Whitney McKnight

GRAND CAYMAN – When considering the use of biologic therapy for psoriasis patients who are at greater risk of cancer or of serious infection, Dr. Kenneth B. Gordon advises clinicians to “look at the patient in front of you” and the impact the disease is having on them.

In an interview at the annual Caribbean Dermatology Symposium, Dr. Gordon, professor of dermatology at Northwestern University, Chicago, discusses the use of biologics to treat psoriasis in patients with a history of cancer, patients at an increased risk for serious infections (such as those with chronic renal disease or diabetes), as well as patients with HIV, who can have significant psoriasis.

He also provides some recommendations on counseling patients and discusses the use of biologics in children with psoriasis.

The meeting is provided by Global Academy for Medical Education. Global Academy and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

This article was updated 1/31/2016.

GRAND CAYMAN – When considering the use of biologic therapy for psoriasis patients who are at greater risk of cancer or of serious infection, Dr. Kenneth B. Gordon advises clinicians to “look at the patient in front of you” and the impact the disease is having on them.

In an interview at the annual Caribbean Dermatology Symposium, Dr. Gordon, professor of dermatology at Northwestern University, Chicago, discusses the use of biologics to treat psoriasis in patients with a history of cancer, patients at an increased risk for serious infections (such as those with chronic renal disease or diabetes), as well as patients with HIV, who can have significant psoriasis.

He also provides some recommendations on counseling patients and discusses the use of biologics in children with psoriasis.

The meeting is provided by Global Academy for Medical Education. Global Academy and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

This article was updated 1/31/2016.

GRAND CAYMAN – When considering the use of biologic therapy for psoriasis patients who are at greater risk of cancer or of serious infection, Dr. Kenneth B. Gordon advises clinicians to “look at the patient in front of you” and the impact the disease is having on them.

In an interview at the annual Caribbean Dermatology Symposium, Dr. Gordon, professor of dermatology at Northwestern University, Chicago, discusses the use of biologics to treat psoriasis in patients with a history of cancer, patients at an increased risk for serious infections (such as those with chronic renal disease or diabetes), as well as patients with HIV, who can have significant psoriasis.

He also provides some recommendations on counseling patients and discusses the use of biologics in children with psoriasis.

The meeting is provided by Global Academy for Medical Education. Global Academy and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

This article was updated 1/31/2016.

GRAND CAYMAN ISLAND – Smartphones and other digital technologies could provide clinicians – and patients – the tools to greatly improve melanoma and other dermatology outcomes, but how might they change actual practice?

“Ten years from now, what is going to distinguish the app world from the dermatology community?” That was the question Dr. Allan C. Halpern, chief of the dermatology service at Memorial Sloan Kettering Cancer Center, New York, posed at the meeting, sponsored by Global Academy for Medical Education.

Many clinicians already use dermatoscopes, which Dr. Halpern said “significantly improves diagnostic accuracy for melanoma by making available to us visual cues that would not be available through routine naked-eye examination.” However, he said, a rapid digital evolution in dermoscopy is already underway, allowing clinicians to use mobile devices that store images and perform short term monitoring of any areas of concern.

“For suspicious lesions, rather than do a biopsy, one of the options is that you can take a dermoscopic image of it, then do so again in another couple of months. If it hasn’t changed, then the data are very convincing that you’re dealing with something other than melanoma,” Dr. Halpern said.

What gives him pause is that there are an increasing number of consumer-based smartphone medical products, including more than 250 for dermatology alone.

“For about 100 dollars or less, patients can purchase their own dermatoscope and attach it to their smartphone” and take images of their own lesions, Dr. Halpern said.

As a result, he believes that the field has reached the “tipping point” for successful teledermatology, where companies can accept and interpret these data.

Because of the exponential growth of mobile medical applications, the Food and Drug Administration issued guidance for their use in 2015, he noted.

Although he said that the FDA is overwhelmed by the task – and that the medical app marketplace is akin to the Wild West – medical apps are here to stay and will continue to develop quickly.

“For one thing, big players are now entering the field,” he said, alluding to a recent Apple initiativeto collect data uploaded by consumers to the Cloud, which can then be parsed by medical researchers. In addition to melanoma, Apple is currently focusing on autism and epilepsy.

“Apple is trying to make the iPhone a conduit for medical research,” Dr. Halpern said.

Over the next 5-10 years, there will be a race to see who can perfect this kind of data analysis. There is even an ongoing competition that pits melanoma researchers around the world against one another to see who can most accurately interpret images uploaded to the archives. The hope, he said, is that it will help dermatologists to develop and agree upon international standards for melanoma diagnosis.

With this kind of standardization, medical apps can help both consumers and practitioners triage care.

“I don’t know when it will happen, but there is no doubt we’re going to reach a point at which these apps are going to be as good as the average dermatologist is today when it comes to looking at a single spot,” Dr. Halpern said.

Aside from some cancer centers’ ability to create three-dimensional images of lesions, another distinguishing technology for dermatologists could be reflectance confocal microscopy.

“As dermatologists, we are trained well enough in pathology that we can use this technology, we will be able to do even better than with dermoscopy alone,” he said. This kind of technology captures images at the cellular level similar to histological examinations, but without the actual biopsy.

In an interview, Dr. Halpern said that while dermatologists have nothing to fear from apps in daily practice, there are some issues to be aware of. “The first is the one we’re most concerned about – automated diagnosis, before we know for certain that the apps work.”

Another issue is that these apps raise awareness among consumers about their individual risk for melanoma, which will “invariably help drive more people in the door,” but there may not be enough clinicians to manage these patients.

The group Dr. Halpern expects will be the most frequent users of personal dermatology technologies initially are “ultra–tech savvy young people motivated to avoid melanoma,” although he expects that over time, this could change as technologies become easier to use.

He disclosed financial relationships with Quintiles, Canfield Scientific, DermTech, SciBase, and Caliber ID.

Global Academy and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

GRAND CAYMAN ISLAND – Smartphones and other digital technologies could provide clinicians – and patients – the tools to greatly improve melanoma and other dermatology outcomes, but how might they change actual practice?

“Ten years from now, what is going to distinguish the app world from the dermatology community?” That was the question Dr. Allan C. Halpern, chief of the dermatology service at Memorial Sloan Kettering Cancer Center, New York, posed at the meeting, sponsored by Global Academy for Medical Education.

Many clinicians already use dermatoscopes, which Dr. Halpern said “significantly improves diagnostic accuracy for melanoma by making available to us visual cues that would not be available through routine naked-eye examination.” However, he said, a rapid digital evolution in dermoscopy is already underway, allowing clinicians to use mobile devices that store images and perform short term monitoring of any areas of concern.

“For suspicious lesions, rather than do a biopsy, one of the options is that you can take a dermoscopic image of it, then do so again in another couple of months. If it hasn’t changed, then the data are very convincing that you’re dealing with something other than melanoma,” Dr. Halpern said.

What gives him pause is that there are an increasing number of consumer-based smartphone medical products, including more than 250 for dermatology alone.

“For about 100 dollars or less, patients can purchase their own dermatoscope and attach it to their smartphone” and take images of their own lesions, Dr. Halpern said.

As a result, he believes that the field has reached the “tipping point” for successful teledermatology, where companies can accept and interpret these data.

Because of the exponential growth of mobile medical applications, the Food and Drug Administration issued guidance for their use in 2015, he noted.

Although he said that the FDA is overwhelmed by the task – and that the medical app marketplace is akin to the Wild West – medical apps are here to stay and will continue to develop quickly.

“For one thing, big players are now entering the field,” he said, alluding to a recent Apple initiativeto collect data uploaded by consumers to the Cloud, which can then be parsed by medical researchers. In addition to melanoma, Apple is currently focusing on autism and epilepsy.

“Apple is trying to make the iPhone a conduit for medical research,” Dr. Halpern said.

Over the next 5-10 years, there will be a race to see who can perfect this kind of data analysis. There is even an ongoing competition that pits melanoma researchers around the world against one another to see who can most accurately interpret images uploaded to the archives. The hope, he said, is that it will help dermatologists to develop and agree upon international standards for melanoma diagnosis.

With this kind of standardization, medical apps can help both consumers and practitioners triage care.

“I don’t know when it will happen, but there is no doubt we’re going to reach a point at which these apps are going to be as good as the average dermatologist is today when it comes to looking at a single spot,” Dr. Halpern said.

Aside from some cancer centers’ ability to create three-dimensional images of lesions, another distinguishing technology for dermatologists could be reflectance confocal microscopy.

