Diana Mahoney

BOSTON — Among men with prostate cancer, those with low plasma cholesterol are significantly less likely to develop more aggressive forms of the disease, compared with those who have higher cholesterol levels, Elizabeth A. Platz, Sc.D., reported at the annual international conference of the American Association for Cancer Research.

In a previous study, Dr. Platz of Johns Hopkins University in Baltimore and her colleagues showed that men who use statin drugs have a significantly reduced risk of developing advanced prostate cancer, suggesting a possible link between cholesterol status and disease progress. Because prostate cancer cells exhibit cholesterol dysregulation and because cholesterol affects multiple factors that could influence carcinogenesis, including sex steroid hormone production and cell-signaling pathways, the investigators narrowed their focus to cholesterol levels specifically for the current investigation, according to Dr. Platz.

To determine whether lower plasma cholesterol is associated with a lower risk of prostate cancer overall, as well as by stage and grade, the investigators compared blood cholesterol levels from nearly 1,400 men enrolled in Harvard University's Health Professionals Follow-up Study who provided a blood sample between 1993 and 1995. The study population included 698 men with incident prostate cancer diagnosed after the blood draw through January 2000, and 698 prostate cancer-free men who were individually matched based on age and other factors.

The mean plasma cholesterol levels were similar in the prostate cancer patients and the controls, “suggesting that cholesterol was not involved in the initial development of prostate cancer,” Dr. Platz said.

But logistic regression analysis showed that prostate cancer patients with cholesterol levels in the lowest quartile, compared with those in the highest quartile, had a significantly reduced risk of developing more advanced disease. “The risk of having high-grade disease [Gleason score of 7 or higher] was reduced by nearly 40% among men in the lowest cholesterol quartile, and the risk of having advanced disease [tumor stage IIIB or worse] was reduced by 50%,” Dr. Platz reported.

After excluding men who had ever used cholesterol-lowering drugs, the risk of developing high-grade or advanced disease among prostate cancer patients in the lowest cholesterol quartile was reduced by 33% and 27%, respectively, compared with the highest quartile, she said.

Although the study is limited by its observational design, when considered in conjunction with the earlier statin findings, “the results suggest that we may be able to prevent dangerous prostate cancers by tampering with cholesterol metabolism,” Dr. Platz noted.

BOSTON — Among men with prostate cancer, those with low plasma cholesterol are significantly less likely to develop more aggressive forms of the disease, compared with those who have higher cholesterol levels, Elizabeth A. Platz, Sc.D., reported at the annual international conference of the American Association for Cancer Research.

In a previous study, Dr. Platz of Johns Hopkins University in Baltimore and her colleagues showed that men who use statin drugs have a significantly reduced risk of developing advanced prostate cancer, suggesting a possible link between cholesterol status and disease progress. Because prostate cancer cells exhibit cholesterol dysregulation and because cholesterol affects multiple factors that could influence carcinogenesis, including sex steroid hormone production and cell-signaling pathways, the investigators narrowed their focus to cholesterol levels specifically for the current investigation, according to Dr. Platz.

To determine whether lower plasma cholesterol is associated with a lower risk of prostate cancer overall, as well as by stage and grade, the investigators compared blood cholesterol levels from nearly 1,400 men enrolled in Harvard University's Health Professionals Follow-up Study who provided a blood sample between 1993 and 1995. The study population included 698 men with incident prostate cancer diagnosed after the blood draw through January 2000, and 698 prostate cancer-free men who were individually matched based on age and other factors.

The mean plasma cholesterol levels were similar in the prostate cancer patients and the controls, “suggesting that cholesterol was not involved in the initial development of prostate cancer,” Dr. Platz said.

But logistic regression analysis showed that prostate cancer patients with cholesterol levels in the lowest quartile, compared with those in the highest quartile, had a significantly reduced risk of developing more advanced disease. “The risk of having high-grade disease [Gleason score of 7 or higher] was reduced by nearly 40% among men in the lowest cholesterol quartile, and the risk of having advanced disease [tumor stage IIIB or worse] was reduced by 50%,” Dr. Platz reported.

After excluding men who had ever used cholesterol-lowering drugs, the risk of developing high-grade or advanced disease among prostate cancer patients in the lowest cholesterol quartile was reduced by 33% and 27%, respectively, compared with the highest quartile, she said.

Although the study is limited by its observational design, when considered in conjunction with the earlier statin findings, “the results suggest that we may be able to prevent dangerous prostate cancers by tampering with cholesterol metabolism,” Dr. Platz noted.

BOSTON — Among men with prostate cancer, those with low plasma cholesterol are significantly less likely to develop more aggressive forms of the disease, compared with those who have higher cholesterol levels, Elizabeth A. Platz, Sc.D., reported at the annual international conference of the American Association for Cancer Research.

In a previous study, Dr. Platz of Johns Hopkins University in Baltimore and her colleagues showed that men who use statin drugs have a significantly reduced risk of developing advanced prostate cancer, suggesting a possible link between cholesterol status and disease progress. Because prostate cancer cells exhibit cholesterol dysregulation and because cholesterol affects multiple factors that could influence carcinogenesis, including sex steroid hormone production and cell-signaling pathways, the investigators narrowed their focus to cholesterol levels specifically for the current investigation, according to Dr. Platz.

To determine whether lower plasma cholesterol is associated with a lower risk of prostate cancer overall, as well as by stage and grade, the investigators compared blood cholesterol levels from nearly 1,400 men enrolled in Harvard University's Health Professionals Follow-up Study who provided a blood sample between 1993 and 1995. The study population included 698 men with incident prostate cancer diagnosed after the blood draw through January 2000, and 698 prostate cancer-free men who were individually matched based on age and other factors.

The mean plasma cholesterol levels were similar in the prostate cancer patients and the controls, “suggesting that cholesterol was not involved in the initial development of prostate cancer,” Dr. Platz said.

But logistic regression analysis showed that prostate cancer patients with cholesterol levels in the lowest quartile, compared with those in the highest quartile, had a significantly reduced risk of developing more advanced disease. “The risk of having high-grade disease [Gleason score of 7 or higher] was reduced by nearly 40% among men in the lowest cholesterol quartile, and the risk of having advanced disease [tumor stage IIIB or worse] was reduced by 50%,” Dr. Platz reported.

After excluding men who had ever used cholesterol-lowering drugs, the risk of developing high-grade or advanced disease among prostate cancer patients in the lowest cholesterol quartile was reduced by 33% and 27%, respectively, compared with the highest quartile, she said.

Although the study is limited by its observational design, when considered in conjunction with the earlier statin findings, “the results suggest that we may be able to prevent dangerous prostate cancers by tampering with cholesterol metabolism,” Dr. Platz noted.

TORONTO — Most cases of septic arthritis resulting from arthroscopic joint surgery can be controlled with conservative treatment comprising prolonged IV antibiotics and surgical drainage, as long as there is no bone involvement and the affected joint has not been compromised, Dr. Carla Vizzotti said at the annual meeting of the Infectious Diseases Society of America.

Although postarthroscopic septic arthritis (PASA) is an infrequent condition, it can result in significant morbidity if not properly treated and can interfere with patients' recovery, Dr. Vizzotti said in a poster presentation.

Because medical and surgical therapies for the condition are not standardized, Dr. Vizzotti and colleagues at the Fundación Centro de Estudios Infectológicos in Buenos Aires, conducted a retrospective investigation to identify optimal management strategies.

The investigators reviewed the records of 61 patients treated for PASA between November 1991 and November 2005. Patients were included in the investigation if, following a diagnostic or operative arthroscopic procedure, they developed at least one of the clinical signs of arthritis—increased pain, swelling, and warmth—in the affected joint, and/or developed a fever and had a positive culture or grossly or macroscopically purulent synovial fluid.

The mean age of the patients was 37.2 years and the mean follow-up period was 32.5 months.

Among the 61 patients, there were a total of 63 infections, including 58 in the knee, 4 in the shoulder, and 1 in the ankle. Of the 63 infections, 41 occurred in patients who underwent arthroscopic ligament repair that included a graft or implant insertion.

In terms of clinical presentation, fever and pain were each noted in 41 cases; red skin, swelling, and/or warmth were present in 53 cases; fistula and purulent discharges were each noted in 9 cases; functional impotence occurred in 10 cases; and an elevated erythrocyte sedimentation rate (greater than 50 mm/hour) was reported in 7 cases.

Microbiologic data were available for all but two of the infections.

Gram-positive cocci were implicated in 39 of the infections, gram-negative bacilli were identified in 9 of them, and negative cultures were noted in 13, Dr. Vizzotti reported. All of the patients received antibiotic therapy—primarily β-lactams—for a mean of 9.2 weeks.

Surgical drainage was used in 48 of the 63 infections, including arthroscopic irrigation and lavage of the joint in 38 cases, lavage of the joint via arthrotomy in 2 cases, needle aspiration in 6 cases, and combined needle aspiration and arthroscopic irrigation in 2 cases.

Of the study population, only four patients required removal of the grafts or implants that were used to repair the ligaments because of joint instability and/or bone involvement, Dr. Vizzotti said.

Treatment resulted in cure or significant improvement in 97% of the patients.

Three patients experienced complications of infection, including osteomyelitis in two patients and toxic shock syndrome in one.

The findings of the study suggest that most patients with postarthroscopic septic arthritis can be successfully treated with a combination of antibiotics and joint irrigation and lavage, Dr. Vizzotti stated.

Additionally, “as long as the joint is stable and functioning, and if there is no bone involvement, it is uncommon for a patient to require graft or implant removal,” she said.

Dr. Vizzotti reported having no financial disclosures relative to her presentation.

TORONTO — Most cases of septic arthritis resulting from arthroscopic joint surgery can be controlled with conservative treatment comprising prolonged IV antibiotics and surgical drainage, as long as there is no bone involvement and the affected joint has not been compromised, Dr. Carla Vizzotti said at the annual meeting of the Infectious Diseases Society of America.

Although postarthroscopic septic arthritis (PASA) is an infrequent condition, it can result in significant morbidity if not properly treated and can interfere with patients' recovery, Dr. Vizzotti said in a poster presentation.

Because medical and surgical therapies for the condition are not standardized, Dr. Vizzotti and colleagues at the Fundación Centro de Estudios Infectológicos in Buenos Aires, conducted a retrospective investigation to identify optimal management strategies.

The investigators reviewed the records of 61 patients treated for PASA between November 1991 and November 2005. Patients were included in the investigation if, following a diagnostic or operative arthroscopic procedure, they developed at least one of the clinical signs of arthritis—increased pain, swelling, and warmth—in the affected joint, and/or developed a fever and had a positive culture or grossly or macroscopically purulent synovial fluid.

The mean age of the patients was 37.2 years and the mean follow-up period was 32.5 months.

Among the 61 patients, there were a total of 63 infections, including 58 in the knee, 4 in the shoulder, and 1 in the ankle. Of the 63 infections, 41 occurred in patients who underwent arthroscopic ligament repair that included a graft or implant insertion.

In terms of clinical presentation, fever and pain were each noted in 41 cases; red skin, swelling, and/or warmth were present in 53 cases; fistula and purulent discharges were each noted in 9 cases; functional impotence occurred in 10 cases; and an elevated erythrocyte sedimentation rate (greater than 50 mm/hour) was reported in 7 cases.

Microbiologic data were available for all but two of the infections.

