics increase the risk for HUS, those studies included only children and were limited by difficulties in controlling for the confounding effects of illness severity, she added.

The only randomized controlled trial was limited to trimethoprim-sulfamethoxazole, she noted.

The findings of the current study suggest that adults are considerably more likely than are children to receive antibiotics for the treatment of STEC 0157 diarrhea, and – as with prior findings in children – suggest that treatment with beta-lactams is associated with increased HUS risk in both children and adults, she said.

"We recommend that beta-lactams should not be prescribed to any patient of any age with known STEC 0157 infection and that clinicians should consider the risk of HUS when prescribing beta-lactams to any patients with diarrhea that could be caused by STEC 0157," she said. It is also prudent to avoid the use of other antibiotics for the treatment of STEC 0157 diarrhea because of evidence of increased HUS risk from other studies, and because of the lack of data demonstrating any therapeutic benefit, she added.

The conference was the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. Dr. Tobin-D’Angelo reported having no disclosures.

SAN FRANCISCO – Treatment of Shiga toxin–producing Escherichia coli 0157 infection with beta-lactams is associated with increased risk for postdiarrheal hemolytic uremic syndrome in both children and adults, according to findings from a population-based study.

Beta-lactam antibiotics are particularly troublesome in this setting, the findings suggest.

Among 1,308 patients with the infection, known as STEC 0157 – the leading cause of postdiarrheal hemolytic uremic syndrome (HUS) in the United States – 137 had HUS, and 44 had partial HUS, Dr. Melissa Tobin-D’Angelo reported at an annual scientific meeting on infectious diseases.

Up to 15% of patients with STEC 0157 diarrhea develop HUS, which comprises microangiopathic hemolytic anemia, acute azotemia, and thrombocytopenia, said Dr. Tobin-D’Angelo of the Georgia Department of Public Health, Atlanta.

Generally in this observational study, antibiotic treatment was used more commonly and HUS occurred less frequently with increasing age quartile. Among those under age 5 years, 12% received antibiotics and 22% had HUS; among those aged 5-14 years, 11% received antibiotics and 11% had HUS; among those aged 15-39 years, 45% received antibiotics and 5% had HUS; and among those aged 40 years or older, 52% received antibiotics and 4% had HUS.

Adults aged 40 and older were more likely than were those in all other age groups to receive beta-lactam antibiotics (8% vs. 4%) or metronidazole (31% vs. 11%), while children under age 15 years were more likely than were others to receive sulfonamides (5% vs. 1%), Dr. Tobin-D’Angelo reported at the conference, the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

No overall association was seen between antibiotic treatment and HUS, but among children aged 5-14 years, treatment with any antibiotic and treatment with metronidazole were significantly associated with HUS (odds ratios, 2.6 and 4.0, respectively). Also, among all subjects, beta-lactam antibiotics and sulfonamides were associated with at least partial HUS (odds ratios, 2.9 and 2.2, respectively), she noted.

Study subjects were patients with STEC 0157 identified through active, population-based surveillance in 10 states during 2006-2010. Patients or caregivers were interviewed, and data were extracted from medical records. Only antibiotic exposures during the first 7 days of illness or before HUS onset were included in the analysis.

"Controversy remains regarding antibiotic treatment of STEC 0157 and its possible association with an increased risk of HUS; antibiotics increase Shiga toxin production and release in vitro, but this varies by antibiotic class and dose, and it has varied by study," Dr. Tobin-D’Angelo said. Although observational studies have suggested that antibiotics increase the risk for HUS, those studies included only children and were limited by difficulties in controlling for the confounding effects of illness severity, she added.

The only randomized controlled trial was limited to trimethoprim-sulfamethoxazole, she noted.

The findings of the current study suggest that adults are considerably more likely than are children to receive antibiotics for the treatment of STEC 0157 diarrhea, and – as with prior findings in children – suggest that treatment with beta-lactams is associated with increased HUS risk in both children and adults, she said.

"We recommend that beta-lactams should not be prescribed to any patient of any age with known STEC 0157 infection and that clinicians should consider the risk of HUS when prescribing beta-lactams to any patients with diarrhea that could be caused by STEC 0157," she said. It is also prudent to avoid the use of other antibiotics for the treatment of STEC 0157 diarrhea because of evidence of increased HUS risk from other studies, and because of the lack of data demonstrating any therapeutic benefit, she added.

The conference was the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. Dr. Tobin-D’Angelo reported having no disclosures.

SAN FRANCISCO – Treatment of Shiga toxin–producing Escherichia coli 0157 infection with beta-lactams is associated with increased risk for postdiarrheal hemolytic uremic syndrome in both children and adults, according to findings from a population-based study.

Beta-lactam antibiotics are particularly troublesome in this setting, the findings suggest.

Among 1,308 patients with the infection, known as STEC 0157 – the leading cause of postdiarrheal hemolytic uremic syndrome (HUS) in the United States – 137 had HUS, and 44 had partial HUS, Dr. Melissa Tobin-D’Angelo reported at an annual scientific meeting on infectious diseases.

Up to 15% of patients with STEC 0157 diarrhea develop HUS, which comprises microangiopathic hemolytic anemia, acute azotemia, and thrombocytopenia, said Dr. Tobin-D’Angelo of the Georgia Department of Public Health, Atlanta.

Generally in this observational study, antibiotic treatment was used more commonly and HUS occurred less frequently with increasing age quartile. Among those under age 5 years, 12% received antibiotics and 22% had HUS; among those aged 5-14 years, 11% received antibiotics and 11% had HUS; among those aged 15-39 years, 45% received antibiotics and 5% had HUS; and among those aged 40 years or older, 52% received antibiotics and 4% had HUS.

Adults aged 40 and older were more likely than were those in all other age groups to receive beta-lactam antibiotics (8% vs. 4%) or metronidazole (31% vs. 11%), while children under age 15 years were more likely than were others to receive sulfonamides (5% vs. 1%), Dr. Tobin-D’Angelo reported at the conference, the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

No overall association was seen between antibiotic treatment and HUS, but among children aged 5-14 years, treatment with any antibiotic and treatment with metronidazole were significantly associated with HUS (odds ratios, 2.6 and 4.0, respectively). Also, among all subjects, beta-lactam antibiotics and sulfonamides were associated with at least partial HUS (odds ratios, 2.9 and 2.2, respectively), she noted.