“As dermatologists, we are trained well enough in pathology that we can use this technology, we will be able to do even better than with dermoscopy alone,” he said. This kind of technology captures images at the cellular level similar to histological examinations, but without the actual biopsy.

In an interview, Dr. Halpern said that while dermatologists have nothing to fear from apps in daily practice, there are some issues to be aware of. “The first is the one we’re most concerned about – automated diagnosis, before we know for certain that the apps work.”

Another issue is that these apps raise awareness among consumers about their individual risk for melanoma, which will “invariably help drive more people in the door,” but there may not be enough clinicians to manage these patients.

The group Dr. Halpern expects will be the most frequent users of personal dermatology technologies initially are “ultra–tech savvy young people motivated to avoid melanoma,” although he expects that over time, this could change as technologies become easier to use.

He disclosed financial relationships with Quintiles, Canfield Scientific, DermTech, SciBase, and Caliber ID.

Global Academy and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

GRAND CAYMAN ISLAND – Smartphones and other digital technologies could provide clinicians – and patients – the tools to greatly improve melanoma and other dermatology outcomes, but how might they change actual practice?

“Ten years from now, what is going to distinguish the app world from the dermatology community?” That was the question Dr. Allan C. Halpern, chief of the dermatology service at Memorial Sloan Kettering Cancer Center, New York, posed at the meeting, sponsored by Global Academy for Medical Education.

Many clinicians already use dermatoscopes, which Dr. Halpern said “significantly improves diagnostic accuracy for melanoma by making available to us visual cues that would not be available through routine naked-eye examination.” However, he said, a rapid digital evolution in dermoscopy is already underway, allowing clinicians to use mobile devices that store images and perform short term monitoring of any areas of concern.

“For suspicious lesions, rather than do a biopsy, one of the options is that you can take a dermoscopic image of it, then do so again in another couple of months. If it hasn’t changed, then the data are very convincing that you’re dealing with something other than melanoma,” Dr. Halpern said.

What gives him pause is that there are an increasing number of consumer-based smartphone medical products, including more than 250 for dermatology alone.

“For about 100 dollars or less, patients can purchase their own dermatoscope and attach it to their smartphone” and take images of their own lesions, Dr. Halpern said.

As a result, he believes that the field has reached the “tipping point” for successful teledermatology, where companies can accept and interpret these data.

Because of the exponential growth of mobile medical applications, the Food and Drug Administration issued guidance for their use in 2015, he noted.

Although he said that the FDA is overwhelmed by the task – and that the medical app marketplace is akin to the Wild West – medical apps are here to stay and will continue to develop quickly.

“For one thing, big players are now entering the field,” he said, alluding to a recent Apple initiativeto collect data uploaded by consumers to the Cloud, which can then be parsed by medical researchers. In addition to melanoma, Apple is currently focusing on autism and epilepsy.

“Apple is trying to make the iPhone a conduit for medical research,” Dr. Halpern said.

Over the next 5-10 years, there will be a race to see who can perfect this kind of data analysis. There is even an ongoing competition that pits melanoma researchers around the world against one another to see who can most accurately interpret images uploaded to the archives. The hope, he said, is that it will help dermatologists to develop and agree upon international standards for melanoma diagnosis.

With this kind of standardization, medical apps can help both consumers and practitioners triage care.

“I don’t know when it will happen, but there is no doubt we’re going to reach a point at which these apps are going to be as good as the average dermatologist is today when it comes to looking at a single spot,” Dr. Halpern said.

Aside from some cancer centers’ ability to create three-dimensional images of lesions, another distinguishing technology for dermatologists could be reflectance confocal microscopy.

“As dermatologists, we are trained well enough in pathology that we can use this technology, we will be able to do even better than with dermoscopy alone,” he said. This kind of technology captures images at the cellular level similar to histological examinations, but without the actual biopsy.

In an interview, Dr. Halpern said that while dermatologists have nothing to fear from apps in daily practice, there are some issues to be aware of. “The first is the one we’re most concerned about – automated diagnosis, before we know for certain that the apps work.”

Another issue is that these apps raise awareness among consumers about their individual risk for melanoma, which will “invariably help drive more people in the door,” but there may not be enough clinicians to manage these patients.

The group Dr. Halpern expects will be the most frequent users of personal dermatology technologies initially are “ultra–tech savvy young people motivated to avoid melanoma,” although he expects that over time, this could change as technologies become easier to use.

He disclosed financial relationships with Quintiles, Canfield Scientific, DermTech, SciBase, and Caliber ID.

Global Academy and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

GRAND CAYMAN – N-acetylcysteine is reemerging as a treatment for ichthyosis, and even some compulsive behaviors like skin picking. In an interview at this year’s Caribbean Dermatology Symposium, Dr. Albert C. Yan, section chief of dermatology at the Children’s Hospital of Philadelphia, discusses in this video interview the use of this agent as an effective treatment for these indications in children.

The meeting is provided by Global Academy for Medical Education. Global Academy and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

GRAND CAYMAN – N-acetylcysteine is reemerging as a treatment for ichthyosis, and even some compulsive behaviors like skin picking. In an interview at this year’s Caribbean Dermatology Symposium, Dr. Albert C. Yan, section chief of dermatology at the Children’s Hospital of Philadelphia, discusses in this video interview the use of this agent as an effective treatment for these indications in children.

The meeting is provided by Global Academy for Medical Education. Global Academy and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

GRAND CAYMAN – N-acetylcysteine is reemerging as a treatment for ichthyosis, and even some compulsive behaviors like skin picking. In an interview at this year’s Caribbean Dermatology Symposium, Dr. Albert C. Yan, section chief of dermatology at the Children’s Hospital of Philadelphia, discusses in this video interview the use of this agent as an effective treatment for these indications in children.

The meeting is provided by Global Academy for Medical Education. Global Academy and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

GRAND CAYMAN – What simple prophylactic measures can you recommend to parents of children at risk of atopic dermatitis? In an interview at this year’s Caribbean Dermatology Symposium, Dr. Albert C. Yan, section chief of dermatology at the Children’s Hospital of Philadelphia and professor of pediatrics and dermatology, University of Pennsylvania, Philadelphia, discusses the evidence indicating that early use of moisturizers reduces the risk of atopic dermatitis in children at risk.

The meeting is provided by Global Academy for Medical Education. Global Academy and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

GRAND CAYMAN – What simple prophylactic measures can you recommend to parents of children at risk of atopic dermatitis? In an interview at this year’s Caribbean Dermatology Symposium, Dr. Albert C. Yan, section chief of dermatology at the Children’s Hospital of Philadelphia and professor of pediatrics and dermatology, University of Pennsylvania, Philadelphia, discusses the evidence indicating that early use of moisturizers reduces the risk of atopic dermatitis in children at risk.

The meeting is provided by Global Academy for Medical Education. Global Academy and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

GRAND CAYMAN – What simple prophylactic measures can you recommend to parents of children at risk of atopic dermatitis? In an interview at this year’s Caribbean Dermatology Symposium, Dr. Albert C. Yan, section chief of dermatology at the Children’s Hospital of Philadelphia and professor of pediatrics and dermatology, University of Pennsylvania, Philadelphia, discusses the evidence indicating that early use of moisturizers reduces the risk of atopic dermatitis in children at risk.

The meeting is provided by Global Academy for Medical Education. Global Academy and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

ORLANDO – You can confidently treat mild to severe Clostridium difficile infection in patients with inflammatory bowel disease (IBD) without disrupting their immunosuppression or other treatments, according to an expert.

“If your patient with IBD needs a fecal transplant for C. diff., you should not be concerned about withholding it,” Dr. Alan C. Moss, AGAF, said during a basic science presentation at a conference on IBD, sponsored by the Crohn’s and Colitis Foundation of America. Dr. Moss is associate professor of medicine and the director of translational research at Harvard Medical School, Boston.

The first step, after you’ve determined that your patient has a C. diff. infection, as opposed to having been only colonized by the bacterium, is choosing the best antibiotic. “Unfortunately, almost all IBD patients are excluded from controlled trials of antibiotics in C. diff. infection, so all we really have to go on are retrospective cohort data,” he said.One such study, uncontrolled for disease severity, showed that a third of 114 inpatients with IBD who had a co-occurring C. diff. infection had higher 30-day readmission rates when treated first with metronidazole, per current standards of care, compared with the remaining two-thirds of patients who were treated first with vancomycin. The metronidazole group also averaged double the length of stays of the vancomycin group (Antimicrob Agents Chemother. 2014 Sep;58:5054-9 [doi: 10.1128/AAC.02606-13]).“This suggests that in IBD patients, especially for those who meet criteria for a severe C. diff. infection, vancomycin is the way to go,” Dr. Moss said, noting a trend of metronidazole for mild infections in this cohort having ever less efficacy.