Gram-positive cocci were implicated in 39 of the infections, gram-negative bacilli were identified in 9 of them, and negative cultures were noted in 13, Dr. Vizzotti reported. All of the patients received antibiotic therapy—primarily β-lactams—for a mean of 9.2 weeks.

Surgical drainage was used in 48 of the 63 infections, including arthroscopic irrigation and lavage of the joint in 38 cases, lavage of the joint via arthrotomy in 2 cases, needle aspiration in 6 cases, and combined needle aspiration and arthroscopic irrigation in 2 cases.

Of the study population, only four patients required removal of the grafts or implants that were used to repair the ligaments because of joint instability and/or bone involvement, Dr. Vizzotti said.

Treatment resulted in cure or significant improvement in 97% of the patients.

Three patients experienced complications of infection, including osteomyelitis in two patients and toxic shock syndrome in one.

The findings of the study suggest that most patients with postarthroscopic septic arthritis can be successfully treated with a combination of antibiotics and joint irrigation and lavage, Dr. Vizzotti stated.

Additionally, “as long as the joint is stable and functioning, and if there is no bone involvement, it is uncommon for a patient to require graft or implant removal,” she said.

Dr. Vizzotti reported having no financial disclosures relative to her presentation.

TORONTO — Most cases of septic arthritis resulting from arthroscopic joint surgery can be controlled with conservative treatment comprising prolonged IV antibiotics and surgical drainage, as long as there is no bone involvement and the affected joint has not been compromised, Dr. Carla Vizzotti said at the annual meeting of the Infectious Diseases Society of America.

Although postarthroscopic septic arthritis (PASA) is an infrequent condition, it can result in significant morbidity if not properly treated and can interfere with patients' recovery, Dr. Vizzotti said in a poster presentation.

Because medical and surgical therapies for the condition are not standardized, Dr. Vizzotti and colleagues at the Fundación Centro de Estudios Infectológicos in Buenos Aires, conducted a retrospective investigation to identify optimal management strategies.

The investigators reviewed the records of 61 patients treated for PASA between November 1991 and November 2005. Patients were included in the investigation if, following a diagnostic or operative arthroscopic procedure, they developed at least one of the clinical signs of arthritis—increased pain, swelling, and warmth—in the affected joint, and/or developed a fever and had a positive culture or grossly or macroscopically purulent synovial fluid.

The mean age of the patients was 37.2 years and the mean follow-up period was 32.5 months.

Among the 61 patients, there were a total of 63 infections, including 58 in the knee, 4 in the shoulder, and 1 in the ankle. Of the 63 infections, 41 occurred in patients who underwent arthroscopic ligament repair that included a graft or implant insertion.

In terms of clinical presentation, fever and pain were each noted in 41 cases; red skin, swelling, and/or warmth were present in 53 cases; fistula and purulent discharges were each noted in 9 cases; functional impotence occurred in 10 cases; and an elevated erythrocyte sedimentation rate (greater than 50 mm/hour) was reported in 7 cases.

Microbiologic data were available for all but two of the infections.

Gram-positive cocci were implicated in 39 of the infections, gram-negative bacilli were identified in 9 of them, and negative cultures were noted in 13, Dr. Vizzotti reported. All of the patients received antibiotic therapy—primarily β-lactams—for a mean of 9.2 weeks.

Surgical drainage was used in 48 of the 63 infections, including arthroscopic irrigation and lavage of the joint in 38 cases, lavage of the joint via arthrotomy in 2 cases, needle aspiration in 6 cases, and combined needle aspiration and arthroscopic irrigation in 2 cases.

Of the study population, only four patients required removal of the grafts or implants that were used to repair the ligaments because of joint instability and/or bone involvement, Dr. Vizzotti said.

Treatment resulted in cure or significant improvement in 97% of the patients.

Three patients experienced complications of infection, including osteomyelitis in two patients and toxic shock syndrome in one.

The findings of the study suggest that most patients with postarthroscopic septic arthritis can be successfully treated with a combination of antibiotics and joint irrigation and lavage, Dr. Vizzotti stated.

Additionally, “as long as the joint is stable and functioning, and if there is no bone involvement, it is uncommon for a patient to require graft or implant removal,” she said.

Dr. Vizzotti reported having no financial disclosures relative to her presentation.

BOSTON — Because patient self-reported rheumatoid arthritis outcomes are insufficient on their own for making therapeutic decisions, a swollen joint count should be conducted at every visit, according to Dr. Edward Keystone.

In a small clinical study, Dr. Keystone and his colleagues of the University of Toronto's Mount Sinai Hospital surveyed 66 rheumatoid arthritis patients about their disease status during routine visits.

“Patients were asked to rate how they were feeling—very well, well, fair, poor, or very poor—on the day of their visit with respect to their rheumatoid arthritis,” Dr. Keystone said at a meeting on rheumatology sponsored by Harvard Medical School. The investigators then correlated the self-reported outcomes with a variety of disease measures including pain and fatigue visual analog scales, physician global assessment quality of life and disease activity scales, and formal joint counts.

“By and large, pain and fatigue dictated the self-assessments,” said Dr. Keystone. Patients who had high scores on these measures were most likely to report “poor” or “very poor.” Yet there was only a modest correlation between patient self-assessment and swollen joint count. In fact, he said, some of the patients with the most swollen joints reported “fair,” “well,” or “very well” with respect to their disease.

The fact that swollen joint count does not correlate with patients' perceptions of their conditions is especially troublesome in light of a recent study suggesting that many rheumatologists don't perform a formal quantitative joint count during routine visits with patients under their care, said Dr. Keystone.

For the study, investigators queried approximately 600 rheumatologists attending the annual European League Against Rheumatism (EULAR) meeting regarding their use of formal joint counts in routine care (Ann. Rheum. Dis. 2006;65:820–2). “More than half [of the respondents] reported performing a joint count at fewer than half of the routine visits, and 45% said they performed joint counts at less than 25% of the visits,” said Dr. Keystone. Thirteen percent of the respondents said they never perform a formal joint count, he noted.

As a result, many physicians are missing signs of disease progression as well as important windows of opportunity for effective intervention, said Dr. Keystone. “Patients with mild to moderate disease activity might report that they're doing 'well,' when in fact a joint count might suggest disease progression,” he said. “And we know that tight, early control of moderate disease can substantially improve patient outcomes.”

It's not enough to ask patients how they are doing and leave it at that, Dr. Keystone stressed. “While it's not feasible to get an MRI or radiographic assessment of disease status at every visit, performing a swollen joint count is easy and extremely valuable in clinical practice.”

'Performing a swollen joint count is easy and extremely valuable in clinical practice.' DR. KEYSTONE

BOSTON — Because patient self-reported rheumatoid arthritis outcomes are insufficient on their own for making therapeutic decisions, a swollen joint count should be conducted at every visit, according to Dr. Edward Keystone.

In a small clinical study, Dr. Keystone and his colleagues of the University of Toronto's Mount Sinai Hospital surveyed 66 rheumatoid arthritis patients about their disease status during routine visits.

“Patients were asked to rate how they were feeling—very well, well, fair, poor, or very poor—on the day of their visit with respect to their rheumatoid arthritis,” Dr. Keystone said at a meeting on rheumatology sponsored by Harvard Medical School. The investigators then correlated the self-reported outcomes with a variety of disease measures including pain and fatigue visual analog scales, physician global assessment quality of life and disease activity scales, and formal joint counts.

“By and large, pain and fatigue dictated the self-assessments,” said Dr. Keystone. Patients who had high scores on these measures were most likely to report “poor” or “very poor.” Yet there was only a modest correlation between patient self-assessment and swollen joint count. In fact, he said, some of the patients with the most swollen joints reported “fair,” “well,” or “very well” with respect to their disease.

The fact that swollen joint count does not correlate with patients' perceptions of their conditions is especially troublesome in light of a recent study suggesting that many rheumatologists don't perform a formal quantitative joint count during routine visits with patients under their care, said Dr. Keystone.

For the study, investigators queried approximately 600 rheumatologists attending the annual European League Against Rheumatism (EULAR) meeting regarding their use of formal joint counts in routine care (Ann. Rheum. Dis. 2006;65:820–2). “More than half [of the respondents] reported performing a joint count at fewer than half of the routine visits, and 45% said they performed joint counts at less than 25% of the visits,” said Dr. Keystone. Thirteen percent of the respondents said they never perform a formal joint count, he noted.

As a result, many physicians are missing signs of disease progression as well as important windows of opportunity for effective intervention, said Dr. Keystone. “Patients with mild to moderate disease activity might report that they're doing 'well,' when in fact a joint count might suggest disease progression,” he said. “And we know that tight, early control of moderate disease can substantially improve patient outcomes.”

It's not enough to ask patients how they are doing and leave it at that, Dr. Keystone stressed. “While it's not feasible to get an MRI or radiographic assessment of disease status at every visit, performing a swollen joint count is easy and extremely valuable in clinical practice.”

'Performing a swollen joint count is easy and extremely valuable in clinical practice.' DR. KEYSTONE

BOSTON — Because patient self-reported rheumatoid arthritis outcomes are insufficient on their own for making therapeutic decisions, a swollen joint count should be conducted at every visit, according to Dr. Edward Keystone.

In a small clinical study, Dr. Keystone and his colleagues of the University of Toronto's Mount Sinai Hospital surveyed 66 rheumatoid arthritis patients about their disease status during routine visits.

“Patients were asked to rate how they were feeling—very well, well, fair, poor, or very poor—on the day of their visit with respect to their rheumatoid arthritis,” Dr. Keystone said at a meeting on rheumatology sponsored by Harvard Medical School. The investigators then correlated the self-reported outcomes with a variety of disease measures including pain and fatigue visual analog scales, physician global assessment quality of life and disease activity scales, and formal joint counts.

“By and large, pain and fatigue dictated the self-assessments,” said Dr. Keystone. Patients who had high scores on these measures were most likely to report “poor” or “very poor.” Yet there was only a modest correlation between patient self-assessment and swollen joint count. In fact, he said, some of the patients with the most swollen joints reported “fair,” “well,” or “very well” with respect to their disease.

The fact that swollen joint count does not correlate with patients' perceptions of their conditions is especially troublesome in light of a recent study suggesting that many rheumatologists don't perform a formal quantitative joint count during routine visits with patients under their care, said Dr. Keystone.

For the study, investigators queried approximately 600 rheumatologists attending the annual European League Against Rheumatism (EULAR) meeting regarding their use of formal joint counts in routine care (Ann. Rheum. Dis. 2006;65:820–2). “More than half [of the respondents] reported performing a joint count at fewer than half of the routine visits, and 45% said they performed joint counts at less than 25% of the visits,” said Dr. Keystone. Thirteen percent of the respondents said they never perform a formal joint count, he noted.

As a result, many physicians are missing signs of disease progression as well as important windows of opportunity for effective intervention, said Dr. Keystone. “Patients with mild to moderate disease activity might report that they're doing 'well,' when in fact a joint count might suggest disease progression,” he said. “And we know that tight, early control of moderate disease can substantially improve patient outcomes.”

It's not enough to ask patients how they are doing and leave it at that, Dr. Keystone stressed. “While it's not feasible to get an MRI or radiographic assessment of disease status at every visit, performing a swollen joint count is easy and extremely valuable in clinical practice.”

'Performing a swollen joint count is easy and extremely valuable in clinical practice.' DR. KEYSTONE

TORONTO — Adults and teens with waning immunity to pertussis are putting infants—particularly minority infants—as well as themselves at unnecessary risk for developing the bacterial disease, Dr. Irini Daskalaki said at the annual meeting of the Infectious Diseases Society of America.