Study subjects were patients with STEC 0157 identified through active, population-based surveillance in 10 states during 2006-2010. Patients or caregivers were interviewed, and data were extracted from medical records. Only antibiotic exposures during the first 7 days of illness or before HUS onset were included in the analysis.

"Controversy remains regarding antibiotic treatment of STEC 0157 and its possible association with an increased risk of HUS; antibiotics increase Shiga toxin production and release in vitro, but this varies by antibiotic class and dose, and it has varied by study," Dr. Tobin-D’Angelo said. Although observational studies have suggested that antibiotics increase the risk for HUS, those studies included only children and were limited by difficulties in controlling for the confounding effects of illness severity, she added.

The only randomized controlled trial was limited to trimethoprim-sulfamethoxazole, she noted.

The findings of the current study suggest that adults are considerably more likely than are children to receive antibiotics for the treatment of STEC 0157 diarrhea, and – as with prior findings in children – suggest that treatment with beta-lactams is associated with increased HUS risk in both children and adults, she said.

"We recommend that beta-lactams should not be prescribed to any patient of any age with known STEC 0157 infection and that clinicians should consider the risk of HUS when prescribing beta-lactams to any patients with diarrhea that could be caused by STEC 0157," she said. It is also prudent to avoid the use of other antibiotics for the treatment of STEC 0157 diarrhea because of evidence of increased HUS risk from other studies, and because of the lack of data demonstrating any therapeutic benefit, she added.

The conference was the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society. Dr. Tobin-D’Angelo reported having no disclosures.

SAN FRANCISCO – Influenza vaccination was associated with a substantial reduction in the risk of life-threatening influenza illness among children during the 2010-2011 and 2011-2012 influenza seasons, according to findings from a case-control study.

However, vaccine coverage was low in this study, even among children with comorbidities that increased their risk of severe influenza-related complications, Dr. Ed Belangia reported at an annual scientific meeting on infectious diseases.

Cases included 44 children with life-threatening confirmed influenza illness, 172 pediatric intensive care unit (PICU) control patients without influenza, and 93 community controls without influenza. Only 18% of cases and 31% of the PICU controls were fully vaccinated, compared with 50% of community controls; those who were fully vaccinated were 74% less likely to be admitted to a PICU for influenza-related illness, said Dr. Belangia of the Marshfield (Wis.) Clinic Research Foundation, who presented that data on behalf of study author Jill Ferdinands, Ph.D., of the Centers for Disease Control and Prevention.

© Yarinca/istockphoto.com

Of the cases, 15 (34%) had conditions that put them at high risk of influenza-related complications, and of the PICU controls and community controls, 89 (51%) and 35 (37%), respectively, had such conditions; 20% of the PICU patients had three or more comorbidities, compared with 3% of community controls, said Dr. Belangia.

After the investigators adjusted for factors including age, sex, date of onset, medical conditions, and – among PICU patients – illness severity and days from illness onset to influenza testing, the vaccine efficacy rate was 77%.

Of note, the receipt of one vaccine dose by children in whom two doses were recommended did not appear to provide protection in this study.

Children in the study, who were aged 6 months to 17 years during the 2010-2011 and 2011-2012 influenza seasons, were recruited within 7 days of symptom onset from 21 U.S. PICUs in the Pediatric Acute Lung Injury and Sepsis Investigators Network. Cases included those with acute severe respiratory illness who tested positive for influenza by reverse-transcription polymerase chain reaction; controls were PICU patients who tested negative for influenza, and children from the community who were matched for comorbidities and geographic region and who had no recent history of an influenza-related hospitalization.

Vaccine status was verified by medical record review, except in the community controls, whose vaccine status was based on parent report.

The low vaccine coverage in this study population, even among those at increased risk for influenza-related complications, is troubling, he said.

Although numerous studies have looked at flu vaccine efficacy in children, this study is among the first to look at the effects on severe influenza-related illness in children, he said, noting that about 1-7/10,000 children are hospitalized with influenza every year, which translates to 8,000-54,000 children per year.

"So that’s substantial morbidity – and of those, about 4%-24% require ICU admission," he said.

The results highlight the value of increasing the use of influenza vaccine among children, he concluded.

Dr. Ferdinand and her coauthors reported having no relevant financial disclosures. Dr. Belangia was not involved in the study.

SAN FRANCISCO – Influenza vaccination was associated with a substantial reduction in the risk of life-threatening influenza illness among children during the 2010-2011 and 2011-2012 influenza seasons, according to findings from a case-control study.

However, vaccine coverage was low in this study, even among children with comorbidities that increased their risk of severe influenza-related complications, Dr. Ed Belangia reported at an annual scientific meeting on infectious diseases.

Cases included 44 children with life-threatening confirmed influenza illness, 172 pediatric intensive care unit (PICU) control patients without influenza, and 93 community controls without influenza. Only 18% of cases and 31% of the PICU controls were fully vaccinated, compared with 50% of community controls; those who were fully vaccinated were 74% less likely to be admitted to a PICU for influenza-related illness, said Dr. Belangia of the Marshfield (Wis.) Clinic Research Foundation, who presented that data on behalf of study author Jill Ferdinands, Ph.D., of the Centers for Disease Control and Prevention.

© Yarinca/istockphoto.com

Of the cases, 15 (34%) had conditions that put them at high risk of influenza-related complications, and of the PICU controls and community controls, 89 (51%) and 35 (37%), respectively, had such conditions; 20% of the PICU patients had three or more comorbidities, compared with 3% of community controls, said Dr. Belangia.

After the investigators adjusted for factors including age, sex, date of onset, medical conditions, and – among PICU patients – illness severity and days from illness onset to influenza testing, the vaccine efficacy rate was 77%.

Of note, the receipt of one vaccine dose by children in whom two doses were recommended did not appear to provide protection in this study.

Children in the study, who were aged 6 months to 17 years during the 2010-2011 and 2011-2012 influenza seasons, were recruited within 7 days of symptom onset from 21 U.S. PICUs in the Pediatric Acute Lung Injury and Sepsis Investigators Network. Cases included those with acute severe respiratory illness who tested positive for influenza by reverse-transcription polymerase chain reaction; controls were PICU patients who tested negative for influenza, and children from the community who were matched for comorbidities and geographic region and who had no recent history of an influenza-related hospitalization.