Beyond mild infection, the first line of treatment should be vancomycin 125 mg four times daily, or 500 mg four times daily if it is complicated disease, he said. If your patient has recurrent C. diff. infection, Dr. Moss recommends a prolonged taper of vancomycin, and vigilance to be sure it’s truly an infection and not a flare-up of colonized bacteria.

“My bar for doing fecal transplant in these patients has dropped considerably in the last few years, because if you really want to squeeze out the niche that C. diff. occupies in the microbiome, fecal transplant is really the most effective way we have of doing that,” Dr. Moss said.

While there is a division in the field over whether to continue immunosuppression during antibiotic treatment, Dr. Moss cited a small study indicating that patients who were on two or more immunosuppressants had a higher risk of death, megacolon, or shock during C. diff. treatment. “It’s hard to draw many conclusions from that,” he said. “It may just be a surrogate marker of severity of disease rather than infection, per se.”

The standard of care for recurrent and refractory C. diff. infection is fecal transplant, Dr. Moss said. A study showed an 89% cure rate of C. diff. infection after a single fecal transplant in IBD patients. Of the 36 IBD patients in the study, half of whom were on biologic and immunosuppressive therapies, 4 had disease flare-ups (Am J Gastroenterol. 2014 Jul;109:1065-71; N Engl J Med. 2013 Jan 31;368:474-5). As for determining if there is an actual infection rather than colonization of C. diff., Dr. Moss said switching from using ELISA (enzyme-linked immunoassay) to PCR (polymerase chain reaction) testing was helpful in first-time infections because the latter is more sensitive for determining actual infection. However, if a patient has recurrent infection, the higher clinical specificity of PCR makes it harder to tell if a positive result is infection or simply colonization. Some institutions have dropped ELISA testing altogether, but the use of single-molecule array testing is, with its exponential sensitivity, a “good half-way step” between ELISA and PCR, and is useful for determining who is colonized vs. who is actually producing the toxin, even at a very low level, Dr Moss said.

Dr. Moss disclosed he has consulted for Janssen, Theravance, and Seres, and has received research support from the National Institute for Diabetes, Digestive, and Kidney Diseases, and Helmsley.

[email protected]
On Twitter @whitneymcknight

ORLANDO – You can confidently treat mild to severe Clostridium difficile infection in patients with inflammatory bowel disease (IBD) without disrupting their immunosuppression or other treatments, according to an expert.

“If your patient with IBD needs a fecal transplant for C. diff., you should not be concerned about withholding it,” Dr. Alan C. Moss, AGAF, said during a basic science presentation at a conference on IBD, sponsored by the Crohn’s and Colitis Foundation of America. Dr. Moss is associate professor of medicine and the director of translational research at Harvard Medical School, Boston.

The first step, after you’ve determined that your patient has a C. diff. infection, as opposed to having been only colonized by the bacterium, is choosing the best antibiotic. “Unfortunately, almost all IBD patients are excluded from controlled trials of antibiotics in C. diff. infection, so all we really have to go on are retrospective cohort data,” he said.One such study, uncontrolled for disease severity, showed that a third of 114 inpatients with IBD who had a co-occurring C. diff. infection had higher 30-day readmission rates when treated first with metronidazole, per current standards of care, compared with the remaining two-thirds of patients who were treated first with vancomycin. The metronidazole group also averaged double the length of stays of the vancomycin group (Antimicrob Agents Chemother. 2014 Sep;58:5054-9 [doi: 10.1128/AAC.02606-13]).“This suggests that in IBD patients, especially for those who meet criteria for a severe C. diff. infection, vancomycin is the way to go,” Dr. Moss said, noting a trend of metronidazole for mild infections in this cohort having ever less efficacy.

Beyond mild infection, the first line of treatment should be vancomycin 125 mg four times daily, or 500 mg four times daily if it is complicated disease, he said. If your patient has recurrent C. diff. infection, Dr. Moss recommends a prolonged taper of vancomycin, and vigilance to be sure it’s truly an infection and not a flare-up of colonized bacteria.

“My bar for doing fecal transplant in these patients has dropped considerably in the last few years, because if you really want to squeeze out the niche that C. diff. occupies in the microbiome, fecal transplant is really the most effective way we have of doing that,” Dr. Moss said.

While there is a division in the field over whether to continue immunosuppression during antibiotic treatment, Dr. Moss cited a small study indicating that patients who were on two or more immunosuppressants had a higher risk of death, megacolon, or shock during C. diff. treatment. “It’s hard to draw many conclusions from that,” he said. “It may just be a surrogate marker of severity of disease rather than infection, per se.”

The standard of care for recurrent and refractory C. diff. infection is fecal transplant, Dr. Moss said. A study showed an 89% cure rate of C. diff. infection after a single fecal transplant in IBD patients. Of the 36 IBD patients in the study, half of whom were on biologic and immunosuppressive therapies, 4 had disease flare-ups (Am J Gastroenterol. 2014 Jul;109:1065-71; N Engl J Med. 2013 Jan 31;368:474-5). As for determining if there is an actual infection rather than colonization of C. diff., Dr. Moss said switching from using ELISA (enzyme-linked immunoassay) to PCR (polymerase chain reaction) testing was helpful in first-time infections because the latter is more sensitive for determining actual infection. However, if a patient has recurrent infection, the higher clinical specificity of PCR makes it harder to tell if a positive result is infection or simply colonization. Some institutions have dropped ELISA testing altogether, but the use of single-molecule array testing is, with its exponential sensitivity, a “good half-way step” between ELISA and PCR, and is useful for determining who is colonized vs. who is actually producing the toxin, even at a very low level, Dr Moss said.

Dr. Moss disclosed he has consulted for Janssen, Theravance, and Seres, and has received research support from the National Institute for Diabetes, Digestive, and Kidney Diseases, and Helmsley.

[email protected]
On Twitter @whitneymcknight

ORLANDO – You can confidently treat mild to severe Clostridium difficile infection in patients with inflammatory bowel disease (IBD) without disrupting their immunosuppression or other treatments, according to an expert.

“If your patient with IBD needs a fecal transplant for C. diff., you should not be concerned about withholding it,” Dr. Alan C. Moss, AGAF, said during a basic science presentation at a conference on IBD, sponsored by the Crohn’s and Colitis Foundation of America. Dr. Moss is associate professor of medicine and the director of translational research at Harvard Medical School, Boston.

The first step, after you’ve determined that your patient has a C. diff. infection, as opposed to having been only colonized by the bacterium, is choosing the best antibiotic. “Unfortunately, almost all IBD patients are excluded from controlled trials of antibiotics in C. diff. infection, so all we really have to go on are retrospective cohort data,” he said.One such study, uncontrolled for disease severity, showed that a third of 114 inpatients with IBD who had a co-occurring C. diff. infection had higher 30-day readmission rates when treated first with metronidazole, per current standards of care, compared with the remaining two-thirds of patients who were treated first with vancomycin. The metronidazole group also averaged double the length of stays of the vancomycin group (Antimicrob Agents Chemother. 2014 Sep;58:5054-9 [doi: 10.1128/AAC.02606-13]).“This suggests that in IBD patients, especially for those who meet criteria for a severe C. diff. infection, vancomycin is the way to go,” Dr. Moss said, noting a trend of metronidazole for mild infections in this cohort having ever less efficacy.

Beyond mild infection, the first line of treatment should be vancomycin 125 mg four times daily, or 500 mg four times daily if it is complicated disease, he said. If your patient has recurrent C. diff. infection, Dr. Moss recommends a prolonged taper of vancomycin, and vigilance to be sure it’s truly an infection and not a flare-up of colonized bacteria.

“My bar for doing fecal transplant in these patients has dropped considerably in the last few years, because if you really want to squeeze out the niche that C. diff. occupies in the microbiome, fecal transplant is really the most effective way we have of doing that,” Dr. Moss said.

While there is a division in the field over whether to continue immunosuppression during antibiotic treatment, Dr. Moss cited a small study indicating that patients who were on two or more immunosuppressants had a higher risk of death, megacolon, or shock during C. diff. treatment. “It’s hard to draw many conclusions from that,” he said. “It may just be a surrogate marker of severity of disease rather than infection, per se.”