In one of three studies designed to track and assess the incidence of pertussis in a metropolitan area, Dr. Daskalaki and colleagues at St. Christopher's Hospital for Children in Philadelphia determined that nearly half of more than 400 cases of pertussis reported in that city during a 6-year period occurred in infants too young to be fully immunized.

“Young infants are especially vulnerable to potential pertussis infection because they are not fully protected from the disease until they receive the last of three [diphtheria, tetanus, and pertussis] vaccines at 6 months,” she said.

Similarly, in a study out of Seattle, children younger than 1 year—and particularly infants younger than 6 months—had the highest incidence of reported pertussis during a 5-year period. And, according to lead investigator Dr. Christopher Czaja of the University of Washington, a majority of the infant cases were linked to a household member as the likely source of infection.

The problem, according to Dr. Daskalaki, is that “a lot of people don't realize [pertussis] is out there.”

And more still don't realize there's something they can do to protect themselves and their children. “Everyone should receive a Tdap [tetanus, diphtheria, and acellular] pertussis booster vaccine to help decrease the burden of disease. With less whooping cough around, young infants who are most vulnerable would have less possibility to be exposed,” she said.

Minority infants, particularly Hispanic infants, have an even greater risk of infection because of the increased prevalence of the disease in minority populations, according to Kathryn Wymore of the California Emerging Infections Program in Oakland.

In the third tracking study presented, Ms. Wymore and her colleagues determined that 76 of 160 (48%) cases of infant pertussis in three San Francisco-area counties reported between 2000 and 2004 occurred among Hispanics.

“The average annual incidence of disease per 100,000 infants was 127.1 among Hispanics and 55.8 among non-Hispanics, which is consistent with national surveillance data,” she said.

There was no difference in clinical outcomes between the Hispanic and non-Hispanic infants, however. Among all of the cases reported, “one infant died from the infection, 14% had pneumonia, and 77% were hospitalized,” she said.

In the Philadelphia study, of 409 cases of reported pertussis, 41% occurred in African American patients and 11% in Hispanic patients. Among the 176 infected infants, 54% were African American and 18% were Hispanic. Given these findings, it's especially imperative to target Tdap booster strategies toward difficult-to-reach populations, Dr. Daskalaki stressed, adding that “the implementation rate of adult vaccination has to be really high in order to have a chance of protecting infants.”

While boosting immunization rates is one component of an effective public health strategy, building physician awareness of the disease in the community is another. In the Seattle study, investigators determined that 15% of all of the patients and one-third of the infants younger than 1 year diagnosed with pertussis during the 5-year study period had been seen by a doctor at least three times before being correctly diagnosed. “Doctors are just not thinking of whooping cough, but they should be in any person with prolonged cough, because earlier diagnosis could decrease disease transmission,” said Dr. Czaja.

The Seattle study showed significant increases in pertussis infections among adolescents and adults between 2000 and 2005, “which explains the significant increase among infants,” according to Dr. Czaja.

In the 5-year study period, pertussis cases increased from a low of 39 in 2001 to a peak of 280 in 2003, with 192 cases reported through August 2005. Although the highest incidence occurred in children younger than 1 year, peaking at 202 per 100,000 in 2003, “the greatest rise in incidence was among people 20 years and older, with an 11-fold increase, followed by adolescents and teens between 10 and 19 years, with an almost sixfold increase,” he said, adding that in 62% of cases that involved an infant, “a household member was identified as the likely source of infection.

“Although the disease tends to be mild in adolescents and adults, it can be quite serious in infants,” Dr. Czaja said.

TORONTO — Adults and teens with waning immunity to pertussis are putting infants—particularly minority infants—as well as themselves at unnecessary risk for developing the bacterial disease, Dr. Irini Daskalaki said at the annual meeting of the Infectious Diseases Society of America.

In one of three studies designed to track and assess the incidence of pertussis in a metropolitan area, Dr. Daskalaki and colleagues at St. Christopher's Hospital for Children in Philadelphia determined that nearly half of more than 400 cases of pertussis reported in that city during a 6-year period occurred in infants too young to be fully immunized.

“Young infants are especially vulnerable to potential pertussis infection because they are not fully protected from the disease until they receive the last of three [diphtheria, tetanus, and pertussis] vaccines at 6 months,” she said.

Similarly, in a study out of Seattle, children younger than 1 year—and particularly infants younger than 6 months—had the highest incidence of reported pertussis during a 5-year period. And, according to lead investigator Dr. Christopher Czaja of the University of Washington, a majority of the infant cases were linked to a household member as the likely source of infection.

The problem, according to Dr. Daskalaki, is that “a lot of people don't realize [pertussis] is out there.”

And more still don't realize there's something they can do to protect themselves and their children. “Everyone should receive a Tdap [tetanus, diphtheria, and acellular] pertussis booster vaccine to help decrease the burden of disease. With less whooping cough around, young infants who are most vulnerable would have less possibility to be exposed,” she said.

Minority infants, particularly Hispanic infants, have an even greater risk of infection because of the increased prevalence of the disease in minority populations, according to Kathryn Wymore of the California Emerging Infections Program in Oakland.

In the third tracking study presented, Ms. Wymore and her colleagues determined that 76 of 160 (48%) cases of infant pertussis in three San Francisco-area counties reported between 2000 and 2004 occurred among Hispanics.

“The average annual incidence of disease per 100,000 infants was 127.1 among Hispanics and 55.8 among non-Hispanics, which is consistent with national surveillance data,” she said.

There was no difference in clinical outcomes between the Hispanic and non-Hispanic infants, however. Among all of the cases reported, “one infant died from the infection, 14% had pneumonia, and 77% were hospitalized,” she said.

In the Philadelphia study, of 409 cases of reported pertussis, 41% occurred in African American patients and 11% in Hispanic patients. Among the 176 infected infants, 54% were African American and 18% were Hispanic. Given these findings, it's especially imperative to target Tdap booster strategies toward difficult-to-reach populations, Dr. Daskalaki stressed, adding that “the implementation rate of adult vaccination has to be really high in order to have a chance of protecting infants.”

While boosting immunization rates is one component of an effective public health strategy, building physician awareness of the disease in the community is another. In the Seattle study, investigators determined that 15% of all of the patients and one-third of the infants younger than 1 year diagnosed with pertussis during the 5-year study period had been seen by a doctor at least three times before being correctly diagnosed. “Doctors are just not thinking of whooping cough, but they should be in any person with prolonged cough, because earlier diagnosis could decrease disease transmission,” said Dr. Czaja.

The Seattle study showed significant increases in pertussis infections among adolescents and adults between 2000 and 2005, “which explains the significant increase among infants,” according to Dr. Czaja.

In the 5-year study period, pertussis cases increased from a low of 39 in 2001 to a peak of 280 in 2003, with 192 cases reported through August 2005. Although the highest incidence occurred in children younger than 1 year, peaking at 202 per 100,000 in 2003, “the greatest rise in incidence was among people 20 years and older, with an 11-fold increase, followed by adolescents and teens between 10 and 19 years, with an almost sixfold increase,” he said, adding that in 62% of cases that involved an infant, “a household member was identified as the likely source of infection.

“Although the disease tends to be mild in adolescents and adults, it can be quite serious in infants,” Dr. Czaja said.

TORONTO — Adults and teens with waning immunity to pertussis are putting infants—particularly minority infants—as well as themselves at unnecessary risk for developing the bacterial disease, Dr. Irini Daskalaki said at the annual meeting of the Infectious Diseases Society of America.

In one of three studies designed to track and assess the incidence of pertussis in a metropolitan area, Dr. Daskalaki and colleagues at St. Christopher's Hospital for Children in Philadelphia determined that nearly half of more than 400 cases of pertussis reported in that city during a 6-year period occurred in infants too young to be fully immunized.

“Young infants are especially vulnerable to potential pertussis infection because they are not fully protected from the disease until they receive the last of three [diphtheria, tetanus, and pertussis] vaccines at 6 months,” she said.

Similarly, in a study out of Seattle, children younger than 1 year—and particularly infants younger than 6 months—had the highest incidence of reported pertussis during a 5-year period. And, according to lead investigator Dr. Christopher Czaja of the University of Washington, a majority of the infant cases were linked to a household member as the likely source of infection.

The problem, according to Dr. Daskalaki, is that “a lot of people don't realize [pertussis] is out there.”

And more still don't realize there's something they can do to protect themselves and their children. “Everyone should receive a Tdap [tetanus, diphtheria, and acellular] pertussis booster vaccine to help decrease the burden of disease. With less whooping cough around, young infants who are most vulnerable would have less possibility to be exposed,” she said.

Minority infants, particularly Hispanic infants, have an even greater risk of infection because of the increased prevalence of the disease in minority populations, according to Kathryn Wymore of the California Emerging Infections Program in Oakland.

In the third tracking study presented, Ms. Wymore and her colleagues determined that 76 of 160 (48%) cases of infant pertussis in three San Francisco-area counties reported between 2000 and 2004 occurred among Hispanics.

“The average annual incidence of disease per 100,000 infants was 127.1 among Hispanics and 55.8 among non-Hispanics, which is consistent with national surveillance data,” she said.

There was no difference in clinical outcomes between the Hispanic and non-Hispanic infants, however. Among all of the cases reported, “one infant died from the infection, 14% had pneumonia, and 77% were hospitalized,” she said.

In the Philadelphia study, of 409 cases of reported pertussis, 41% occurred in African American patients and 11% in Hispanic patients. Among the 176 infected infants, 54% were African American and 18% were Hispanic. Given these findings, it's especially imperative to target Tdap booster strategies toward difficult-to-reach populations, Dr. Daskalaki stressed, adding that “the implementation rate of adult vaccination has to be really high in order to have a chance of protecting infants.”

While boosting immunization rates is one component of an effective public health strategy, building physician awareness of the disease in the community is another. In the Seattle study, investigators determined that 15% of all of the patients and one-third of the infants younger than 1 year diagnosed with pertussis during the 5-year study period had been seen by a doctor at least three times before being correctly diagnosed. “Doctors are just not thinking of whooping cough, but they should be in any person with prolonged cough, because earlier diagnosis could decrease disease transmission,” said Dr. Czaja.

The Seattle study showed significant increases in pertussis infections among adolescents and adults between 2000 and 2005, “which explains the significant increase among infants,” according to Dr. Czaja.

In the 5-year study period, pertussis cases increased from a low of 39 in 2001 to a peak of 280 in 2003, with 192 cases reported through August 2005. Although the highest incidence occurred in children younger than 1 year, peaking at 202 per 100,000 in 2003, “the greatest rise in incidence was among people 20 years and older, with an 11-fold increase, followed by adolescents and teens between 10 and 19 years, with an almost sixfold increase,” he said, adding that in 62% of cases that involved an infant, “a household member was identified as the likely source of infection.

“Although the disease tends to be mild in adolescents and adults, it can be quite serious in infants,” Dr. Czaja said.

TORONTO — Fluconazole prophylaxis for invasive candidiasis in extremely low-birth-weight infants is not associated with the emergence of fluconazole-resistant Candida species, Dr. C. Mary Healy said at the annual meeting of the Infectious Diseases Society of America.

In infants weighing less than 1,000 g at birth, 42 days of fluconazole prophylaxis (FP) has been shown to reduced Candida colonization and invasive candidiasis, “but the possibility that [this regimen] could lead to a resistant Candida species is an ongoing concern,” said Dr. Healy of Baylor College of Medicine in Houston. “The worry is that FP will cause overgrowth and infection by inherently less susceptible species, particularly C. glabrata.”