Vaccine status was verified by medical record review, except in the community controls, whose vaccine status was based on parent report.

The low vaccine coverage in this study population, even among those at increased risk for influenza-related complications, is troubling, he said.

Although numerous studies have looked at flu vaccine efficacy in children, this study is among the first to look at the effects on severe influenza-related illness in children, he said, noting that about 1-7/10,000 children are hospitalized with influenza every year, which translates to 8,000-54,000 children per year.

"So that’s substantial morbidity – and of those, about 4%-24% require ICU admission," he said.

The results highlight the value of increasing the use of influenza vaccine among children, he concluded.

Dr. Ferdinand and her coauthors reported having no relevant financial disclosures. Dr. Belangia was not involved in the study.

SAN FRANCISCO – Influenza vaccination was associated with a substantial reduction in the risk of life-threatening influenza illness among children during the 2010-2011 and 2011-2012 influenza seasons, according to findings from a case-control study.

However, vaccine coverage was low in this study, even among children with comorbidities that increased their risk of severe influenza-related complications, Dr. Ed Belangia reported at an annual scientific meeting on infectious diseases.

Cases included 44 children with life-threatening confirmed influenza illness, 172 pediatric intensive care unit (PICU) control patients without influenza, and 93 community controls without influenza. Only 18% of cases and 31% of the PICU controls were fully vaccinated, compared with 50% of community controls; those who were fully vaccinated were 74% less likely to be admitted to a PICU for influenza-related illness, said Dr. Belangia of the Marshfield (Wis.) Clinic Research Foundation, who presented that data on behalf of study author Jill Ferdinands, Ph.D., of the Centers for Disease Control and Prevention.

© Yarinca/istockphoto.com

Of the cases, 15 (34%) had conditions that put them at high risk of influenza-related complications, and of the PICU controls and community controls, 89 (51%) and 35 (37%), respectively, had such conditions; 20% of the PICU patients had three or more comorbidities, compared with 3% of community controls, said Dr. Belangia.

After the investigators adjusted for factors including age, sex, date of onset, medical conditions, and – among PICU patients – illness severity and days from illness onset to influenza testing, the vaccine efficacy rate was 77%.

Of note, the receipt of one vaccine dose by children in whom two doses were recommended did not appear to provide protection in this study.

Children in the study, who were aged 6 months to 17 years during the 2010-2011 and 2011-2012 influenza seasons, were recruited within 7 days of symptom onset from 21 U.S. PICUs in the Pediatric Acute Lung Injury and Sepsis Investigators Network. Cases included those with acute severe respiratory illness who tested positive for influenza by reverse-transcription polymerase chain reaction; controls were PICU patients who tested negative for influenza, and children from the community who were matched for comorbidities and geographic region and who had no recent history of an influenza-related hospitalization.

Vaccine status was verified by medical record review, except in the community controls, whose vaccine status was based on parent report.

The low vaccine coverage in this study population, even among those at increased risk for influenza-related complications, is troubling, he said.

Although numerous studies have looked at flu vaccine efficacy in children, this study is among the first to look at the effects on severe influenza-related illness in children, he said, noting that about 1-7/10,000 children are hospitalized with influenza every year, which translates to 8,000-54,000 children per year.

"So that’s substantial morbidity – and of those, about 4%-24% require ICU admission," he said.

The results highlight the value of increasing the use of influenza vaccine among children, he concluded.

Dr. Ferdinand and her coauthors reported having no relevant financial disclosures. Dr. Belangia was not involved in the study.

SAN FRANCISCO – Most group A streptococcus tests performed in pediatric outpatients at a major children’s hospital were indicated based on current guidelines, but a significantly higher than expected proportion of children were treated with antibiotics, according to findings from a chart review.

Furthermore, 11.1% of the antibiotics prescribed to those patients were nonrecommended agents, Dr. Thea Brennan-Krohn reported in a poster at an annual scientific meeting on infectious diseases.

Included in the study were 234 patients, aged 3-18 years, who had a streptococcal rapid antigen detection test and/or a throat culture performed between Aug. 1, 2011, and July 31, 2013. The tests were indicated – based on a McIsaac score of 2 or greater as recommended by Infectious Diseases Society of America (IDSA) guidelines – in 95.7% of cases. If the patients had been managed according to guidelines, 8.1% would have received antibiotics, but 11.5% actually received antibiotics, reported Dr. Brennan-Krohn of Boston Children’s Hospital.

Children whose charts were reviewed as part of this study presented with pharyngitis to a clinic or emergency department at the hospital. According to the IDSA guidelines, testing is not recommended for those with acute pharyngitis with features that strongly suggest viral etiology, such as cough, rhinorrhea, hoarseness, or oral ulcers. Recommended antimicrobial agents in those who have group A streptococcus include penicillin V, amoxicillin, or intramuscular benzathine penicillin G in those without penicillin allergy, and cephalexin/cefadroxil, clindamycin, or azithromycin/clarithromycin in those who do have penicillin allergy.

Prior studies have demonstrated that guidelines are not consistently followed in adults. The current study is among the first to use individual patient data to assess guideline adherence in the pediatric population. The findings suggest that "there remains a role for targeted antimicrobial stewardship education regarding pharyngitis management in pediatric outpatient settings," Dr. Brennan-Krohn said.

Plans are underway to repeat the study in a large community-based practice setting to evaluate management of pharyngitis beyond the academic medical center setting, she noted at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

"Further investigation may help to clarify why pediatric providers appear to adhere more closely to pharyngitis management guidelines than adult providers," she concluded.

This study was supported by the Fred Lovejoy Housestaff Research and Education fund.

SAN FRANCISCO – Most group A streptococcus tests performed in pediatric outpatients at a major children’s hospital were indicated based on current guidelines, but a significantly higher than expected proportion of children were treated with antibiotics, according to findings from a chart review.

Furthermore, 11.1% of the antibiotics prescribed to those patients were nonrecommended agents, Dr. Thea Brennan-Krohn reported in a poster at an annual scientific meeting on infectious diseases.