The standard of care for recurrent and refractory C. diff. infection is fecal transplant, Dr. Moss said. A study showed an 89% cure rate of C. diff. infection after a single fecal transplant in IBD patients. Of the 36 IBD patients in the study, half of whom were on biologic and immunosuppressive therapies, 4 had disease flare-ups (Am J Gastroenterol. 2014 Jul;109:1065-71; N Engl J Med. 2013 Jan 31;368:474-5). As for determining if there is an actual infection rather than colonization of C. diff., Dr. Moss said switching from using ELISA (enzyme-linked immunoassay) to PCR (polymerase chain reaction) testing was helpful in first-time infections because the latter is more sensitive for determining actual infection. However, if a patient has recurrent infection, the higher clinical specificity of PCR makes it harder to tell if a positive result is infection or simply colonization. Some institutions have dropped ELISA testing altogether, but the use of single-molecule array testing is, with its exponential sensitivity, a “good half-way step” between ELISA and PCR, and is useful for determining who is colonized vs. who is actually producing the toxin, even at a very low level, Dr Moss said.

Dr. Moss disclosed he has consulted for Janssen, Theravance, and Seres, and has received research support from the National Institute for Diabetes, Digestive, and Kidney Diseases, and Helmsley.

[email protected]
On Twitter @whitneymcknight

Screening for cardiovascular disease and other known comorbidities of psoriatic arthritis take new precedence in updated treatment recommendations for rheumatologists from the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis.

“There is some controversy in that addressing comorbidities is thought to be a primary care physician’s responsibility, but I think what’s recognized is that primary care physicians don’t know the literature about psoriatic arthritis in general, so they may not know about the association with these comorbidities,” Dr. Alexis Ogdie-Beatty, one of the recommendations’ authors, said in an interview.

Other common comorbidities cited in the recommendations include obesity, diabetes, and depression, among others (Arthritis Rheumatol. 2016 Jan 8. doi: 10.1002/art.39573).

“These comorbidities exist, and rheumatologists should take them into consideration when making their treatment selection and when discussing things with the patient,” Dr. Ogdie-Beatty said.

GRAPPA’s emphasis on comorbidities sets it apart from other groups that issue treatment guidelines and recommendations, such as the European League Against Rheumatism, she added (Ann Rheum Dis. 2015 Dec 7. doi: 10.1136/annrheumdis-2015-208337).

GRAPPA specifically states that rheumatology specialists should screen patients for a variety of comorbid conditions, including anxiety, depression, and skin cancer, and that they should take an active role in helping overweight and obese patients achieve healthy body weights to reduce their disease activity, particularly patients using tumor necrosis factor inhibitors (TNFis).

If specialists did not want this responsibility, then GRAPPA’s goal was that they “should at least try to educate the primary care physicians about these issues, and educate the patient, too. The primary care doctor could still be responsible for the actual screening,” Dr. Ogdie-Beatty said.

Along with factoring comorbidities in the calculus of treatment, the revised recommendations now are grouped according to disease features, rather than just by the established GRAPPA grid algorithms. Distinctions between mild, moderate, and severe disease as previously described by the grid were removed, the authors wrote, “because the cut-offs are not evidence-based or applicable to all patients.”

Agreement on the development of six new overarching principles of treatment reached at least 80% among the 135 clinicians and 10 patient researchers who evaluated all relevant PsA literature published since 2009 when the last update was published (Ann Rheum Dis. 2009 Sep; 68[9]:1387-94). The most strongly endorsed principle is that the goal of treatment is to “achieve the lowest possible level of disease activity in all domains of disease,” and to “optimize functional status, improve quality of life and well-being, and prevent structural damage to the greatest extent possible.”

The remaining five new guiding principles largely point to the need for an integrated approach to therapy, and an elevated role of the patient in treatment selection. The six clinical domains include peripheral arthritis, axial disease, enthesitis, dactylitis, psoriasis, and nail disease in the setting of PsA. Because patients often have multiple manifestations of disease, GRAPPA recommends working with patients in an “iterative process” to choose therapies that address as many of these as possible, beginning with the most severe.

The updated recommendations also address the use of treatments such as IL-17 inhibitors that were unavailable at the time of the last update in 2009, and how they may interplay with the six disease subgroups and comorbidities.

Following are some of the specific recommendations per clinical subgroup. All recommendations are based on the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) method of evidence evaluation.

Peripheral arthritis: With the exception of cyclosporine, in disease-modifying antirheumatic drug (DMARD)–naive patients, DMARDS and TNFis are strongly recommended. Patients with poor prognostic factors, such as high inflammatory markers, are candidates for early escalation of therapy. Patients who fail DMARDs are strongly recommended for either biologics or phosphodiesterase-4 inhibitors, although GRAPPA gives IL-17 inhibitors a conditional recommendation pending more explicit data. NSAIDs are conditionally recommended for symptom relief.

Axial disease: Since relevant data for this subgroup are not available, the recommendations are derived from ankylosing spondylitis and include TNFi for patients who have not responded to NSAIDs. As an adjunct to further therapy when patients fail TNFi, NSAIDs are conditionally recommended. Switching TNFi if there is no response to initial TNFi treatment is also conditionally recommended.

Enthesitis: GRAPPA did not make any recommendations for this subgroup but did note that there is high-quality evidence for TNFi and ustekinumab. The group also did not find any published data to support DMARDs in this group.

Dactylitis: Again, a lack of published data meant GRAPPA had little to recommend for this subgroup, but it did recommend DMARDs based on limited studies for this indication. There was no outright recommendation for corticosteroid injections, although GRAPPA stated they “should be considered.”

Skin disease: In patients who do not respond to first-line therapies, followed by phototherapy and DMARDs, biologics are recommended. Biologics can also be used as first-line therapy without adjuncts in some patients.

Nail disease: Very few data exist for this subgroup, so drawing from skin psoriasis data, GRAPPA recommended biologics, particularly TNFi, for patients with moderate to severe nail involvement.

GRAPPA receives funding from pharmaceutical companies, which at present include AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Eli Lilly & Company, Novartis, Pfizer, and UCB, with Covagen and Crescendo as Innovation Partners. The authors reported that all deliberations and decisions were made completely independently of, and without input from or review by, any industry representatives.

[email protected]

On Twitter @whitneymcknight

Screening for cardiovascular disease and other known comorbidities of psoriatic arthritis take new precedence in updated treatment recommendations for rheumatologists from the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis.

“There is some controversy in that addressing comorbidities is thought to be a primary care physician’s responsibility, but I think what’s recognized is that primary care physicians don’t know the literature about psoriatic arthritis in general, so they may not know about the association with these comorbidities,” Dr. Alexis Ogdie-Beatty, one of the recommendations’ authors, said in an interview.

Other common comorbidities cited in the recommendations include obesity, diabetes, and depression, among others (Arthritis Rheumatol. 2016 Jan 8. doi: 10.1002/art.39573).

“These comorbidities exist, and rheumatologists should take them into consideration when making their treatment selection and when discussing things with the patient,” Dr. Ogdie-Beatty said.

GRAPPA’s emphasis on comorbidities sets it apart from other groups that issue treatment guidelines and recommendations, such as the European League Against Rheumatism, she added (Ann Rheum Dis. 2015 Dec 7. doi: 10.1136/annrheumdis-2015-208337).

GRAPPA specifically states that rheumatology specialists should screen patients for a variety of comorbid conditions, including anxiety, depression, and skin cancer, and that they should take an active role in helping overweight and obese patients achieve healthy body weights to reduce their disease activity, particularly patients using tumor necrosis factor inhibitors (TNFis).

If specialists did not want this responsibility, then GRAPPA’s goal was that they “should at least try to educate the primary care physicians about these issues, and educate the patient, too. The primary care doctor could still be responsible for the actual screening,” Dr. Ogdie-Beatty said.

Along with factoring comorbidities in the calculus of treatment, the revised recommendations now are grouped according to disease features, rather than just by the established GRAPPA grid algorithms. Distinctions between mild, moderate, and severe disease as previously described by the grid were removed, the authors wrote, “because the cut-offs are not evidence-based or applicable to all patients.”