To evaluate the impact of FP on the incidence of invasive candidiasis (IC), as well as IC-related mortality and fluconazole susceptibility of Candida isolates, Dr. Healy and her colleagues reviewed data from the neonatal intensive care unit (NICU) at the Women's Hospital of Texas in Houston for infants treated both before and after the implementation of an FP strategy in 2002.

For the purposes of this investigation, IC was defined as the presence of a Candida species isolated from blood or cerebrospinal fluid in NICU infants.

Since April 2002, as per hospital protocol, extremely low-birth-weight infants younger than 5 days in the NICU of the Women's Hospital of Texas have been eligible to receive intravenous FP at a dose of 3 mg/kg for 6 weeks on a dosing schedule that varies by age: every third day for the first 3 weeks, every second day for the subsequent 2 weeks, and daily for the final 2 weeks, said Dr. Healy.

Using pharmacy and electronic records, Dr. Healy and her colleagues reviewed the demographic, clinical, and laboratory data for all of the NICU infants of any birth weight during the first 4 years of FP implementation and compared it with that of infants who were in the NICU in 2000–2001, before the use of FP.

Between April 2002 and March 2006, 362 extremely low-birth-weight infants in the hospital's NICU received FP, along with 47 infants with a body weight greater than 1,000 g who were started on the preventive therapy at the discretion of the neonatologist. The median body weight of the 409 infants was 775 g, the median gestation was 26 weeks, and the median dose they received was 13 mg/kg over 29 days.

Twenty-nine percent of those infants receiving FP completed the 6-week protocol. Fifty-nine percent discontinued the therapy because IV access was no longer needed, 7% died from non IC-related causes, 2% transferred to other hospitals, 2% had breakthrough infections, and 1% had transient elevation of liver transaminases, which resolved when FP was discontinued, Dr. Healy reported.

Comparing infants who developed IC during the pre- and post-FP time periods, there were 19 cases in 2000–2001 and 22 cases in 2002–2006.

“Infants [who developed IC] during the FP period were of significantly greater gestational age and had significantly higher birth weight than those who developed it before FP,” said Dr. Healy. “There was also a strong trend toward them being older, although this did not reach significance.” There was no difference in prenatal or perinatal complications, nor were there differences in complications of prematurity.

With respect to potential resistance, “our findings are reassuring,” said Dr. Healy. “The IC species distribution remained stable both before and after FP implementation. In the IC cases prior to FP, C. albicans was identified in 14 infants, C. parapsilosis in 3, C. tropicalis in 1, and C. glabrata in 1. After FP, the species distribution was C. albicans in 13 infants, C. parapsilosis in 6, C. tropicalis in 1, and C. glabrata in 2. “It's particularly reassuring that C. glabrata is no more common now than it was before FP,” she said.

Similarly, the minimum inhibitory concentrations (MICs) for fluconazole were consistent. “Even though, as you would expect, MICs were higher for C. glabrata isolates than for C. albicans, we have not yet detected any resistant isolates.”

The treatment of IC was the same during both periods—all of the infants received amphotericin B for similar durations, and three also received caspofungin since 2002—and there was no significant difference in the duration of IC between the two periods.

Regarding the overall impact of FP on IC in the NICU, “when we look at infants of any birth weight since the FP protocol was established, the IC rate has been halved, from 0.6% to 0.3%,” said Dr. Healy. “These rates become more impressive when we look at our target population of extremely low-birth-weight infants, in whom the IC rate decreased 3.6-fold, from 7% to 2%.”

Dr. Healy reported having no conflicts of interest related to this presentation.

TORONTO — Fluconazole prophylaxis for invasive candidiasis in extremely low-birth-weight infants is not associated with the emergence of fluconazole-resistant Candida species, Dr. C. Mary Healy said at the annual meeting of the Infectious Diseases Society of America.

In infants weighing less than 1,000 g at birth, 42 days of fluconazole prophylaxis (FP) has been shown to reduced Candida colonization and invasive candidiasis, “but the possibility that [this regimen] could lead to a resistant Candida species is an ongoing concern,” said Dr. Healy of Baylor College of Medicine in Houston. “The worry is that FP will cause overgrowth and infection by inherently less susceptible species, particularly C. glabrata.”

To evaluate the impact of FP on the incidence of invasive candidiasis (IC), as well as IC-related mortality and fluconazole susceptibility of Candida isolates, Dr. Healy and her colleagues reviewed data from the neonatal intensive care unit (NICU) at the Women's Hospital of Texas in Houston for infants treated both before and after the implementation of an FP strategy in 2002.

For the purposes of this investigation, IC was defined as the presence of a Candida species isolated from blood or cerebrospinal fluid in NICU infants.

Since April 2002, as per hospital protocol, extremely low-birth-weight infants younger than 5 days in the NICU of the Women's Hospital of Texas have been eligible to receive intravenous FP at a dose of 3 mg/kg for 6 weeks on a dosing schedule that varies by age: every third day for the first 3 weeks, every second day for the subsequent 2 weeks, and daily for the final 2 weeks, said Dr. Healy.

Using pharmacy and electronic records, Dr. Healy and her colleagues reviewed the demographic, clinical, and laboratory data for all of the NICU infants of any birth weight during the first 4 years of FP implementation and compared it with that of infants who were in the NICU in 2000–2001, before the use of FP.

Between April 2002 and March 2006, 362 extremely low-birth-weight infants in the hospital's NICU received FP, along with 47 infants with a body weight greater than 1,000 g who were started on the preventive therapy at the discretion of the neonatologist. The median body weight of the 409 infants was 775 g, the median gestation was 26 weeks, and the median dose they received was 13 mg/kg over 29 days.

Twenty-nine percent of those infants receiving FP completed the 6-week protocol. Fifty-nine percent discontinued the therapy because IV access was no longer needed, 7% died from non IC-related causes, 2% transferred to other hospitals, 2% had breakthrough infections, and 1% had transient elevation of liver transaminases, which resolved when FP was discontinued, Dr. Healy reported.

Comparing infants who developed IC during the pre- and post-FP time periods, there were 19 cases in 2000–2001 and 22 cases in 2002–2006.

“Infants [who developed IC] during the FP period were of significantly greater gestational age and had significantly higher birth weight than those who developed it before FP,” said Dr. Healy. “There was also a strong trend toward them being older, although this did not reach significance.” There was no difference in prenatal or perinatal complications, nor were there differences in complications of prematurity.

With respect to potential resistance, “our findings are reassuring,” said Dr. Healy. “The IC species distribution remained stable both before and after FP implementation. In the IC cases prior to FP, C. albicans was identified in 14 infants, C. parapsilosis in 3, C. tropicalis in 1, and C. glabrata in 1. After FP, the species distribution was C. albicans in 13 infants, C. parapsilosis in 6, C. tropicalis in 1, and C. glabrata in 2. “It's particularly reassuring that C. glabrata is no more common now than it was before FP,” she said.

Similarly, the minimum inhibitory concentrations (MICs) for fluconazole were consistent. “Even though, as you would expect, MICs were higher for C. glabrata isolates than for C. albicans, we have not yet detected any resistant isolates.”

The treatment of IC was the same during both periods—all of the infants received amphotericin B for similar durations, and three also received caspofungin since 2002—and there was no significant difference in the duration of IC between the two periods.

Regarding the overall impact of FP on IC in the NICU, “when we look at infants of any birth weight since the FP protocol was established, the IC rate has been halved, from 0.6% to 0.3%,” said Dr. Healy. “These rates become more impressive when we look at our target population of extremely low-birth-weight infants, in whom the IC rate decreased 3.6-fold, from 7% to 2%.”

Dr. Healy reported having no conflicts of interest related to this presentation.

TORONTO — Fluconazole prophylaxis for invasive candidiasis in extremely low-birth-weight infants is not associated with the emergence of fluconazole-resistant Candida species, Dr. C. Mary Healy said at the annual meeting of the Infectious Diseases Society of America.

In infants weighing less than 1,000 g at birth, 42 days of fluconazole prophylaxis (FP) has been shown to reduced Candida colonization and invasive candidiasis, “but the possibility that [this regimen] could lead to a resistant Candida species is an ongoing concern,” said Dr. Healy of Baylor College of Medicine in Houston. “The worry is that FP will cause overgrowth and infection by inherently less susceptible species, particularly C. glabrata.”

To evaluate the impact of FP on the incidence of invasive candidiasis (IC), as well as IC-related mortality and fluconazole susceptibility of Candida isolates, Dr. Healy and her colleagues reviewed data from the neonatal intensive care unit (NICU) at the Women's Hospital of Texas in Houston for infants treated both before and after the implementation of an FP strategy in 2002.

For the purposes of this investigation, IC was defined as the presence of a Candida species isolated from blood or cerebrospinal fluid in NICU infants.

Since April 2002, as per hospital protocol, extremely low-birth-weight infants younger than 5 days in the NICU of the Women's Hospital of Texas have been eligible to receive intravenous FP at a dose of 3 mg/kg for 6 weeks on a dosing schedule that varies by age: every third day for the first 3 weeks, every second day for the subsequent 2 weeks, and daily for the final 2 weeks, said Dr. Healy.

Using pharmacy and electronic records, Dr. Healy and her colleagues reviewed the demographic, clinical, and laboratory data for all of the NICU infants of any birth weight during the first 4 years of FP implementation and compared it with that of infants who were in the NICU in 2000–2001, before the use of FP.

Between April 2002 and March 2006, 362 extremely low-birth-weight infants in the hospital's NICU received FP, along with 47 infants with a body weight greater than 1,000 g who were started on the preventive therapy at the discretion of the neonatologist. The median body weight of the 409 infants was 775 g, the median gestation was 26 weeks, and the median dose they received was 13 mg/kg over 29 days.

Twenty-nine percent of those infants receiving FP completed the 6-week protocol. Fifty-nine percent discontinued the therapy because IV access was no longer needed, 7% died from non IC-related causes, 2% transferred to other hospitals, 2% had breakthrough infections, and 1% had transient elevation of liver transaminases, which resolved when FP was discontinued, Dr. Healy reported.

Comparing infants who developed IC during the pre- and post-FP time periods, there were 19 cases in 2000–2001 and 22 cases in 2002–2006.

“Infants [who developed IC] during the FP period were of significantly greater gestational age and had significantly higher birth weight than those who developed it before FP,” said Dr. Healy. “There was also a strong trend toward them being older, although this did not reach significance.” There was no difference in prenatal or perinatal complications, nor were there differences in complications of prematurity.

With respect to potential resistance, “our findings are reassuring,” said Dr. Healy. “The IC species distribution remained stable both before and after FP implementation. In the IC cases prior to FP, C. albicans was identified in 14 infants, C. parapsilosis in 3, C. tropicalis in 1, and C. glabrata in 1. After FP, the species distribution was C. albicans in 13 infants, C. parapsilosis in 6, C. tropicalis in 1, and C. glabrata in 2. “It's particularly reassuring that C. glabrata is no more common now than it was before FP,” she said.

Similarly, the minimum inhibitory concentrations (MICs) for fluconazole were consistent. “Even though, as you would expect, MICs were higher for C. glabrata isolates than for C. albicans, we have not yet detected any resistant isolates.”

The treatment of IC was the same during both periods—all of the infants received amphotericin B for similar durations, and three also received caspofungin since 2002—and there was no significant difference in the duration of IC between the two periods.