Included in the study were 234 patients, aged 3-18 years, who had a streptococcal rapid antigen detection test and/or a throat culture performed between Aug. 1, 2011, and July 31, 2013. The tests were indicated – based on a McIsaac score of 2 or greater as recommended by Infectious Diseases Society of America (IDSA) guidelines – in 95.7% of cases. If the patients had been managed according to guidelines, 8.1% would have received antibiotics, but 11.5% actually received antibiotics, reported Dr. Brennan-Krohn of Boston Children’s Hospital.

Children whose charts were reviewed as part of this study presented with pharyngitis to a clinic or emergency department at the hospital. According to the IDSA guidelines, testing is not recommended for those with acute pharyngitis with features that strongly suggest viral etiology, such as cough, rhinorrhea, hoarseness, or oral ulcers. Recommended antimicrobial agents in those who have group A streptococcus include penicillin V, amoxicillin, or intramuscular benzathine penicillin G in those without penicillin allergy, and cephalexin/cefadroxil, clindamycin, or azithromycin/clarithromycin in those who do have penicillin allergy.

Prior studies have demonstrated that guidelines are not consistently followed in adults. The current study is among the first to use individual patient data to assess guideline adherence in the pediatric population. The findings suggest that "there remains a role for targeted antimicrobial stewardship education regarding pharyngitis management in pediatric outpatient settings," Dr. Brennan-Krohn said.

Plans are underway to repeat the study in a large community-based practice setting to evaluate management of pharyngitis beyond the academic medical center setting, she noted at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

"Further investigation may help to clarify why pediatric providers appear to adhere more closely to pharyngitis management guidelines than adult providers," she concluded.

This study was supported by the Fred Lovejoy Housestaff Research and Education fund.

SAN FRANCISCO – Most group A streptococcus tests performed in pediatric outpatients at a major children’s hospital were indicated based on current guidelines, but a significantly higher than expected proportion of children were treated with antibiotics, according to findings from a chart review.

Furthermore, 11.1% of the antibiotics prescribed to those patients were nonrecommended agents, Dr. Thea Brennan-Krohn reported in a poster at an annual scientific meeting on infectious diseases.

Included in the study were 234 patients, aged 3-18 years, who had a streptococcal rapid antigen detection test and/or a throat culture performed between Aug. 1, 2011, and July 31, 2013. The tests were indicated – based on a McIsaac score of 2 or greater as recommended by Infectious Diseases Society of America (IDSA) guidelines – in 95.7% of cases. If the patients had been managed according to guidelines, 8.1% would have received antibiotics, but 11.5% actually received antibiotics, reported Dr. Brennan-Krohn of Boston Children’s Hospital.

Children whose charts were reviewed as part of this study presented with pharyngitis to a clinic or emergency department at the hospital. According to the IDSA guidelines, testing is not recommended for those with acute pharyngitis with features that strongly suggest viral etiology, such as cough, rhinorrhea, hoarseness, or oral ulcers. Recommended antimicrobial agents in those who have group A streptococcus include penicillin V, amoxicillin, or intramuscular benzathine penicillin G in those without penicillin allergy, and cephalexin/cefadroxil, clindamycin, or azithromycin/clarithromycin in those who do have penicillin allergy.

Prior studies have demonstrated that guidelines are not consistently followed in adults. The current study is among the first to use individual patient data to assess guideline adherence in the pediatric population. The findings suggest that "there remains a role for targeted antimicrobial stewardship education regarding pharyngitis management in pediatric outpatient settings," Dr. Brennan-Krohn said.

Plans are underway to repeat the study in a large community-based practice setting to evaluate management of pharyngitis beyond the academic medical center setting, she noted at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

"Further investigation may help to clarify why pediatric providers appear to adhere more closely to pharyngitis management guidelines than adult providers," she concluded.

This study was supported by the Fred Lovejoy Housestaff Research and Education fund.

SAN FRANCISCO – Most group A streptococcus tests performed in pediatric outpatients at a major children’s hospital were indicated based on current guidelines, but a significantly higher than expected proportion of children were treated with antibiotics, according to findings from a chart review.

Furthermore, 11.1% of the antibiotics prescribed to those patients were nonrecommended agents, Dr. Thea Brennan-Krohn reported in a poster at an annual scientific meeting on infectious diseases.

Included in the study were 234 patients, aged 3-18 years, who had a streptococcal rapid antigen detection test and/or a throat culture performed between Aug. 1, 2011, and July 31, 2013. The tests were indicated – based on a McIsaac score of 2 or greater as recommended by Infectious Diseases Society of America (IDSA) guidelines – in 95.7% of cases. If the patients had been managed according to guidelines, 8.1% would have received antibiotics, but 11.5% actually received antibiotics, reported Dr. Brennan-Krohn of Boston Children’s Hospital.

Children whose charts were reviewed as part of this study presented with pharyngitis to a clinic or emergency department at the hospital. According to the IDSA guidelines, testing is not recommended for those with acute pharyngitis with features that strongly suggest viral etiology, such as cough, rhinorrhea, hoarseness, or oral ulcers. Recommended antimicrobial agents in those who have group A streptococcus include penicillin V, amoxicillin, or intramuscular benzathine penicillin G in those without penicillin allergy, and cephalexin/cefadroxil, clindamycin, or azithromycin/clarithromycin in those who do have penicillin allergy.

Prior studies have demonstrated that guidelines are not consistently followed in adults. The current study is among the first to use individual patient data to assess guideline adherence in the pediatric population. The findings suggest that "there remains a role for targeted antimicrobial stewardship education regarding pharyngitis management in pediatric outpatient settings," Dr. Brennan-Krohn said.

Plans are underway to repeat the study in a large community-based practice setting to evaluate management of pharyngitis beyond the academic medical center setting, she noted at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

"Further investigation may help to clarify why pediatric providers appear to adhere more closely to pharyngitis management guidelines than adult providers," she concluded.

This study was supported by the Fred Lovejoy Housestaff Research and Education fund.

SAN FRANCISCO – Most group A streptococcus tests performed in pediatric outpatients at a major children’s hospital were indicated based on current guidelines, but a significantly higher than expected proportion of children were treated with antibiotics, according to findings from a chart review.

Furthermore, 11.1% of the antibiotics prescribed to those patients were nonrecommended agents, Dr. Thea Brennan-Krohn reported in a poster at an annual scientific meeting on infectious diseases.