Agreement on the development of six new overarching principles of treatment reached at least 80% among the 135 clinicians and 10 patient researchers who evaluated all relevant PsA literature published since 2009 when the last update was published (Ann Rheum Dis. 2009 Sep; 68[9]:1387-94). The most strongly endorsed principle is that the goal of treatment is to “achieve the lowest possible level of disease activity in all domains of disease,” and to “optimize functional status, improve quality of life and well-being, and prevent structural damage to the greatest extent possible.”

The remaining five new guiding principles largely point to the need for an integrated approach to therapy, and an elevated role of the patient in treatment selection. The six clinical domains include peripheral arthritis, axial disease, enthesitis, dactylitis, psoriasis, and nail disease in the setting of PsA. Because patients often have multiple manifestations of disease, GRAPPA recommends working with patients in an “iterative process” to choose therapies that address as many of these as possible, beginning with the most severe.

The updated recommendations also address the use of treatments such as IL-17 inhibitors that were unavailable at the time of the last update in 2009, and how they may interplay with the six disease subgroups and comorbidities.

Following are some of the specific recommendations per clinical subgroup. All recommendations are based on the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) method of evidence evaluation.

Peripheral arthritis: With the exception of cyclosporine, in disease-modifying antirheumatic drug (DMARD)–naive patients, DMARDS and TNFis are strongly recommended. Patients with poor prognostic factors, such as high inflammatory markers, are candidates for early escalation of therapy. Patients who fail DMARDs are strongly recommended for either biologics or phosphodiesterase-4 inhibitors, although GRAPPA gives IL-17 inhibitors a conditional recommendation pending more explicit data. NSAIDs are conditionally recommended for symptom relief.

Axial disease: Since relevant data for this subgroup are not available, the recommendations are derived from ankylosing spondylitis and include TNFi for patients who have not responded to NSAIDs. As an adjunct to further therapy when patients fail TNFi, NSAIDs are conditionally recommended. Switching TNFi if there is no response to initial TNFi treatment is also conditionally recommended.

Enthesitis: GRAPPA did not make any recommendations for this subgroup but did note that there is high-quality evidence for TNFi and ustekinumab. The group also did not find any published data to support DMARDs in this group.

Dactylitis: Again, a lack of published data meant GRAPPA had little to recommend for this subgroup, but it did recommend DMARDs based on limited studies for this indication. There was no outright recommendation for corticosteroid injections, although GRAPPA stated they “should be considered.”

Skin disease: In patients who do not respond to first-line therapies, followed by phototherapy and DMARDs, biologics are recommended. Biologics can also be used as first-line therapy without adjuncts in some patients.

Nail disease: Very few data exist for this subgroup, so drawing from skin psoriasis data, GRAPPA recommended biologics, particularly TNFi, for patients with moderate to severe nail involvement.

GRAPPA receives funding from pharmaceutical companies, which at present include AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Eli Lilly & Company, Novartis, Pfizer, and UCB, with Covagen and Crescendo as Innovation Partners. The authors reported that all deliberations and decisions were made completely independently of, and without input from or review by, any industry representatives.

[email protected]

On Twitter @whitneymcknight

Screening for cardiovascular disease and other known comorbidities of psoriatic arthritis take new precedence in updated treatment recommendations for rheumatologists from the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis.

“There is some controversy in that addressing comorbidities is thought to be a primary care physician’s responsibility, but I think what’s recognized is that primary care physicians don’t know the literature about psoriatic arthritis in general, so they may not know about the association with these comorbidities,” Dr. Alexis Ogdie-Beatty, one of the recommendations’ authors, said in an interview.

Other common comorbidities cited in the recommendations include obesity, diabetes, and depression, among others (Arthritis Rheumatol. 2016 Jan 8. doi: 10.1002/art.39573).

“These comorbidities exist, and rheumatologists should take them into consideration when making their treatment selection and when discussing things with the patient,” Dr. Ogdie-Beatty said.

GRAPPA’s emphasis on comorbidities sets it apart from other groups that issue treatment guidelines and recommendations, such as the European League Against Rheumatism, she added (Ann Rheum Dis. 2015 Dec 7. doi: 10.1136/annrheumdis-2015-208337).

GRAPPA specifically states that rheumatology specialists should screen patients for a variety of comorbid conditions, including anxiety, depression, and skin cancer, and that they should take an active role in helping overweight and obese patients achieve healthy body weights to reduce their disease activity, particularly patients using tumor necrosis factor inhibitors (TNFis).

If specialists did not want this responsibility, then GRAPPA’s goal was that they “should at least try to educate the primary care physicians about these issues, and educate the patient, too. The primary care doctor could still be responsible for the actual screening,” Dr. Ogdie-Beatty said.

Along with factoring comorbidities in the calculus of treatment, the revised recommendations now are grouped according to disease features, rather than just by the established GRAPPA grid algorithms. Distinctions between mild, moderate, and severe disease as previously described by the grid were removed, the authors wrote, “because the cut-offs are not evidence-based or applicable to all patients.”

Agreement on the development of six new overarching principles of treatment reached at least 80% among the 135 clinicians and 10 patient researchers who evaluated all relevant PsA literature published since 2009 when the last update was published (Ann Rheum Dis. 2009 Sep; 68[9]:1387-94). The most strongly endorsed principle is that the goal of treatment is to “achieve the lowest possible level of disease activity in all domains of disease,” and to “optimize functional status, improve quality of life and well-being, and prevent structural damage to the greatest extent possible.”

The remaining five new guiding principles largely point to the need for an integrated approach to therapy, and an elevated role of the patient in treatment selection. The six clinical domains include peripheral arthritis, axial disease, enthesitis, dactylitis, psoriasis, and nail disease in the setting of PsA. Because patients often have multiple manifestations of disease, GRAPPA recommends working with patients in an “iterative process” to choose therapies that address as many of these as possible, beginning with the most severe.

The updated recommendations also address the use of treatments such as IL-17 inhibitors that were unavailable at the time of the last update in 2009, and how they may interplay with the six disease subgroups and comorbidities.

Following are some of the specific recommendations per clinical subgroup. All recommendations are based on the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) method of evidence evaluation.

Peripheral arthritis: With the exception of cyclosporine, in disease-modifying antirheumatic drug (DMARD)–naive patients, DMARDS and TNFis are strongly recommended. Patients with poor prognostic factors, such as high inflammatory markers, are candidates for early escalation of therapy. Patients who fail DMARDs are strongly recommended for either biologics or phosphodiesterase-4 inhibitors, although GRAPPA gives IL-17 inhibitors a conditional recommendation pending more explicit data. NSAIDs are conditionally recommended for symptom relief.

Axial disease: Since relevant data for this subgroup are not available, the recommendations are derived from ankylosing spondylitis and include TNFi for patients who have not responded to NSAIDs. As an adjunct to further therapy when patients fail TNFi, NSAIDs are conditionally recommended. Switching TNFi if there is no response to initial TNFi treatment is also conditionally recommended.

Enthesitis: GRAPPA did not make any recommendations for this subgroup but did note that there is high-quality evidence for TNFi and ustekinumab. The group also did not find any published data to support DMARDs in this group.

Dactylitis: Again, a lack of published data meant GRAPPA had little to recommend for this subgroup, but it did recommend DMARDs based on limited studies for this indication. There was no outright recommendation for corticosteroid injections, although GRAPPA stated they “should be considered.”

Skin disease: In patients who do not respond to first-line therapies, followed by phototherapy and DMARDs, biologics are recommended. Biologics can also be used as first-line therapy without adjuncts in some patients.

Nail disease: Very few data exist for this subgroup, so drawing from skin psoriasis data, GRAPPA recommended biologics, particularly TNFi, for patients with moderate to severe nail involvement.

GRAPPA receives funding from pharmaceutical companies, which at present include AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Janssen, Eli Lilly & Company, Novartis, Pfizer, and UCB, with Covagen and Crescendo as Innovation Partners. The authors reported that all deliberations and decisions were made completely independently of, and without input from or review by, any industry representatives.

[email protected]

On Twitter @whitneymcknight

Don’t walk away from meaningful use quite yet. That’s the message from CMS leaders Andy Slavitt and Dr. Karen DeSalvo.

Mr. Slavitt, acting administrator of the Centers for Medicare & Medicaid Services, announced on Jan. 11 that change would be coming to health care IT. “The meaningful use program as it has existed will now be effectively over and replaced with something better,” he said at the annual J.P. Morgan Healthcare Conference.