Regarding the overall impact of FP on IC in the NICU, “when we look at infants of any birth weight since the FP protocol was established, the IC rate has been halved, from 0.6% to 0.3%,” said Dr. Healy. “These rates become more impressive when we look at our target population of extremely low-birth-weight infants, in whom the IC rate decreased 3.6-fold, from 7% to 2%.”

Dr. Healy reported having no conflicts of interest related to this presentation.

TORONTO — Adults and teens with waning immunity to pertussis are putting infants—particularly minority infants—as well as themselves at unnecessary risk for developing the bacterial disease, Dr. Irini Daskalaki said at the annual meeting of the Infectious Diseases Society of America.

In one of three studies designed to track and assess the incidence of pertussis in a metropolitan area, Dr. Daskalaki and colleagues at St. Christopher's Hospital for Children in Philadelphia determined that nearly half of more than 400 cases of pertussis reported in that city during a 6-year period occurred in infants too young to be fully immunized.

Similarly, in a study out of Seattle, children younger than 1 year—and particularly infants younger than 6 months—had the highest incidence of reported pertussis during a 5-year period. And, according to lead investigator Dr. Christopher Czaja of the University of Washington, a majority of the infant cases were linked to a household member as the likely source of infection.

The problem, according to Dr. Daskalaki, is that “a lot of people don't realize [pertussis] is out there.”

And more still don't realize there's something they can do to protect themselves and their children. “Everyone should receive a Tdap [tetanus, diphtheria, and acellular pertussis] booster vaccine to help decrease the burden of disease. With less whooping cough around, young infants who are most vulnerable would have less possibility to be exposed,” she said.

Minority infants, particularly Hispanic infants, have an even greater risk of infection because of the increased prevalence of the disease in minority populations, according to Kathryn Wymore of the California Emerging Infections Program in Oakland.

In the third tracking study presented, Ms. Wymore and her colleagues determined that 76 of 160 (48%) cases of infant pertussis in three San Francisco-area counties reported between 2000 and 2004 occurred among Hispanics.

“The average annual incidence of disease per 100,000 infants was 127.1 among Hispanics and 55.8 among non-Hispanics, which is consistent with national surveillance data,” she said.

In the Philadelphia study, of 409 cases of reported pertussis, 41% occurred in African American patients and 11% in Hispanic patients. Among the 176 infected infants, 54% were African American and 18% were Hispanic. Given these findings, it's especially imperative to target Tdap booster strategies toward difficult-to-reach populations, Dr. Daskalaki stressed, adding that “the implementation rate of adult vaccination has to be really high in order to have a chance of protecting infants.”

While boosting immunization rates is one component of an effective public health strategy, building physician awareness of the disease in the community is another. In the Seattle study, investigators determined that 15% of all of the patients and one-third of the infants younger than 1 year diagnosed with pertussis during the 5-year study period had been seen by a doctor at least three times before being correctly diagnosed. “Doctors are just not thinking of whooping cough, but they should be in any person with prolonged cough, because earlier diagnosis could decrease disease transmission,” said Dr. Czaja.

The Seattle study showed significant increases in pertussis infections among adolescents and adults between 2000 and 2005, “which explains the significant increase among infants,” according to Dr. Czaja.

In the 5-year study period, pertussis cases increased from a low of 39 in 2001 to a peak of 280 in 2003, with 192 cases reported through August 2005. Although the highest incidence occurred in children younger than 1 year, peaking at 202 per 100,000 in 2003, “the greatest rise in incidence was among people 20 years and older, with an 11-fold increase, followed by adolescents and teens between 10 and 19 years, with an almost 6-fold increase,” he said, adding that in 62% of cases that involved an infant, “a household member was identified as the likely source of infection.”

TORONTO — Adults and teens with waning immunity to pertussis are putting infants—particularly minority infants—as well as themselves at unnecessary risk for developing the bacterial disease, Dr. Irini Daskalaki said at the annual meeting of the Infectious Diseases Society of America.

In one of three studies designed to track and assess the incidence of pertussis in a metropolitan area, Dr. Daskalaki and colleagues at St. Christopher's Hospital for Children in Philadelphia determined that nearly half of more than 400 cases of pertussis reported in that city during a 6-year period occurred in infants too young to be fully immunized.

Similarly, in a study out of Seattle, children younger than 1 year—and particularly infants younger than 6 months—had the highest incidence of reported pertussis during a 5-year period. And, according to lead investigator Dr. Christopher Czaja of the University of Washington, a majority of the infant cases were linked to a household member as the likely source of infection.

The problem, according to Dr. Daskalaki, is that “a lot of people don't realize [pertussis] is out there.”

And more still don't realize there's something they can do to protect themselves and their children. “Everyone should receive a Tdap [tetanus, diphtheria, and acellular pertussis] booster vaccine to help decrease the burden of disease. With less whooping cough around, young infants who are most vulnerable would have less possibility to be exposed,” she said.

Minority infants, particularly Hispanic infants, have an even greater risk of infection because of the increased prevalence of the disease in minority populations, according to Kathryn Wymore of the California Emerging Infections Program in Oakland.

In the third tracking study presented, Ms. Wymore and her colleagues determined that 76 of 160 (48%) cases of infant pertussis in three San Francisco-area counties reported between 2000 and 2004 occurred among Hispanics.

“The average annual incidence of disease per 100,000 infants was 127.1 among Hispanics and 55.8 among non-Hispanics, which is consistent with national surveillance data,” she said.

In the Philadelphia study, of 409 cases of reported pertussis, 41% occurred in African American patients and 11% in Hispanic patients. Among the 176 infected infants, 54% were African American and 18% were Hispanic. Given these findings, it's especially imperative to target Tdap booster strategies toward difficult-to-reach populations, Dr. Daskalaki stressed, adding that “the implementation rate of adult vaccination has to be really high in order to have a chance of protecting infants.”

While boosting immunization rates is one component of an effective public health strategy, building physician awareness of the disease in the community is another. In the Seattle study, investigators determined that 15% of all of the patients and one-third of the infants younger than 1 year diagnosed with pertussis during the 5-year study period had been seen by a doctor at least three times before being correctly diagnosed. “Doctors are just not thinking of whooping cough, but they should be in any person with prolonged cough, because earlier diagnosis could decrease disease transmission,” said Dr. Czaja.

The Seattle study showed significant increases in pertussis infections among adolescents and adults between 2000 and 2005, “which explains the significant increase among infants,” according to Dr. Czaja.

In the 5-year study period, pertussis cases increased from a low of 39 in 2001 to a peak of 280 in 2003, with 192 cases reported through August 2005. Although the highest incidence occurred in children younger than 1 year, peaking at 202 per 100,000 in 2003, “the greatest rise in incidence was among people 20 years and older, with an 11-fold increase, followed by adolescents and teens between 10 and 19 years, with an almost 6-fold increase,” he said, adding that in 62% of cases that involved an infant, “a household member was identified as the likely source of infection.”

TORONTO — Adults and teens with waning immunity to pertussis are putting infants—particularly minority infants—as well as themselves at unnecessary risk for developing the bacterial disease, Dr. Irini Daskalaki said at the annual meeting of the Infectious Diseases Society of America.

In one of three studies designed to track and assess the incidence of pertussis in a metropolitan area, Dr. Daskalaki and colleagues at St. Christopher's Hospital for Children in Philadelphia determined that nearly half of more than 400 cases of pertussis reported in that city during a 6-year period occurred in infants too young to be fully immunized.

Similarly, in a study out of Seattle, children younger than 1 year—and particularly infants younger than 6 months—had the highest incidence of reported pertussis during a 5-year period. And, according to lead investigator Dr. Christopher Czaja of the University of Washington, a majority of the infant cases were linked to a household member as the likely source of infection.

The problem, according to Dr. Daskalaki, is that “a lot of people don't realize [pertussis] is out there.”

And more still don't realize there's something they can do to protect themselves and their children. “Everyone should receive a Tdap [tetanus, diphtheria, and acellular pertussis] booster vaccine to help decrease the burden of disease. With less whooping cough around, young infants who are most vulnerable would have less possibility to be exposed,” she said.

Minority infants, particularly Hispanic infants, have an even greater risk of infection because of the increased prevalence of the disease in minority populations, according to Kathryn Wymore of the California Emerging Infections Program in Oakland.

In the third tracking study presented, Ms. Wymore and her colleagues determined that 76 of 160 (48%) cases of infant pertussis in three San Francisco-area counties reported between 2000 and 2004 occurred among Hispanics.

“The average annual incidence of disease per 100,000 infants was 127.1 among Hispanics and 55.8 among non-Hispanics, which is consistent with national surveillance data,” she said.

In the Philadelphia study, of 409 cases of reported pertussis, 41% occurred in African American patients and 11% in Hispanic patients. Among the 176 infected infants, 54% were African American and 18% were Hispanic. Given these findings, it's especially imperative to target Tdap booster strategies toward difficult-to-reach populations, Dr. Daskalaki stressed, adding that “the implementation rate of adult vaccination has to be really high in order to have a chance of protecting infants.”

While boosting immunization rates is one component of an effective public health strategy, building physician awareness of the disease in the community is another. In the Seattle study, investigators determined that 15% of all of the patients and one-third of the infants younger than 1 year diagnosed with pertussis during the 5-year study period had been seen by a doctor at least three times before being correctly diagnosed. “Doctors are just not thinking of whooping cough, but they should be in any person with prolonged cough, because earlier diagnosis could decrease disease transmission,” said Dr. Czaja.

The Seattle study showed significant increases in pertussis infections among adolescents and adults between 2000 and 2005, “which explains the significant increase among infants,” according to Dr. Czaja.

In the 5-year study period, pertussis cases increased from a low of 39 in 2001 to a peak of 280 in 2003, with 192 cases reported through August 2005. Although the highest incidence occurred in children younger than 1 year, peaking at 202 per 100,000 in 2003, “the greatest rise in incidence was among people 20 years and older, with an 11-fold increase, followed by adolescents and teens between 10 and 19 years, with an almost 6-fold increase,” he said, adding that in 62% of cases that involved an infant, “a household member was identified as the likely source of infection.”

Intranasal zolmitriptan is an effective, well-tolerated treatment for acute cluster headache, a study has shown.

Both 5-mg and 10-mg doses of the selective serotonin (5-HT) receptor agonist demonstrated significantly higher rates of headache relief 30 minutes after administration than did placebo in a randomized, placebo-controlled, double-blind crossover trial, according to lead investigator Dr. Elizabeth Cittadini of London's National Hospital for Neurology and Neurosurgery and colleagues.

Already proved an effective treatment for acute migraine, intranasal zolmitriptan has been shown to be effective for acute cluster headache in an earlier preliminary single-blind study. In the present study, investigators sought to assess the drug's efficacy compared with placebo in the acute treatment of cluster headache attacks lasting at least 45 minutes using a crossover study design intended both to facilitate recruitment and to provide homogeneity for comparisons, the authors wrote (Arch. Neurol. 2006 Sept. 11 [Epub doi:10:1001/archneur.63.11.nct60002]).

Of 92 patients recruited for the study, 69 were available for an intention-to-treat analysis; their mean age was 40 years. Each patient was asked to treat three cluster headache attacks at least 24 hours apart using placebo for one attack and 5 mg and 10 mg of zolmitriptan nasal spray for each of the other two attacks.