Included in the study were 234 patients, aged 3-18 years, who had a streptococcal rapid antigen detection test and/or a throat culture performed between Aug. 1, 2011, and July 31, 2013. The tests were indicated – based on a McIsaac score of 2 or greater as recommended by Infectious Diseases Society of America (IDSA) guidelines – in 95.7% of cases. If the patients had been managed according to guidelines, 8.1% would have received antibiotics, but 11.5% actually received antibiotics, reported Dr. Brennan-Krohn of Boston Children’s Hospital.

Children whose charts were reviewed as part of this study presented with pharyngitis to a clinic or emergency department at the hospital. According to the IDSA guidelines, testing is not recommended for those with acute pharyngitis with features that strongly suggest viral etiology, such as cough, rhinorrhea, hoarseness, or oral ulcers. Recommended antimicrobial agents in those who have group A streptococcus include penicillin V, amoxicillin, or intramuscular benzathine penicillin G in those without penicillin allergy, and cephalexin/cefadroxil, clindamycin, or azithromycin/clarithromycin in those who do have penicillin allergy.

Prior studies have demonstrated that guidelines are not consistently followed in adults. The current study is among the first to use individual patient data to assess guideline adherence in the pediatric population. The findings suggest that "there remains a role for targeted antimicrobial stewardship education regarding pharyngitis management in pediatric outpatient settings," Dr. Brennan-Krohn said.

Plans are underway to repeat the study in a large community-based practice setting to evaluate management of pharyngitis beyond the academic medical center setting, she noted at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

"Further investigation may help to clarify why pediatric providers appear to adhere more closely to pharyngitis management guidelines than adult providers," she concluded.

This study was supported by the Fred Lovejoy Housestaff Research and Education fund.

SAN FRANCISCO – Most group A streptococcus tests performed in pediatric outpatients at a major children’s hospital were indicated based on current guidelines, but a significantly higher than expected proportion of children were treated with antibiotics, according to findings from a chart review.

Furthermore, 11.1% of the antibiotics prescribed to those patients were nonrecommended agents, Dr. Thea Brennan-Krohn reported in a poster at an annual scientific meeting on infectious diseases.

Included in the study were 234 patients, aged 3-18 years, who had a streptococcal rapid antigen detection test and/or a throat culture performed between Aug. 1, 2011, and July 31, 2013. The tests were indicated – based on a McIsaac score of 2 or greater as recommended by Infectious Diseases Society of America (IDSA) guidelines – in 95.7% of cases. If the patients had been managed according to guidelines, 8.1% would have received antibiotics, but 11.5% actually received antibiotics, reported Dr. Brennan-Krohn of Boston Children’s Hospital.

Children whose charts were reviewed as part of this study presented with pharyngitis to a clinic or emergency department at the hospital. According to the IDSA guidelines, testing is not recommended for those with acute pharyngitis with features that strongly suggest viral etiology, such as cough, rhinorrhea, hoarseness, or oral ulcers. Recommended antimicrobial agents in those who have group A streptococcus include penicillin V, amoxicillin, or intramuscular benzathine penicillin G in those without penicillin allergy, and cephalexin/cefadroxil, clindamycin, or azithromycin/clarithromycin in those who do have penicillin allergy.

Prior studies have demonstrated that guidelines are not consistently followed in adults. The current study is among the first to use individual patient data to assess guideline adherence in the pediatric population. The findings suggest that "there remains a role for targeted antimicrobial stewardship education regarding pharyngitis management in pediatric outpatient settings," Dr. Brennan-Krohn said.

Plans are underway to repeat the study in a large community-based practice setting to evaluate management of pharyngitis beyond the academic medical center setting, she noted at the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

"Further investigation may help to clarify why pediatric providers appear to adhere more closely to pharyngitis management guidelines than adult providers," she concluded.

This study was supported by the Fred Lovejoy Housestaff Research and Education fund.

Selenium supplementation provided no benefit over placebo for the prevention of second primary tumors in patients with completely resected stage 1 non–small cell lung cancer in a randomized phase III trial.

In 1,040 patients who were randomized to receive selenium and 521 patients randomized to receive placebo, the incidence rates of lung and overall second primary tumors (SPTs) were similar (1.62 and 3.54 per 100 person-years vs. 1.30 and 3.39 per 100 person-years, respectively). Five-year disease-free survival (DFS) rates were 74.4% and 79.6% for the selenium and placebo groups, respectively, Dr. Daniel D. Karp of the University of Texas M.D. Anderson Cancer Center, Houston, and his colleagues reported.

The findings were published online in the Journal of Clinical Oncology.

Patients included in the double-blind study were adults aged 18 years or older who were 6-36 months out from complete resection of histologically proven stage 1A or 1B non–small cell lung cancer (NSCLC). Selenium was given at a dose of 200 mcg daily for up to 48 months (J. Clin. Oncol. 2013 Sept. 3 [doi: 10.1200/JCO.2013.49.2173]).

At a planned interim analysis in October 2009, a data monitoring committee determined that "it was highly unlikely that this study could eventually show significant evidence of benefit from selenium," and the following month accrual was discontinued and participating patients discontinued treatment and entered the follow-up phase.

At the interim analysis, there were 83 cases of lung SPT, corresponding to 46% of the originally planned end points. The incidence rates of lung SPT were 1.91 and 1.36 per 100 person-years in the selenium and placebo groups, respectively.

"Overall, the SPT incidence rate was higher in the selenium arm but not significantly. Five-year DFS was 72% for selenium and 78% for placebo," the authors noted.

At the more recent analysis in June 2011, there were 252 reported SPTs in 224 patients. Of these, 98 were lung cancers, corresponding to 56% of the originally planned endpoints.

Although prior studies suggested a possible benefit of selenium for tertiary chemoprevention in completely resected NSCLC patients, the findings of the current study suggest otherwise.

Although selenium treatment was safe, with similar rates of grade 1 to 2 toxicity (31% and 26%, respectively), and grade 3 or greater toxicity (2% and 3%, respectively) occurring in the treatment and placebo groups, and no increased risk of diabetes or skin cancer among those treated with selenium, no significant differences were seen with respect to SPT prevention, the investigators said.