In a blog post intended to elaborate on those statements, Mr. Slavitt and Dr. DeSalvo, National Coordinator for Health IT, wrote that “the approach to meaningful use under the [Medicare Access & CHIP Reauthorization Act of 2015 (MACRA)] won’t happen overnight. Our goal in communicating our principles now is to give everyone time to plan for what’s next and to continue to give us input. We encourage you to look for the MACRA regulations this year; in the meantime, our existing regulations – including meaningful use stage 3 – are still in effect.”

Although CMS had been hinting since late in 2015 that it was considering dropping or modifying the meaningful use program, Mr. Slavitt made it official during the J.P. Morgan conference. The latest announcement asks providers to have patience with this process. “We will continue to listen and learn and make improvements based on what happens on the front line,” Mr. Slavitt and Dr. DeSalvo wrote. “The process will be ongoing, not an instant fix and we must all commit to learning and improving and collaborating on the best solutions.”

Since health IT changes under MACRA apply only to Medicare, the CMS leaders pointed out that electronic health record incentives for Medicaid and Medicare hospitals are unchanged; however, they noted that the agency would seek ways to help health care institutions streamline their IT needs as well.

The blog post also pointed out that late last year, CMS was given the authority to allow groups of providers – rather than individuals – to receive hardship exemptions under meaningful use. “This should make the process much simpler for physicians and their practice managers in the future. We will be releasing guidance on this new process soon,” Mr. Slavitt and Dr. DeSalvo noted.

The American Medical Association lauded the coming changes to health IT. This is “a win for patients, physicians and common sense,” Dr. Steven J. Sack said in a statement.

But as CMS forges ahead with new tech mandates, others advised the agency not to throw away the good with the bad.

“We are heartened that CMS has its ears to the ground and is trying to shape the program in a way that will be genuinely beneficial for providers and patients,” Ed Park, chief operating officer at AthenaHealth, a Boston-based health IT solutions firm, said in an interview. “With that said, just because providers found meaningful use stage 2 hard doesn’t by itself make it a bad program.”

This latest information out of CMS would seem to reinforce Mr. Slavitt’s promise to the investors at the J.P. Morgan conference that the move away from meaningful use would be to “start small and leave a lot of tool-building opportunities for the private sector.” He told attendees that CMS would level the playing field for start-ups and new entrants into the health IT space who can help providers securely transfer patient data and close the loops on referrals and other essentials of continuous care.

Some are not so optimistic about the private sector’s ability to help make MACRA a sustained reality, however. “As to whether the systems will be ready for the new payment regime, I am not holding my breath,” Johnathan Graham, a health economist and senior fellow at the National Center for Policy Analysis, Washington, D.C., said in an interview.

Even with updated technologies, physician satisfaction will not rise overall, he predicted, because of what he referred to as a too-slow rate of growth in Medicare’s Part B budget.

He also called out MACRA payment adjustments as onerous to physicians: The implementation of MACRA’s range of positive or negative payment adjustments in the MIPS program of minus 3.5% to plus 4.5% in 2019, plus or minus 5% in 2020, plus or minus 7% in 2021, and plus or minus 9% after that, meaning that the more providers who score above the threshold for the positive payment update, the narrower the update will be to each practice.

“I think MACRA will fall apart within 2 or 3 years as practicing physicians learn they are in a dog-eat-dog environment, or zero-sum game. The can will get kicked down the road just like meaningful use was,” Mr. Graham said.

But forcing doctors to face off is the point, according to Mr. Park: “Our health care system is on a transformational journey and we should all expect it to be hard. We want to encourage CMS to continue to keep the bar high on the right things and we hope that CMS doesn’t water down merit-based incentive pay so that the definition of success is that everyone succeeds.”

[email protected]

On Twitter @whitneymcknight

Don’t walk away from meaningful use quite yet. That’s the message from CMS leaders Andy Slavitt and Dr. Karen DeSalvo.

Mr. Slavitt, acting administrator of the Centers for Medicare & Medicaid Services, announced on Jan. 11 that change would be coming to health care IT. “The meaningful use program as it has existed will now be effectively over and replaced with something better,” he said at the annual J.P. Morgan Healthcare Conference.

In a blog post intended to elaborate on those statements, Mr. Slavitt and Dr. DeSalvo, National Coordinator for Health IT, wrote that “the approach to meaningful use under the [Medicare Access & CHIP Reauthorization Act of 2015 (MACRA)] won’t happen overnight. Our goal in communicating our principles now is to give everyone time to plan for what’s next and to continue to give us input. We encourage you to look for the MACRA regulations this year; in the meantime, our existing regulations – including meaningful use stage 3 – are still in effect.”

Although CMS had been hinting since late in 2015 that it was considering dropping or modifying the meaningful use program, Mr. Slavitt made it official during the J.P. Morgan conference. The latest announcement asks providers to have patience with this process. “We will continue to listen and learn and make improvements based on what happens on the front line,” Mr. Slavitt and Dr. DeSalvo wrote. “The process will be ongoing, not an instant fix and we must all commit to learning and improving and collaborating on the best solutions.”

Since health IT changes under MACRA apply only to Medicare, the CMS leaders pointed out that electronic health record incentives for Medicaid and Medicare hospitals are unchanged; however, they noted that the agency would seek ways to help health care institutions streamline their IT needs as well.

The blog post also pointed out that late last year, CMS was given the authority to allow groups of providers – rather than individuals – to receive hardship exemptions under meaningful use. “This should make the process much simpler for physicians and their practice managers in the future. We will be releasing guidance on this new process soon,” Mr. Slavitt and Dr. DeSalvo noted.

The American Medical Association lauded the coming changes to health IT. This is “a win for patients, physicians and common sense,” Dr. Steven J. Sack said in a statement.

But as CMS forges ahead with new tech mandates, others advised the agency not to throw away the good with the bad.

“We are heartened that CMS has its ears to the ground and is trying to shape the program in a way that will be genuinely beneficial for providers and patients,” Ed Park, chief operating officer at AthenaHealth, a Boston-based health IT solutions firm, said in an interview. “With that said, just because providers found meaningful use stage 2 hard doesn’t by itself make it a bad program.”

This latest information out of CMS would seem to reinforce Mr. Slavitt’s promise to the investors at the J.P. Morgan conference that the move away from meaningful use would be to “start small and leave a lot of tool-building opportunities for the private sector.” He told attendees that CMS would level the playing field for start-ups and new entrants into the health IT space who can help providers securely transfer patient data and close the loops on referrals and other essentials of continuous care.

Some are not so optimistic about the private sector’s ability to help make MACRA a sustained reality, however. “As to whether the systems will be ready for the new payment regime, I am not holding my breath,” Johnathan Graham, a health economist and senior fellow at the National Center for Policy Analysis, Washington, D.C., said in an interview.

Even with updated technologies, physician satisfaction will not rise overall, he predicted, because of what he referred to as a too-slow rate of growth in Medicare’s Part B budget.

He also called out MACRA payment adjustments as onerous to physicians: The implementation of MACRA’s range of positive or negative payment adjustments in the MIPS program of minus 3.5% to plus 4.5% in 2019, plus or minus 5% in 2020, plus or minus 7% in 2021, and plus or minus 9% after that, meaning that the more providers who score above the threshold for the positive payment update, the narrower the update will be to each practice.

“I think MACRA will fall apart within 2 or 3 years as practicing physicians learn they are in a dog-eat-dog environment, or zero-sum game. The can will get kicked down the road just like meaningful use was,” Mr. Graham said.

But forcing doctors to face off is the point, according to Mr. Park: “Our health care system is on a transformational journey and we should all expect it to be hard. We want to encourage CMS to continue to keep the bar high on the right things and we hope that CMS doesn’t water down merit-based incentive pay so that the definition of success is that everyone succeeds.”

[email protected]

On Twitter @whitneymcknight

Don’t walk away from meaningful use quite yet. That’s the message from CMS leaders Andy Slavitt and Dr. Karen DeSalvo.

Mr. Slavitt, acting administrator of the Centers for Medicare & Medicaid Services, announced on Jan. 11 that change would be coming to health care IT. “The meaningful use program as it has existed will now be effectively over and replaced with something better,” he said at the annual J.P. Morgan Healthcare Conference.

In a blog post intended to elaborate on those statements, Mr. Slavitt and Dr. DeSalvo, National Coordinator for Health IT, wrote that “the approach to meaningful use under the [Medicare Access & CHIP Reauthorization Act of 2015 (MACRA)] won’t happen overnight. Our goal in communicating our principles now is to give everyone time to plan for what’s next and to continue to give us input. We encourage you to look for the MACRA regulations this year; in the meantime, our existing regulations – including meaningful use stage 3 – are still in effect.”