For purposes of the study, participants first rated their pain at the time of the attack on a scale of 1–5, ranging from no pain to very severe pain. They then applied one dose of either active agent or placebo in the contralateral nostril when the headache reached moderate severity and then reassessed their pain at 5, 10, 15, and 30 minutes. The primary study outcome was the combined headache response at 30 minutes, compared with placebo.

Patients in the study were allowed to use either oxygen or analgesic as escape medication at 30 minutes post dose if necessary; investigators did not allow use of either a triptan or an ergotamine derivative. Use of escape medication within 30 minutes was considered a treatment failure.

A total of 65 attacks were treated with 5-mg zolmitriptan nasal spray, 63 were treated with the 10-mg dose, and 61 were treated with placebo. Of those attacks treated with the 5-mg and 10-mg doses, 27 and 38 patients, respectively, reported headache relief at 30 minutes, significantly more than the 14 patients who reported headache relief with placebo. Additionally, with the 5-mg and 10-mg doses, 18 and 31 patients, respectively, were pain free at 30 minutes, significantly more than the 10 patients with placebo.

The investigators also evaluated the impact of zolmitriptan on associated symptoms occurring immediately before treatment, including, most frequently, conjunctival injection/lacrimation, nasal congestion/rhinorrhea, and ptosis/eyelid edema. Although no statistical analysis was performed because of multiple comparison issues, numerically more patients reported relief from associated symptoms when treated with either dose of zolmitriptan, the authors wrote.

Study participants used escape medication in 30 placebo-treated attacks, compared with 23 of the 5-mg treatment and 17 of the 10-mg treatment attacks.

No serious adverse events were reported in either zolmitriptan- or placebo-treated attacks. One withdrawal occurred in a patient treated with 5-mg zolmitriptan who reported shortness of breath, vomiting, and rheumatic pain.

The findings suggest that zolmitriptan nasal spray can be used as a first-line abortive therapy for managing cluster headache. Because there is good evidence of safety with the 15-mg daily dose of the drug for migraine, it may be safe to give three 5-mg doses of the agent in a 24-hour period for patients who do not respond to oxygen and subcutaneous sumatriptan.

AstraZeneca provided support for the study but did not initiate or design it or analyze the data, said the authors.

Intranasal zolmitriptan is an effective, well-tolerated treatment for acute cluster headache, a study has shown.

Both 5-mg and 10-mg doses of the selective serotonin (5-HT) receptor agonist demonstrated significantly higher rates of headache relief 30 minutes after administration than did placebo in a randomized, placebo-controlled, double-blind crossover trial, according to lead investigator Dr. Elizabeth Cittadini of London's National Hospital for Neurology and Neurosurgery and colleagues.

Already proved an effective treatment for acute migraine, intranasal zolmitriptan has been shown to be effective for acute cluster headache in an earlier preliminary single-blind study. In the present study, investigators sought to assess the drug's efficacy compared with placebo in the acute treatment of cluster headache attacks lasting at least 45 minutes using a crossover study design intended both to facilitate recruitment and to provide homogeneity for comparisons, the authors wrote (Arch. Neurol. 2006 Sept. 11 [Epub doi:10:1001/archneur.63.11.nct60002]).

Of 92 patients recruited for the study, 69 were available for an intention-to-treat analysis; their mean age was 40 years. Each patient was asked to treat three cluster headache attacks at least 24 hours apart using placebo for one attack and 5 mg and 10 mg of zolmitriptan nasal spray for each of the other two attacks.

For purposes of the study, participants first rated their pain at the time of the attack on a scale of 1–5, ranging from no pain to very severe pain. They then applied one dose of either active agent or placebo in the contralateral nostril when the headache reached moderate severity and then reassessed their pain at 5, 10, 15, and 30 minutes. The primary study outcome was the combined headache response at 30 minutes, compared with placebo.

Patients in the study were allowed to use either oxygen or analgesic as escape medication at 30 minutes post dose if necessary; investigators did not allow use of either a triptan or an ergotamine derivative. Use of escape medication within 30 minutes was considered a treatment failure.

A total of 65 attacks were treated with 5-mg zolmitriptan nasal spray, 63 were treated with the 10-mg dose, and 61 were treated with placebo. Of those attacks treated with the 5-mg and 10-mg doses, 27 and 38 patients, respectively, reported headache relief at 30 minutes, significantly more than the 14 patients who reported headache relief with placebo. Additionally, with the 5-mg and 10-mg doses, 18 and 31 patients, respectively, were pain free at 30 minutes, significantly more than the 10 patients with placebo.

The investigators also evaluated the impact of zolmitriptan on associated symptoms occurring immediately before treatment, including, most frequently, conjunctival injection/lacrimation, nasal congestion/rhinorrhea, and ptosis/eyelid edema. Although no statistical analysis was performed because of multiple comparison issues, numerically more patients reported relief from associated symptoms when treated with either dose of zolmitriptan, the authors wrote.

Study participants used escape medication in 30 placebo-treated attacks, compared with 23 of the 5-mg treatment and 17 of the 10-mg treatment attacks.

No serious adverse events were reported in either zolmitriptan- or placebo-treated attacks. One withdrawal occurred in a patient treated with 5-mg zolmitriptan who reported shortness of breath, vomiting, and rheumatic pain.

The findings suggest that zolmitriptan nasal spray can be used as a first-line abortive therapy for managing cluster headache. Because there is good evidence of safety with the 15-mg daily dose of the drug for migraine, it may be safe to give three 5-mg doses of the agent in a 24-hour period for patients who do not respond to oxygen and subcutaneous sumatriptan.

AstraZeneca provided support for the study but did not initiate or design it or analyze the data, said the authors.

Intranasal zolmitriptan is an effective, well-tolerated treatment for acute cluster headache, a study has shown.

Both 5-mg and 10-mg doses of the selective serotonin (5-HT) receptor agonist demonstrated significantly higher rates of headache relief 30 minutes after administration than did placebo in a randomized, placebo-controlled, double-blind crossover trial, according to lead investigator Dr. Elizabeth Cittadini of London's National Hospital for Neurology and Neurosurgery and colleagues.

Already proved an effective treatment for acute migraine, intranasal zolmitriptan has been shown to be effective for acute cluster headache in an earlier preliminary single-blind study. In the present study, investigators sought to assess the drug's efficacy compared with placebo in the acute treatment of cluster headache attacks lasting at least 45 minutes using a crossover study design intended both to facilitate recruitment and to provide homogeneity for comparisons, the authors wrote (Arch. Neurol. 2006 Sept. 11 [Epub doi:10:1001/archneur.63.11.nct60002]).

Of 92 patients recruited for the study, 69 were available for an intention-to-treat analysis; their mean age was 40 years. Each patient was asked to treat three cluster headache attacks at least 24 hours apart using placebo for one attack and 5 mg and 10 mg of zolmitriptan nasal spray for each of the other two attacks.

For purposes of the study, participants first rated their pain at the time of the attack on a scale of 1–5, ranging from no pain to very severe pain. They then applied one dose of either active agent or placebo in the contralateral nostril when the headache reached moderate severity and then reassessed their pain at 5, 10, 15, and 30 minutes. The primary study outcome was the combined headache response at 30 minutes, compared with placebo.

Patients in the study were allowed to use either oxygen or analgesic as escape medication at 30 minutes post dose if necessary; investigators did not allow use of either a triptan or an ergotamine derivative. Use of escape medication within 30 minutes was considered a treatment failure.

A total of 65 attacks were treated with 5-mg zolmitriptan nasal spray, 63 were treated with the 10-mg dose, and 61 were treated with placebo. Of those attacks treated with the 5-mg and 10-mg doses, 27 and 38 patients, respectively, reported headache relief at 30 minutes, significantly more than the 14 patients who reported headache relief with placebo. Additionally, with the 5-mg and 10-mg doses, 18 and 31 patients, respectively, were pain free at 30 minutes, significantly more than the 10 patients with placebo.

The investigators also evaluated the impact of zolmitriptan on associated symptoms occurring immediately before treatment, including, most frequently, conjunctival injection/lacrimation, nasal congestion/rhinorrhea, and ptosis/eyelid edema. Although no statistical analysis was performed because of multiple comparison issues, numerically more patients reported relief from associated symptoms when treated with either dose of zolmitriptan, the authors wrote.

Study participants used escape medication in 30 placebo-treated attacks, compared with 23 of the 5-mg treatment and 17 of the 10-mg treatment attacks.

No serious adverse events were reported in either zolmitriptan- or placebo-treated attacks. One withdrawal occurred in a patient treated with 5-mg zolmitriptan who reported shortness of breath, vomiting, and rheumatic pain.

The findings suggest that zolmitriptan nasal spray can be used as a first-line abortive therapy for managing cluster headache. Because there is good evidence of safety with the 15-mg daily dose of the drug for migraine, it may be safe to give three 5-mg doses of the agent in a 24-hour period for patients who do not respond to oxygen and subcutaneous sumatriptan.

AstraZeneca provided support for the study but did not initiate or design it or analyze the data, said the authors.

BOSTON — Antibiotic therapy decreases the duration of persistent joint inflammation in Lyme arthritis, and disease-modifying antirheumatic drugs can reduce its severity in individuals with antibiotic-refractory disease, Dr. Alan Steere reported at a rheumatology conference sponsored by Harvard Medical School, Boston.

Antibiotics remain the cornerstone of treatment for Lyme arthritis, with most patients responding to a 1-month course of oral doxycycline or amoxicillin, said Dr. Steere of Massachusetts General Hospital, Boston. In patients with mild, residual joint swelling, the oral antibiotic regimen is repeated for an additional 30 days. When joint swelling is moderate to severe, an additional month of intravenous antibiotic therapy with ceftriaxone, cefotaxime, or penicillin is a standard course, he said.

To assess postantibiotic treatment strategies in refractory patients and to compare disease course in antibiotic-responsive and -refractory patients, Dr. Steere and his colleagues reviewed the outcomes of 117 patients seen from November 1987 through May 2004. Of the study group, 50 were antibiotic responsive and 67 had antibiotic-refractory Lyme arthritis.

All patients met Centers for Disease Control and Prevention criteria for Lyme arthritis as well as the Infectious Diseases Society of America guidelines for antibiotic treatment. The antibiotic-refractory patients tended to receive intra-articular steroids more often than the antibiotic-responsive patients did, but “the majority of the refractory patients were not given this medication,” he said.

“In patients with antibiotic-responsive arthritis, a 1-month course of oral doxycycline was usually successful, while patients with refractory arthritis tended to have persistent disease even after 2 months of oral antibiotics and 1 month of IV ceftriaxone,” Dr. Steere said.

Of the 67 patients with refractory arthritis, 22 were treated with NSAIDs or intra-articular corticosteroids. If arthritis persisted for 12–24 months, they underwent arthroscopic synovectomy. In the remaining 45 patients, DMARD therapy (primarily hydroxychloroquine) was added to the regimen if polymerase chain reaction (PCR) testing was negative for Borrelia burgdorferi. If the arthritis persisted, patients received oral methotrexate for 3–4 months, or two to four infusions of intravenous inifliximab, after which arthroscopic synovectomy was offered, if needed.

Data on 20 of the 22 patients treated with NSAIDs or intraarticular corticosteroids showed that 11 had complete resolution of arthritis within a median of 11 months after the start of antibiotic therapy, and 9 underwent arthroscopic synovectomies. “Arthritis resolved in the all of the patients within a median of 14 months,” Dr. Steere said.