However, a recurring theme in this and prior SPT prevention trials in lung cancer and head and neck cancer – including studies evaluating retinoids for chemoprevention – is that the lowest rates of SPTs to be seen were in never-smokers, followed by former smokers, according to the investigators.

In the current study, active smokers in the selenium group had a 30% risk of recurrence or SPT, compared with a 24% risk for former smokers and a 20% risk for never-smokers. Also, the 3- and 5-year overall survival rates were 85.5% and 74.9%, respectively, in those who were active smokers or who had stopped smoking within 1 year, compared with 90% and 83.6%, respectively, for never-smokers.

"It is now clear that there is no demonstrable benefit in giving supplements such as selenium or retinoids to current smokers. However, the data suggest that a better approach might be to treat never-smokers with low serum selenium levels," they said, explaining that descriptive data from the current study suggest that any beneficial effect of selenium is limited to patients with a low baseline selenium level.

"In the current era of molecularly targeted therapies for lung cancer, it seems that persisting with broad approaches in genomically unselected patient populations who continue to smoke is highly unlikely to be successful," they said.

Selenium supplementation provided no benefit over placebo for the prevention of second primary tumors in patients with completely resected stage 1 non–small cell lung cancer in a randomized phase III trial.

In 1,040 patients who were randomized to receive selenium and 521 patients randomized to receive placebo, the incidence rates of lung and overall second primary tumors (SPTs) were similar (1.62 and 3.54 per 100 person-years vs. 1.30 and 3.39 per 100 person-years, respectively). Five-year disease-free survival (DFS) rates were 74.4% and 79.6% for the selenium and placebo groups, respectively, Dr. Daniel D. Karp of the University of Texas M.D. Anderson Cancer Center, Houston, and his colleagues reported.

The findings were published online in the Journal of Clinical Oncology.

Patients included in the double-blind study were adults aged 18 years or older who were 6-36 months out from complete resection of histologically proven stage 1A or 1B non–small cell lung cancer (NSCLC). Selenium was given at a dose of 200 mcg daily for up to 48 months (J. Clin. Oncol. 2013 Sept. 3 [doi: 10.1200/JCO.2013.49.2173]).

At a planned interim analysis in October 2009, a data monitoring committee determined that "it was highly unlikely that this study could eventually show significant evidence of benefit from selenium," and the following month accrual was discontinued and participating patients discontinued treatment and entered the follow-up phase.

At the interim analysis, there were 83 cases of lung SPT, corresponding to 46% of the originally planned end points. The incidence rates of lung SPT were 1.91 and 1.36 per 100 person-years in the selenium and placebo groups, respectively.

"Overall, the SPT incidence rate was higher in the selenium arm but not significantly. Five-year DFS was 72% for selenium and 78% for placebo," the authors noted.

At the more recent analysis in June 2011, there were 252 reported SPTs in 224 patients. Of these, 98 were lung cancers, corresponding to 56% of the originally planned endpoints.

Although prior studies suggested a possible benefit of selenium for tertiary chemoprevention in completely resected NSCLC patients, the findings of the current study suggest otherwise.

Although selenium treatment was safe, with similar rates of grade 1 to 2 toxicity (31% and 26%, respectively), and grade 3 or greater toxicity (2% and 3%, respectively) occurring in the treatment and placebo groups, and no increased risk of diabetes or skin cancer among those treated with selenium, no significant differences were seen with respect to SPT prevention, the investigators said.

However, a recurring theme in this and prior SPT prevention trials in lung cancer and head and neck cancer – including studies evaluating retinoids for chemoprevention – is that the lowest rates of SPTs to be seen were in never-smokers, followed by former smokers, according to the investigators.

In the current study, active smokers in the selenium group had a 30% risk of recurrence or SPT, compared with a 24% risk for former smokers and a 20% risk for never-smokers. Also, the 3- and 5-year overall survival rates were 85.5% and 74.9%, respectively, in those who were active smokers or who had stopped smoking within 1 year, compared with 90% and 83.6%, respectively, for never-smokers.

"It is now clear that there is no demonstrable benefit in giving supplements such as selenium or retinoids to current smokers. However, the data suggest that a better approach might be to treat never-smokers with low serum selenium levels," they said, explaining that descriptive data from the current study suggest that any beneficial effect of selenium is limited to patients with a low baseline selenium level.

"In the current era of molecularly targeted therapies for lung cancer, it seems that persisting with broad approaches in genomically unselected patient populations who continue to smoke is highly unlikely to be successful," they said.

Selenium supplementation provided no benefit over placebo for the prevention of second primary tumors in patients with completely resected stage 1 non–small cell lung cancer in a randomized phase III trial.

In 1,040 patients who were randomized to receive selenium and 521 patients randomized to receive placebo, the incidence rates of lung and overall second primary tumors (SPTs) were similar (1.62 and 3.54 per 100 person-years vs. 1.30 and 3.39 per 100 person-years, respectively). Five-year disease-free survival (DFS) rates were 74.4% and 79.6% for the selenium and placebo groups, respectively, Dr. Daniel D. Karp of the University of Texas M.D. Anderson Cancer Center, Houston, and his colleagues reported.

The findings were published online in the Journal of Clinical Oncology.

Patients included in the double-blind study were adults aged 18 years or older who were 6-36 months out from complete resection of histologically proven stage 1A or 1B non–small cell lung cancer (NSCLC). Selenium was given at a dose of 200 mcg daily for up to 48 months (J. Clin. Oncol. 2013 Sept. 3 [doi: 10.1200/JCO.2013.49.2173]).

At a planned interim analysis in October 2009, a data monitoring committee determined that "it was highly unlikely that this study could eventually show significant evidence of benefit from selenium," and the following month accrual was discontinued and participating patients discontinued treatment and entered the follow-up phase.

At the interim analysis, there were 83 cases of lung SPT, corresponding to 46% of the originally planned end points. The incidence rates of lung SPT were 1.91 and 1.36 per 100 person-years in the selenium and placebo groups, respectively.

"Overall, the SPT incidence rate was higher in the selenium arm but not significantly. Five-year DFS was 72% for selenium and 78% for placebo," the authors noted.

At the more recent analysis in June 2011, there were 252 reported SPTs in 224 patients. Of these, 98 were lung cancers, corresponding to 56% of the originally planned endpoints.