Although CMS had been hinting since late in 2015 that it was considering dropping or modifying the meaningful use program, Mr. Slavitt made it official during the J.P. Morgan conference. The latest announcement asks providers to have patience with this process. “We will continue to listen and learn and make improvements based on what happens on the front line,” Mr. Slavitt and Dr. DeSalvo wrote. “The process will be ongoing, not an instant fix and we must all commit to learning and improving and collaborating on the best solutions.”

Since health IT changes under MACRA apply only to Medicare, the CMS leaders pointed out that electronic health record incentives for Medicaid and Medicare hospitals are unchanged; however, they noted that the agency would seek ways to help health care institutions streamline their IT needs as well.

The blog post also pointed out that late last year, CMS was given the authority to allow groups of providers – rather than individuals – to receive hardship exemptions under meaningful use. “This should make the process much simpler for physicians and their practice managers in the future. We will be releasing guidance on this new process soon,” Mr. Slavitt and Dr. DeSalvo noted.

The American Medical Association lauded the coming changes to health IT. This is “a win for patients, physicians and common sense,” Dr. Steven J. Sack said in a statement.

But as CMS forges ahead with new tech mandates, others advised the agency not to throw away the good with the bad.

“We are heartened that CMS has its ears to the ground and is trying to shape the program in a way that will be genuinely beneficial for providers and patients,” Ed Park, chief operating officer at AthenaHealth, a Boston-based health IT solutions firm, said in an interview. “With that said, just because providers found meaningful use stage 2 hard doesn’t by itself make it a bad program.”

This latest information out of CMS would seem to reinforce Mr. Slavitt’s promise to the investors at the J.P. Morgan conference that the move away from meaningful use would be to “start small and leave a lot of tool-building opportunities for the private sector.” He told attendees that CMS would level the playing field for start-ups and new entrants into the health IT space who can help providers securely transfer patient data and close the loops on referrals and other essentials of continuous care.

Some are not so optimistic about the private sector’s ability to help make MACRA a sustained reality, however. “As to whether the systems will be ready for the new payment regime, I am not holding my breath,” Johnathan Graham, a health economist and senior fellow at the National Center for Policy Analysis, Washington, D.C., said in an interview.

Even with updated technologies, physician satisfaction will not rise overall, he predicted, because of what he referred to as a too-slow rate of growth in Medicare’s Part B budget.

He also called out MACRA payment adjustments as onerous to physicians: The implementation of MACRA’s range of positive or negative payment adjustments in the MIPS program of minus 3.5% to plus 4.5% in 2019, plus or minus 5% in 2020, plus or minus 7% in 2021, and plus or minus 9% after that, meaning that the more providers who score above the threshold for the positive payment update, the narrower the update will be to each practice.

“I think MACRA will fall apart within 2 or 3 years as practicing physicians learn they are in a dog-eat-dog environment, or zero-sum game. The can will get kicked down the road just like meaningful use was,” Mr. Graham said.

But forcing doctors to face off is the point, according to Mr. Park: “Our health care system is on a transformational journey and we should all expect it to be hard. We want to encourage CMS to continue to keep the bar high on the right things and we hope that CMS doesn’t water down merit-based incentive pay so that the definition of success is that everyone succeeds.”

[email protected]

On Twitter @whitneymcknight

Pregnant women and those planning to become pregnant should avoid traveling to 14 tropical countries and territories in Central and South America and the Caribbean, where there is a rapidly escalating outbreak of the mosquito-borne zika virus, according to the Centers for Disease Control & Prevention in an advisory issued Jan. 15.

The CDC advisory covers Brazil, Colombia, El Salvador, French Guiana, Guatemala, Haiti, Honduras, Martinique, Mexico, Panama, Paraguay, Suriname, Venezuela, and the Commonwealth of Puerto Rico.

Courtesy Wikimedia Commons/Muhammad Mahdi Karim/Creative Commons License

Although illness due to the zika virus tends to be mild with symptoms lasting from several days to a week, research has indicated a correlation between the virus and a skyrocketing number of babies born with microcephaly and other poor outcomes in Brazil. The Brazilian Ministry of Health has declared a national health emergency (link in Portuguese) as officials there fear the numbers of cases will go higher.

“Until more is known, and out of an abundance of caution, CDC recommends special precautions for pregnant women and women trying to become pregnant,” the CDC said in a statement. Specifically, women at any trimester of pregnancy should cancel or postpone travel to the areas covered by the advisory. Any pregnant women who must travel should consult with a physician prior to travel and take great care to avoid mosquito bites. The advice should be observed by women who are thinking of becoming pregnant, according to the CDC.

The government of Canada has issued a similar travel warning for pregnant women.

CDC warns that because the mosquitoes of the Aedes aegypti species that spread zika virus are found worldwide, further outbreaks are likely in other countries. Indeed, zika virus transmission has been seen in several countries in Africa and Asia.

In December 2015, Puerto Rico reported its first confirmed zika virus case. Although zika has not been reported in the continental United States, the CDC reports there have been infected travelers returning from affected countries.

Advice for those who must travel to areas where zika virus transmission has been documented can be found on the CDC website.

[email protected]

On Twitter @whitneymcknight

Pregnant women and those planning to become pregnant should avoid traveling to 14 tropical countries and territories in Central and South America and the Caribbean, where there is a rapidly escalating outbreak of the mosquito-borne zika virus, according to the Centers for Disease Control & Prevention in an advisory issued Jan. 15.

The CDC advisory covers Brazil, Colombia, El Salvador, French Guiana, Guatemala, Haiti, Honduras, Martinique, Mexico, Panama, Paraguay, Suriname, Venezuela, and the Commonwealth of Puerto Rico.

Courtesy Wikimedia Commons/Muhammad Mahdi Karim/Creative Commons License

Although illness due to the zika virus tends to be mild with symptoms lasting from several days to a week, research has indicated a correlation between the virus and a skyrocketing number of babies born with microcephaly and other poor outcomes in Brazil. The Brazilian Ministry of Health has declared a national health emergency (link in Portuguese) as officials there fear the numbers of cases will go higher.

“Until more is known, and out of an abundance of caution, CDC recommends special precautions for pregnant women and women trying to become pregnant,” the CDC said in a statement. Specifically, women at any trimester of pregnancy should cancel or postpone travel to the areas covered by the advisory. Any pregnant women who must travel should consult with a physician prior to travel and take great care to avoid mosquito bites. The advice should be observed by women who are thinking of becoming pregnant, according to the CDC.

The government of Canada has issued a similar travel warning for pregnant women.

CDC warns that because the mosquitoes of the Aedes aegypti species that spread zika virus are found worldwide, further outbreaks are likely in other countries. Indeed, zika virus transmission has been seen in several countries in Africa and Asia.

In December 2015, Puerto Rico reported its first confirmed zika virus case. Although zika has not been reported in the continental United States, the CDC reports there have been infected travelers returning from affected countries.

Advice for those who must travel to areas where zika virus transmission has been documented can be found on the CDC website.

[email protected]

On Twitter @whitneymcknight

Pregnant women and those planning to become pregnant should avoid traveling to 14 tropical countries and territories in Central and South America and the Caribbean, where there is a rapidly escalating outbreak of the mosquito-borne zika virus, according to the Centers for Disease Control & Prevention in an advisory issued Jan. 15.

The CDC advisory covers Brazil, Colombia, El Salvador, French Guiana, Guatemala, Haiti, Honduras, Martinique, Mexico, Panama, Paraguay, Suriname, Venezuela, and the Commonwealth of Puerto Rico.

Courtesy Wikimedia Commons/Muhammad Mahdi Karim/Creative Commons License

Although illness due to the zika virus tends to be mild with symptoms lasting from several days to a week, research has indicated a correlation between the virus and a skyrocketing number of babies born with microcephaly and other poor outcomes in Brazil. The Brazilian Ministry of Health has declared a national health emergency (link in Portuguese) as officials there fear the numbers of cases will go higher.

“Until more is known, and out of an abundance of caution, CDC recommends special precautions for pregnant women and women trying to become pregnant,” the CDC said in a statement. Specifically, women at any trimester of pregnancy should cancel or postpone travel to the areas covered by the advisory. Any pregnant women who must travel should consult with a physician prior to travel and take great care to avoid mosquito bites. The advice should be observed by women who are thinking of becoming pregnant, according to the CDC.