Follow-up data on 42 patients treated with DMARDs showed that 34 had resolution of arthritis within a median of 8 months after the start of antibiotic therapy, 3 of the remaining 8 patients who did not respond to treatment with hydroxychloroquine elected to have arthroscopic synovectomies, which was successful in only 1 patient.

The two patients with failed synovectomies, plus the remaining five with unresolved arthritis, received methotrexate or intravenous inifliximab. Both drugs induced responses, he said, but “inifliximab resulted in particularly marked reductions in joint inflammation.”

Overall, arthritis persisted in the 42 patients who received DMARDs for a median of 9 months. One of these patients had a breakthrough case of persistent infection.

Based on these findings, a “reasonable management plan” for Lyme arthritis that persists after 60 days of antibiotics (including 30 days of intravenous therapy) should include an additional month of oral antibiotic therapy if PCR testing for B. burgdorferi DNA is still positive; treatment with NSAIDs if PCR results for B. burgdorferi DNA are negative; and the addition of 200 mg oral hydroxychloroquine twice daily if arthritis still persists. If arthritis persists for 3–6 more months, arthroscopic synovectomy should be considered, Dr. Steere said.

Because Lyme arthritis eventually resolves even without antibiotic therapy, he and his colleagues also sought to determine whether antibiotic therapy altered the natural course of the disease in patients with antibiotic-refractory arthritis.

They compared the current findings to those of 21 patients treated for Lyme arthritis in the late 1970s “before the etiologic agent of Lyme disease was known,” he said.

Those patients received NSAIDs and intra-articular steroids, but not antibiotics, and had episodes of arthritis for a median of 43 months. For the antibiotic-responsive patients and the antibiotic-refractory patients in the current study, the median total time of arthritis episode was 4 and 16 months, respectively.

BOSTON — Antibiotic therapy decreases the duration of persistent joint inflammation in Lyme arthritis, and disease-modifying antirheumatic drugs can reduce its severity in individuals with antibiotic-refractory disease, Dr. Alan Steere reported at a rheumatology conference sponsored by Harvard Medical School, Boston.

Antibiotics remain the cornerstone of treatment for Lyme arthritis, with most patients responding to a 1-month course of oral doxycycline or amoxicillin, said Dr. Steere of Massachusetts General Hospital, Boston. In patients with mild, residual joint swelling, the oral antibiotic regimen is repeated for an additional 30 days. When joint swelling is moderate to severe, an additional month of intravenous antibiotic therapy with ceftriaxone, cefotaxime, or penicillin is a standard course, he said.

To assess postantibiotic treatment strategies in refractory patients and to compare disease course in antibiotic-responsive and -refractory patients, Dr. Steere and his colleagues reviewed the outcomes of 117 patients seen from November 1987 through May 2004. Of the study group, 50 were antibiotic responsive and 67 had antibiotic-refractory Lyme arthritis.

All patients met Centers for Disease Control and Prevention criteria for Lyme arthritis as well as the Infectious Diseases Society of America guidelines for antibiotic treatment. The antibiotic-refractory patients tended to receive intra-articular steroids more often than the antibiotic-responsive patients did, but “the majority of the refractory patients were not given this medication,” he said.

“In patients with antibiotic-responsive arthritis, a 1-month course of oral doxycycline was usually successful, while patients with refractory arthritis tended to have persistent disease even after 2 months of oral antibiotics and 1 month of IV ceftriaxone,” Dr. Steere said.

Of the 67 patients with refractory arthritis, 22 were treated with NSAIDs or intra-articular corticosteroids. If arthritis persisted for 12–24 months, they underwent arthroscopic synovectomy. In the remaining 45 patients, DMARD therapy (primarily hydroxychloroquine) was added to the regimen if polymerase chain reaction (PCR) testing was negative for Borrelia burgdorferi. If the arthritis persisted, patients received oral methotrexate for 3–4 months, or two to four infusions of intravenous inifliximab, after which arthroscopic synovectomy was offered, if needed.

Data on 20 of the 22 patients treated with NSAIDs or intraarticular corticosteroids showed that 11 had complete resolution of arthritis within a median of 11 months after the start of antibiotic therapy, and 9 underwent arthroscopic synovectomies. “Arthritis resolved in the all of the patients within a median of 14 months,” Dr. Steere said.

Follow-up data on 42 patients treated with DMARDs showed that 34 had resolution of arthritis within a median of 8 months after the start of antibiotic therapy, 3 of the remaining 8 patients who did not respond to treatment with hydroxychloroquine elected to have arthroscopic synovectomies, which was successful in only 1 patient.

The two patients with failed synovectomies, plus the remaining five with unresolved arthritis, received methotrexate or intravenous inifliximab. Both drugs induced responses, he said, but “inifliximab resulted in particularly marked reductions in joint inflammation.”

Overall, arthritis persisted in the 42 patients who received DMARDs for a median of 9 months. One of these patients had a breakthrough case of persistent infection.

Based on these findings, a “reasonable management plan” for Lyme arthritis that persists after 60 days of antibiotics (including 30 days of intravenous therapy) should include an additional month of oral antibiotic therapy if PCR testing for B. burgdorferi DNA is still positive; treatment with NSAIDs if PCR results for B. burgdorferi DNA are negative; and the addition of 200 mg oral hydroxychloroquine twice daily if arthritis still persists. If arthritis persists for 3–6 more months, arthroscopic synovectomy should be considered, Dr. Steere said.

Because Lyme arthritis eventually resolves even without antibiotic therapy, he and his colleagues also sought to determine whether antibiotic therapy altered the natural course of the disease in patients with antibiotic-refractory arthritis.

They compared the current findings to those of 21 patients treated for Lyme arthritis in the late 1970s “before the etiologic agent of Lyme disease was known,” he said.

Those patients received NSAIDs and intra-articular steroids, but not antibiotics, and had episodes of arthritis for a median of 43 months. For the antibiotic-responsive patients and the antibiotic-refractory patients in the current study, the median total time of arthritis episode was 4 and 16 months, respectively.

BOSTON — Antibiotic therapy decreases the duration of persistent joint inflammation in Lyme arthritis, and disease-modifying antirheumatic drugs can reduce its severity in individuals with antibiotic-refractory disease, Dr. Alan Steere reported at a rheumatology conference sponsored by Harvard Medical School, Boston.

Antibiotics remain the cornerstone of treatment for Lyme arthritis, with most patients responding to a 1-month course of oral doxycycline or amoxicillin, said Dr. Steere of Massachusetts General Hospital, Boston. In patients with mild, residual joint swelling, the oral antibiotic regimen is repeated for an additional 30 days. When joint swelling is moderate to severe, an additional month of intravenous antibiotic therapy with ceftriaxone, cefotaxime, or penicillin is a standard course, he said.

To assess postantibiotic treatment strategies in refractory patients and to compare disease course in antibiotic-responsive and -refractory patients, Dr. Steere and his colleagues reviewed the outcomes of 117 patients seen from November 1987 through May 2004. Of the study group, 50 were antibiotic responsive and 67 had antibiotic-refractory Lyme arthritis.

All patients met Centers for Disease Control and Prevention criteria for Lyme arthritis as well as the Infectious Diseases Society of America guidelines for antibiotic treatment. The antibiotic-refractory patients tended to receive intra-articular steroids more often than the antibiotic-responsive patients did, but “the majority of the refractory patients were not given this medication,” he said.

“In patients with antibiotic-responsive arthritis, a 1-month course of oral doxycycline was usually successful, while patients with refractory arthritis tended to have persistent disease even after 2 months of oral antibiotics and 1 month of IV ceftriaxone,” Dr. Steere said.

Of the 67 patients with refractory arthritis, 22 were treated with NSAIDs or intra-articular corticosteroids. If arthritis persisted for 12–24 months, they underwent arthroscopic synovectomy. In the remaining 45 patients, DMARD therapy (primarily hydroxychloroquine) was added to the regimen if polymerase chain reaction (PCR) testing was negative for Borrelia burgdorferi. If the arthritis persisted, patients received oral methotrexate for 3–4 months, or two to four infusions of intravenous inifliximab, after which arthroscopic synovectomy was offered, if needed.

Data on 20 of the 22 patients treated with NSAIDs or intraarticular corticosteroids showed that 11 had complete resolution of arthritis within a median of 11 months after the start of antibiotic therapy, and 9 underwent arthroscopic synovectomies. “Arthritis resolved in the all of the patients within a median of 14 months,” Dr. Steere said.

Follow-up data on 42 patients treated with DMARDs showed that 34 had resolution of arthritis within a median of 8 months after the start of antibiotic therapy, 3 of the remaining 8 patients who did not respond to treatment with hydroxychloroquine elected to have arthroscopic synovectomies, which was successful in only 1 patient.

The two patients with failed synovectomies, plus the remaining five with unresolved arthritis, received methotrexate or intravenous inifliximab. Both drugs induced responses, he said, but “inifliximab resulted in particularly marked reductions in joint inflammation.”

Overall, arthritis persisted in the 42 patients who received DMARDs for a median of 9 months. One of these patients had a breakthrough case of persistent infection.

Based on these findings, a “reasonable management plan” for Lyme arthritis that persists after 60 days of antibiotics (including 30 days of intravenous therapy) should include an additional month of oral antibiotic therapy if PCR testing for B. burgdorferi DNA is still positive; treatment with NSAIDs if PCR results for B. burgdorferi DNA are negative; and the addition of 200 mg oral hydroxychloroquine twice daily if arthritis still persists. If arthritis persists for 3–6 more months, arthroscopic synovectomy should be considered, Dr. Steere said.

Because Lyme arthritis eventually resolves even without antibiotic therapy, he and his colleagues also sought to determine whether antibiotic therapy altered the natural course of the disease in patients with antibiotic-refractory arthritis.

They compared the current findings to those of 21 patients treated for Lyme arthritis in the late 1970s “before the etiologic agent of Lyme disease was known,” he said.

Those patients received NSAIDs and intra-articular steroids, but not antibiotics, and had episodes of arthritis for a median of 43 months. For the antibiotic-responsive patients and the antibiotic-refractory patients in the current study, the median total time of arthritis episode was 4 and 16 months, respectively.

TORONTO — Vancomycin is a better first-line treatment for severe cases of diarrhea caused by Clostridium difficile infection than metronidazole, Dr. Melinda B. Davis said at the annual meeting of the Infectious Diseases Society of America.

In a prospective, placebo-controlled trial designed to compare the efficacy of vancomycin and metronidazole (Flagyl) for the treatment of C. difficile-associated diarrhea, 172 patients who tested positive for the C. difficile toxin A or B in the stool and had three or more loose stools per day or who had pseudomembranous colitis on endoscopy were randomized to receive 125 mg of liquid vancomycin and a placebo tablet or a 250-mg tablet of metronidazole and a placebo liquid for 10 days.

After randomization, 22 patients were withdrawn from the study because of noncompliance, intolerance, loss to follow-up, or death before day 3 of therapy. Of the remaining 150 patients, 71 were in the vancomycin group and 79 were in the metronidazole group.

Patients were categorized with severe C. difficile-associated diarrhea if they had endoscopy-proven pseudomembranous colitis, if they required treatment in the intensive care unit, or if they had two of the following: fever, elevated white blood cell count, low albumin, or age older than 60 years. Diarrheal disease that did not meet these criteria was classified as mild.

The cure rate in the 31 patients with severe diarrhea in the vancomycin group was 97%, compared with 76% for the 38 patients with severe diarrhea in the metronidazole group, said Dr. Davis of the University of Illinois at Chicago. In those with mild diarrhea, including 40 patients on vancomycin and 41 on metronidazole, cure rates were similar, 98% and 90%, respectively. Patients were considered cured if the diarrhea resolved within 6 days of treatment initiation and if the resolution was sustained through day 10.