Although prior studies suggested a possible benefit of selenium for tertiary chemoprevention in completely resected NSCLC patients, the findings of the current study suggest otherwise.

Although selenium treatment was safe, with similar rates of grade 1 to 2 toxicity (31% and 26%, respectively), and grade 3 or greater toxicity (2% and 3%, respectively) occurring in the treatment and placebo groups, and no increased risk of diabetes or skin cancer among those treated with selenium, no significant differences were seen with respect to SPT prevention, the investigators said.

However, a recurring theme in this and prior SPT prevention trials in lung cancer and head and neck cancer – including studies evaluating retinoids for chemoprevention – is that the lowest rates of SPTs to be seen were in never-smokers, followed by former smokers, according to the investigators.

In the current study, active smokers in the selenium group had a 30% risk of recurrence or SPT, compared with a 24% risk for former smokers and a 20% risk for never-smokers. Also, the 3- and 5-year overall survival rates were 85.5% and 74.9%, respectively, in those who were active smokers or who had stopped smoking within 1 year, compared with 90% and 83.6%, respectively, for never-smokers.

"It is now clear that there is no demonstrable benefit in giving supplements such as selenium or retinoids to current smokers. However, the data suggest that a better approach might be to treat never-smokers with low serum selenium levels," they said, explaining that descriptive data from the current study suggest that any beneficial effect of selenium is limited to patients with a low baseline selenium level.

"In the current era of molecularly targeted therapies for lung cancer, it seems that persisting with broad approaches in genomically unselected patient populations who continue to smoke is highly unlikely to be successful," they said.

SAN FRANCISCO – Symptoms of acute respiratory infections occur in 22% of health care providers during the respiratory viral season, and almost as many have asymptomatic infection, according to findings from the Respiratory Protection Effectiveness Clinical Trial.

Mandatory influenza vaccination may help reduce absenteeism resulting from flulike symptoms, according to a separate report from the same study.

The Respiratory Protection Effectiveness Clinical Trial (ResPECT) is an ongoing cluster randomized trial taking place at 99 outpatient departments and emergency departments in seven locations across the United States. The current analyses are based on data collected during 12 weeks of the 2011-12 and 2012-13 respiratory seasons.

For one analysis, 1,686 health care providers were surveyed for signs and symptoms of acute respiratory infection (ARI). Cultures from swabs obtained from those with symptoms, as well as paired blood samples obtained at the start of the intervention and 2 weeks later, revealed that the most common viral isolates were for coronavirus (34%), followed by influenza A and B (32% combined), and rhinovirus (17%), Dr. Trish M. Perl of Johns Hopkins University, Baltimore, reported at an annual scientific meeting on infectious diseases.

Of the 22% of health care providers with ARI symptoms, 28% had identifiable viral causes. Nearly 20% of the providers were asymptomatic but were found to have an identifiable viral infection.

Interestingly, the same three viruses – coronavirus, influenza, and rhinovirus – topped the list of isolates in both symptomatic and asymptomatic patients, Dr. Perl noted.

Also of note, 9 of the 10 patients with influenza in the 2011-12 study period had been vaccinated. The data on influenza among vaccinated individuals were not available for the 2012-13 study period, she said.

At least some of the effect of ARI exposures among providers might be attenuated by a mandatory vaccine program, according to another report from ResPECT.

Of 1,077 health care providers included in that analysis, 64% were from private sites with mandatory vaccine policies and 36% were from Veterans Affairs sites and private sites without a mandatory vaccine policy. Those from sites with mandatory vaccination had significantly higher mean influenza vaccination rates (88% vs. 59%) and a lower mean sick day ratio, defined as symptomatic absenteeism/number of participants (0.56 vs. 0.90), said John Frederick of New York Harbor Healthcare System, New York.

Hand hygiene compliance rates did not differ significantly between the private site and VA site participants (33.1% vs. 33.8%, respectively), and facial protective equipment compliance differed only marginally during respiratory illness exposures (24.7% vs. 19.8%), despite a significantly greater exposure rate among the VA site subjects (11.1% vs. 6.7%), Mr. Frederick noted.

Furthermore, institutional impact of influenza was higher in systems with mandatory vaccine policies and lower sick day ratios.

"So this would suggest that, even in the face of increased influenza rates – an increased burden of disease – increased vaccination rates can actually provide a protective effect to health care personnel, and vaccination rates may very well be the driving differential force," he said.

Though limited by certain factors, such as the use of observational and self-reported data, and possible variability in how participants define ARI symptoms, it still is possible to draw some important conclusions from the findings, he said at the conference, part of the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

"Mandating vaccination does indeed appear to increase vaccination rates, and increasing vaccination rates does appear to decrease symptomatic absenteeism. So, combining those two, it appears that mandating vaccination does indeed decrease symptomatic absenteeism among health care personnel during viral respiratory season, even in the face of higher influenza rates," he concluded, adding that other factors, such as sick-leave policies, may certainly be in play as well, and that future studies should focus on these.

Dr. Perl and Mr. Frederick reported having no disclosures. The ResPECT trial is supported by Johns Hopkins University, the Centers for Disease Control and Prevention, the Department of Veterans Affairs, and the National Institute for Occupational Safety and Health.

SAN FRANCISCO – Symptoms of acute respiratory infections occur in 22% of health care providers during the respiratory viral season, and almost as many have asymptomatic infection, according to findings from the Respiratory Protection Effectiveness Clinical Trial.

Mandatory influenza vaccination may help reduce absenteeism resulting from flulike symptoms, according to a separate report from the same study.

The Respiratory Protection Effectiveness Clinical Trial (ResPECT) is an ongoing cluster randomized trial taking place at 99 outpatient departments and emergency departments in seven locations across the United States. The current analyses are based on data collected during 12 weeks of the 2011-12 and 2012-13 respiratory seasons.

For one analysis, 1,686 health care providers were surveyed for signs and symptoms of acute respiratory infection (ARI). Cultures from swabs obtained from those with symptoms, as well as paired blood samples obtained at the start of the intervention and 2 weeks later, revealed that the most common viral isolates were for coronavirus (34%), followed by influenza A and B (32% combined), and rhinovirus (17%), Dr. Trish M. Perl of Johns Hopkins University, Baltimore, reported at an annual scientific meeting on infectious diseases.

Of the 22% of health care providers with ARI symptoms, 28% had identifiable viral causes. Nearly 20% of the providers were asymptomatic but were found to have an identifiable viral infection.

Interestingly, the same three viruses – coronavirus, influenza, and rhinovirus – topped the list of isolates in both symptomatic and asymptomatic patients, Dr. Perl noted.

Also of note, 9 of the 10 patients with influenza in the 2011-12 study period had been vaccinated. The data on influenza among vaccinated individuals were not available for the 2012-13 study period, she said.

At least some of the effect of ARI exposures among providers might be attenuated by a mandatory vaccine program, according to another report from ResPECT.

Of 1,077 health care providers included in that analysis, 64% were from private sites with mandatory vaccine policies and 36% were from Veterans Affairs sites and private sites without a mandatory vaccine policy. Those from sites with mandatory vaccination had significantly higher mean influenza vaccination rates (88% vs. 59%) and a lower mean sick day ratio, defined as symptomatic absenteeism/number of participants (0.56 vs. 0.90), said John Frederick of New York Harbor Healthcare System, New York.

Hand hygiene compliance rates did not differ significantly between the private site and VA site participants (33.1% vs. 33.8%, respectively), and facial protective equipment compliance differed only marginally during respiratory illness exposures (24.7% vs. 19.8%), despite a significantly greater exposure rate among the VA site subjects (11.1% vs. 6.7%), Mr. Frederick noted.

Furthermore, institutional impact of influenza was higher in systems with mandatory vaccine policies and lower sick day ratios.

"So this would suggest that, even in the face of increased influenza rates – an increased burden of disease – increased vaccination rates can actually provide a protective effect to health care personnel, and vaccination rates may very well be the driving differential force," he said.

Though limited by certain factors, such as the use of observational and self-reported data, and possible variability in how participants define ARI symptoms, it still is possible to draw some important conclusions from the findings, he said at the conference, part of the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

"Mandating vaccination does indeed appear to increase vaccination rates, and increasing vaccination rates does appear to decrease symptomatic absenteeism. So, combining those two, it appears that mandating vaccination does indeed decrease symptomatic absenteeism among health care personnel during viral respiratory season, even in the face of higher influenza rates," he concluded, adding that other factors, such as sick-leave policies, may certainly be in play as well, and that future studies should focus on these.

Dr. Perl and Mr. Frederick reported having no disclosures. The ResPECT trial is supported by Johns Hopkins University, the Centers for Disease Control and Prevention, the Department of Veterans Affairs, and the National Institute for Occupational Safety and Health.

SAN FRANCISCO – Symptoms of acute respiratory infections occur in 22% of health care providers during the respiratory viral season, and almost as many have asymptomatic infection, according to findings from the Respiratory Protection Effectiveness Clinical Trial.

Mandatory influenza vaccination may help reduce absenteeism resulting from flulike symptoms, according to a separate report from the same study.

The Respiratory Protection Effectiveness Clinical Trial (ResPECT) is an ongoing cluster randomized trial taking place at 99 outpatient departments and emergency departments in seven locations across the United States. The current analyses are based on data collected during 12 weeks of the 2011-12 and 2012-13 respiratory seasons.

For one analysis, 1,686 health care providers were surveyed for signs and symptoms of acute respiratory infection (ARI). Cultures from swabs obtained from those with symptoms, as well as paired blood samples obtained at the start of the intervention and 2 weeks later, revealed that the most common viral isolates were for coronavirus (34%), followed by influenza A and B (32% combined), and rhinovirus (17%), Dr. Trish M. Perl of Johns Hopkins University, Baltimore, reported at an annual scientific meeting on infectious diseases.

Of the 22% of health care providers with ARI symptoms, 28% had identifiable viral causes. Nearly 20% of the providers were asymptomatic but were found to have an identifiable viral infection.

Interestingly, the same three viruses – coronavirus, influenza, and rhinovirus – topped the list of isolates in both symptomatic and asymptomatic patients, Dr. Perl noted.

Also of note, 9 of the 10 patients with influenza in the 2011-12 study period had been vaccinated. The data on influenza among vaccinated individuals were not available for the 2012-13 study period, she said.

At least some of the effect of ARI exposures among providers might be attenuated by a mandatory vaccine program, according to another report from ResPECT.

Of 1,077 health care providers included in that analysis, 64% were from private sites with mandatory vaccine policies and 36% were from Veterans Affairs sites and private sites without a mandatory vaccine policy. Those from sites with mandatory vaccination had significantly higher mean influenza vaccination rates (88% vs. 59%) and a lower mean sick day ratio, defined as symptomatic absenteeism/number of participants (0.56 vs. 0.90), said John Frederick of New York Harbor Healthcare System, New York.

Hand hygiene compliance rates did not differ significantly between the private site and VA site participants (33.1% vs. 33.8%, respectively), and facial protective equipment compliance differed only marginally during respiratory illness exposures (24.7% vs. 19.8%), despite a significantly greater exposure rate among the VA site subjects (11.1% vs. 6.7%), Mr. Frederick noted.

Furthermore, institutional impact of influenza was higher in systems with mandatory vaccine policies and lower sick day ratios.

"So this would suggest that, even in the face of increased influenza rates – an increased burden of disease – increased vaccination rates can actually provide a protective effect to health care personnel, and vaccination rates may very well be the driving differential force," he said.

Though limited by certain factors, such as the use of observational and self-reported data, and possible variability in how participants define ARI symptoms, it still is possible to draw some important conclusions from the findings, he said at the conference, part of the combined annual meetings of the Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, the HIV Medicine Association, and the Pediatric Infectious Diseases Society.

"Mandating vaccination does indeed appear to increase vaccination rates, and increasing vaccination rates does appear to decrease symptomatic absenteeism. So, combining those two, it appears that mandating vaccination does indeed decrease symptomatic absenteeism among health care personnel during viral respiratory season, even in the face of higher influenza rates," he concluded, adding that other factors, such as sick-leave policies, may certainly be in play as well, and that future studies should focus on these.

Dr. Perl and Mr. Frederick reported having no disclosures. The ResPECT trial is supported by Johns Hopkins University, the Centers for Disease Control and Prevention, the Department of Veterans Affairs, and the National Institute for Occupational Safety and Health.