In severe and mild disease, relapse rates were higher among patients treated with metronidazole compared with those treated with vancomycin. The rate of disease recurrence within 21 days of successful treatment completion in those with severe disease was 10% in the vancomycin group and 21% in the metronidazole group. For those with mild disease, 5% of those on vancomycin and 8% of those on metronidazole relapsed.

Dr. Davis reported no financial disclosures with respect to her presentation.

TORONTO — Vancomycin is a better first-line treatment for severe cases of diarrhea caused by Clostridium difficile infection than metronidazole, Dr. Melinda B. Davis said at the annual meeting of the Infectious Diseases Society of America.

In a prospective, placebo-controlled trial designed to compare the efficacy of vancomycin and metronidazole (Flagyl) for the treatment of C. difficile-associated diarrhea, 172 patients who tested positive for the C. difficile toxin A or B in the stool and had three or more loose stools per day or who had pseudomembranous colitis on endoscopy were randomized to receive 125 mg of liquid vancomycin and a placebo tablet or a 250-mg tablet of metronidazole and a placebo liquid for 10 days.

After randomization, 22 patients were withdrawn from the study because of noncompliance, intolerance, loss to follow-up, or death before day 3 of therapy. Of the remaining 150 patients, 71 were in the vancomycin group and 79 were in the metronidazole group.

Patients were categorized with severe C. difficile-associated diarrhea if they had endoscopy-proven pseudomembranous colitis, if they required treatment in the intensive care unit, or if they had two of the following: fever, elevated white blood cell count, low albumin, or age older than 60 years. Diarrheal disease that did not meet these criteria was classified as mild.

The cure rate in the 31 patients with severe diarrhea in the vancomycin group was 97%, compared with 76% for the 38 patients with severe diarrhea in the metronidazole group, said Dr. Davis of the University of Illinois at Chicago. In those with mild diarrhea, including 40 patients on vancomycin and 41 on metronidazole, cure rates were similar, 98% and 90%, respectively. Patients were considered cured if the diarrhea resolved within 6 days of treatment initiation and if the resolution was sustained through day 10.

In severe and mild disease, relapse rates were higher among patients treated with metronidazole compared with those treated with vancomycin. The rate of disease recurrence within 21 days of successful treatment completion in those with severe disease was 10% in the vancomycin group and 21% in the metronidazole group. For those with mild disease, 5% of those on vancomycin and 8% of those on metronidazole relapsed.

Dr. Davis reported no financial disclosures with respect to her presentation.

TORONTO — Vancomycin is a better first-line treatment for severe cases of diarrhea caused by Clostridium difficile infection than metronidazole, Dr. Melinda B. Davis said at the annual meeting of the Infectious Diseases Society of America.

In a prospective, placebo-controlled trial designed to compare the efficacy of vancomycin and metronidazole (Flagyl) for the treatment of C. difficile-associated diarrhea, 172 patients who tested positive for the C. difficile toxin A or B in the stool and had three or more loose stools per day or who had pseudomembranous colitis on endoscopy were randomized to receive 125 mg of liquid vancomycin and a placebo tablet or a 250-mg tablet of metronidazole and a placebo liquid for 10 days.

After randomization, 22 patients were withdrawn from the study because of noncompliance, intolerance, loss to follow-up, or death before day 3 of therapy. Of the remaining 150 patients, 71 were in the vancomycin group and 79 were in the metronidazole group.

Patients were categorized with severe C. difficile-associated diarrhea if they had endoscopy-proven pseudomembranous colitis, if they required treatment in the intensive care unit, or if they had two of the following: fever, elevated white blood cell count, low albumin, or age older than 60 years. Diarrheal disease that did not meet these criteria was classified as mild.

The cure rate in the 31 patients with severe diarrhea in the vancomycin group was 97%, compared with 76% for the 38 patients with severe diarrhea in the metronidazole group, said Dr. Davis of the University of Illinois at Chicago. In those with mild diarrhea, including 40 patients on vancomycin and 41 on metronidazole, cure rates were similar, 98% and 90%, respectively. Patients were considered cured if the diarrhea resolved within 6 days of treatment initiation and if the resolution was sustained through day 10.

In severe and mild disease, relapse rates were higher among patients treated with metronidazole compared with those treated with vancomycin. The rate of disease recurrence within 21 days of successful treatment completion in those with severe disease was 10% in the vancomycin group and 21% in the metronidazole group. For those with mild disease, 5% of those on vancomycin and 8% of those on metronidazole relapsed.

Dr. Davis reported no financial disclosures with respect to her presentation.

TORONTO — Think C. difficile when evaluating severe or ongoing diarrhea in previously healthy young women, said Dr. Judith O'Donnell at the annual meeting of the Infectious Diseases Society of America.

Although healthy women of reproductive age in the community have traditionally been considered at low risk for infection with the Clostridium difficile bacteria, recent data from a Philadelphia hospital suggest a shifting epidemiology for C. difficile-associated disease.

From January to June of 2006, six otherwise healthy women between the ages of 18 and 47 were admitted to Hahnemann University Hospital for treatment of severe C. difficile infections. Of the six, three were pregnant, one had given birth three weeks before treatment, and two had recently undergone elective hysterectomies, said Dr. O'Donnell of Drexel University in Philadelphia. All of the women had taken antibiotics in the months before developing C. difficile infections, although in some cases, the antibiotic use was limited, she said.

The two women who underwent hysterectomy received two doses each of perioperative antibiotics. Two of the pregnant women had received outpatient antibiotic treatment for bacterial vaginosis and one received a single antibiotic dose following laparoscopic cholecystectomy. And the woman who had recently given birth was admitted for diarrheal disease 3 weeks after a caesarean delivery.

The absence of a common risk factor for infection suggests “these women likely contracted their infections outside of the hospital setting,” said Dr. O'Donnell. The severity of disease they experienced suggests their infections were caused by a newer, hypervirulent strain of C. difficile.

Five of the six women had evidence of severe diffuse colitis on abdominal CT scans, and two of the six developed sepsis requiring treatment in the intensive care unit. One of the two women treated for sepsis died of complications from C. difficile-associated disease after undergoing a total colectomy, subsequent resection of a large portion of ileum when the sepsis did not resolve, and 14 days of intensive antibiotic therapy with intravenous metronidazole and oral and rectal vancomycin. The second septic patient responded to continuous colonic vancomycin infusion.

The remaining four patients responded to dual antibiotic therapy, “although two were subsequently diagnosed with a recurrence of C. difficile [infection], and one required a second hospitalization,” she said.

Physicians treating women should be cognizant of the possibility of community-acquired C. difficile infection in this population, she said. Those providing obstetric and gynecologic care “should be thinking about this because it's not something they've seen very often, especially in pregnant patients.” Dr. O'Donnell said she had no financial conflicts of interest related to the presentation.

TORONTO — Think C. difficile when evaluating severe or ongoing diarrhea in previously healthy young women, said Dr. Judith O'Donnell at the annual meeting of the Infectious Diseases Society of America.

Although healthy women of reproductive age in the community have traditionally been considered at low risk for infection with the Clostridium difficile bacteria, recent data from a Philadelphia hospital suggest a shifting epidemiology for C. difficile-associated disease.

From January to June of 2006, six otherwise healthy women between the ages of 18 and 47 were admitted to Hahnemann University Hospital for treatment of severe C. difficile infections. Of the six, three were pregnant, one had given birth three weeks before treatment, and two had recently undergone elective hysterectomies, said Dr. O'Donnell of Drexel University in Philadelphia. All of the women had taken antibiotics in the months before developing C. difficile infections, although in some cases, the antibiotic use was limited, she said.

The two women who underwent hysterectomy received two doses each of perioperative antibiotics. Two of the pregnant women had received outpatient antibiotic treatment for bacterial vaginosis and one received a single antibiotic dose following laparoscopic cholecystectomy. And the woman who had recently given birth was admitted for diarrheal disease 3 weeks after a caesarean delivery.

The absence of a common risk factor for infection suggests “these women likely contracted their infections outside of the hospital setting,” said Dr. O'Donnell. The severity of disease they experienced suggests their infections were caused by a newer, hypervirulent strain of C. difficile.

Five of the six women had evidence of severe diffuse colitis on abdominal CT scans, and two of the six developed sepsis requiring treatment in the intensive care unit. One of the two women treated for sepsis died of complications from C. difficile-associated disease after undergoing a total colectomy, subsequent resection of a large portion of ileum when the sepsis did not resolve, and 14 days of intensive antibiotic therapy with intravenous metronidazole and oral and rectal vancomycin. The second septic patient responded to continuous colonic vancomycin infusion.

The remaining four patients responded to dual antibiotic therapy, “although two were subsequently diagnosed with a recurrence of C. difficile [infection], and one required a second hospitalization,” she said.

Physicians treating women should be cognizant of the possibility of community-acquired C. difficile infection in this population, she said. Those providing obstetric and gynecologic care “should be thinking about this because it's not something they've seen very often, especially in pregnant patients.” Dr. O'Donnell said she had no financial conflicts of interest related to the presentation.

TORONTO — Think C. difficile when evaluating severe or ongoing diarrhea in previously healthy young women, said Dr. Judith O'Donnell at the annual meeting of the Infectious Diseases Society of America.

Although healthy women of reproductive age in the community have traditionally been considered at low risk for infection with the Clostridium difficile bacteria, recent data from a Philadelphia hospital suggest a shifting epidemiology for C. difficile-associated disease.

From January to June of 2006, six otherwise healthy women between the ages of 18 and 47 were admitted to Hahnemann University Hospital for treatment of severe C. difficile infections. Of the six, three were pregnant, one had given birth three weeks before treatment, and two had recently undergone elective hysterectomies, said Dr. O'Donnell of Drexel University in Philadelphia. All of the women had taken antibiotics in the months before developing C. difficile infections, although in some cases, the antibiotic use was limited, she said.

The two women who underwent hysterectomy received two doses each of perioperative antibiotics. Two of the pregnant women had received outpatient antibiotic treatment for bacterial vaginosis and one received a single antibiotic dose following laparoscopic cholecystectomy. And the woman who had recently given birth was admitted for diarrheal disease 3 weeks after a caesarean delivery.

The absence of a common risk factor for infection suggests “these women likely contracted their infections outside of the hospital setting,” said Dr. O'Donnell. The severity of disease they experienced suggests their infections were caused by a newer, hypervirulent strain of C. difficile.

Five of the six women had evidence of severe diffuse colitis on abdominal CT scans, and two of the six developed sepsis requiring treatment in the intensive care unit. One of the two women treated for sepsis died of complications from C. difficile-associated disease after undergoing a total colectomy, subsequent resection of a large portion of ileum when the sepsis did not resolve, and 14 days of intensive antibiotic therapy with intravenous metronidazole and oral and rectal vancomycin. The second septic patient responded to continuous colonic vancomycin infusion.

The remaining four patients responded to dual antibiotic therapy, “although two were subsequently diagnosed with a recurrence of C. difficile [infection], and one required a second hospitalization,” she said.

Physicians treating women should be cognizant of the possibility of community-acquired C. difficile infection in this population, she said. Those providing obstetric and gynecologic care “should be thinking about this because it's not something they've seen very often, especially in pregnant patients.” Dr. O'Donnell said she had no financial conflicts of interest related to the presentation.