The government of Canada has issued a similar travel warning for pregnant women.

CDC warns that because the mosquitoes of the Aedes aegypti species that spread zika virus are found worldwide, further outbreaks are likely in other countries. Indeed, zika virus transmission has been seen in several countries in Africa and Asia.

In December 2015, Puerto Rico reported its first confirmed zika virus case. Although zika has not been reported in the continental United States, the CDC reports there have been infected travelers returning from affected countries.

Advice for those who must travel to areas where zika virus transmission has been documented can be found on the CDC website.

[email protected]

On Twitter @whitneymcknight

Meaningful use is on its way out.

Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services, told investors attending the annual J.P. Morgan Healthcare Conference that CMS is pulling back from the health care IT incentive program in the coming months.

“The meaningful use program as it has existed will now be effectively over and replaced with something better,” Mr. Slavitt said.*

“We have to get the hearts and minds of physicians back. I think we’ve lost them,” Mr. Slavitt said. He noted that, when the meaningful use incentive program began, few physicians and practices used electronic health records and concerns were that many would not willingly embrace information technology. Now that “virtually everywhere care is delivered has a computer,” it’s time to make health care technology serve beneficiaries and the physicians who serve them, Mr. Slavitt said.

The cost, however, was too high, Mr. Slavitt said. “As any physician will tell you, physician burden and frustration levels are real. Programs that are designed to improve often distract. Done poorly, measures are divorced from how physicians practice and add to the cynicism that the people who build these programs just don’t get it.”

Soon, CMS will no longer reward health care providers for using technology, but will instead focus on patient outcomes through the merit-based incentive pay systems created by last year’s Medicare Access and CHIP Reauthorization Act (MACRA) legislation. In addition to asking physicians to work with health care IT innovators to create systems that work best according to their practice’s respective needs, CMS is calling on the private sector to create apps and analytic tools that will keep data secure while fostering true and widespread interoperability.

Anyone seeking to block data transfer will find CMS is not their friend. Mr. Slavitt said. “We’re deadly serious about interoperability. Technology companies that look for ways to practice data blocking in opposition to new regulations will find that it will not be tolerated.”

Dr. James L. Madara, CEO of the American Medical Association, echoed Mr. Slavitt’s comments on the current, negative impact of EHRs on physicians’ practices. He noted that many physicians are spending at least 2 hours each workday using their EHR and may click up to 4,000 times per 8-hour shift.

Dr. Madara outlined three AMA goals to help restore the physician-patient relationship. The first is to restructure the medical school curriculum, which he said essentially is the same as it has been for 100 years. New generations of physicians should be taught how to deliver collaborative care that includes telemedicine, more ambulatory care, and home care. Community-based partnerships, he said, would become key to treating chronic diseases like diabetes and would have to be factored into reimbursement models. The AMA also seeks to improve health outcomes and ensure thriving physician practices.

Central to the AMA’s plan for the future: Helping physicians restructure practice via technology. He announced that the AMA is a founding partner in the Silicon Valley (Calif.) based Health2047, a company focused on supporting health IT and other entrepreneurs in their efforts to provide physicians with digital tools that improve patient outcomes, among other innovations.

With MACRA set to go into full effect in 2019, Dr. Madara said that a “daunting” level of change is about to take place. Citing the successful shift to ICD-10, he said he was optimistic there would be positive changes, largely brought about through incentives to the private marketplace and by dropping meaningful use.

Although having metrics in health care delivery is important, Dr. Madara said that, up to this point, “We kinda got it wrong” with quality measures that are more processed based, rather than evidence based. “It was really great to hear about the move from meaningful use to a more aggregated program.”

*Correction, 1/12/2016: A previous version of this story included an incorrect start-up date for meaningful use changes.

[email protected]

On Twitter @whitneymcknight

Meaningful use is on its way out.

Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services, told investors attending the annual J.P. Morgan Healthcare Conference that CMS is pulling back from the health care IT incentive program in the coming months.

“The meaningful use program as it has existed will now be effectively over and replaced with something better,” Mr. Slavitt said.*

“We have to get the hearts and minds of physicians back. I think we’ve lost them,” Mr. Slavitt said. He noted that, when the meaningful use incentive program began, few physicians and practices used electronic health records and concerns were that many would not willingly embrace information technology. Now that “virtually everywhere care is delivered has a computer,” it’s time to make health care technology serve beneficiaries and the physicians who serve them, Mr. Slavitt said.

The cost, however, was too high, Mr. Slavitt said. “As any physician will tell you, physician burden and frustration levels are real. Programs that are designed to improve often distract. Done poorly, measures are divorced from how physicians practice and add to the cynicism that the people who build these programs just don’t get it.”

Soon, CMS will no longer reward health care providers for using technology, but will instead focus on patient outcomes through the merit-based incentive pay systems created by last year’s Medicare Access and CHIP Reauthorization Act (MACRA) legislation. In addition to asking physicians to work with health care IT innovators to create systems that work best according to their practice’s respective needs, CMS is calling on the private sector to create apps and analytic tools that will keep data secure while fostering true and widespread interoperability.

Anyone seeking to block data transfer will find CMS is not their friend. Mr. Slavitt said. “We’re deadly serious about interoperability. Technology companies that look for ways to practice data blocking in opposition to new regulations will find that it will not be tolerated.”

Dr. James L. Madara, CEO of the American Medical Association, echoed Mr. Slavitt’s comments on the current, negative impact of EHRs on physicians’ practices. He noted that many physicians are spending at least 2 hours each workday using their EHR and may click up to 4,000 times per 8-hour shift.

Dr. Madara outlined three AMA goals to help restore the physician-patient relationship. The first is to restructure the medical school curriculum, which he said essentially is the same as it has been for 100 years. New generations of physicians should be taught how to deliver collaborative care that includes telemedicine, more ambulatory care, and home care. Community-based partnerships, he said, would become key to treating chronic diseases like diabetes and would have to be factored into reimbursement models. The AMA also seeks to improve health outcomes and ensure thriving physician practices.

Central to the AMA’s plan for the future: Helping physicians restructure practice via technology. He announced that the AMA is a founding partner in the Silicon Valley (Calif.) based Health2047, a company focused on supporting health IT and other entrepreneurs in their efforts to provide physicians with digital tools that improve patient outcomes, among other innovations.

With MACRA set to go into full effect in 2019, Dr. Madara said that a “daunting” level of change is about to take place. Citing the successful shift to ICD-10, he said he was optimistic there would be positive changes, largely brought about through incentives to the private marketplace and by dropping meaningful use.

Although having metrics in health care delivery is important, Dr. Madara said that, up to this point, “We kinda got it wrong” with quality measures that are more processed based, rather than evidence based. “It was really great to hear about the move from meaningful use to a more aggregated program.”

*Correction, 1/12/2016: A previous version of this story included an incorrect start-up date for meaningful use changes.

[email protected]

On Twitter @whitneymcknight

Meaningful use is on its way out.

Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services, told investors attending the annual J.P. Morgan Healthcare Conference that CMS is pulling back from the health care IT incentive program in the coming months.

“The meaningful use program as it has existed will now be effectively over and replaced with something better,” Mr. Slavitt said.*

“We have to get the hearts and minds of physicians back. I think we’ve lost them,” Mr. Slavitt said. He noted that, when the meaningful use incentive program began, few physicians and practices used electronic health records and concerns were that many would not willingly embrace information technology. Now that “virtually everywhere care is delivered has a computer,” it’s time to make health care technology serve beneficiaries and the physicians who serve them, Mr. Slavitt said.

The cost, however, was too high, Mr. Slavitt said. “As any physician will tell you, physician burden and frustration levels are real. Programs that are designed to improve often distract. Done poorly, measures are divorced from how physicians practice and add to the cynicism that the people who build these programs just don’t get it.”

Soon, CMS will no longer reward health care providers for using technology, but will instead focus on patient outcomes through the merit-based incentive pay systems created by last year’s Medicare Access and CHIP Reauthorization Act (MACRA) legislation. In addition to asking physicians to work with health care IT innovators to create systems that work best according to their practice’s respective needs, CMS is calling on the private sector to create apps and analytic tools that will keep data secure while fostering true and widespread interoperability.

Anyone seeking to block data transfer will find CMS is not their friend. Mr. Slavitt said. “We’re deadly serious about interoperability. Technology companies that look for ways to practice data blocking in opposition to new regulations will find that it will not be tolerated.”

Dr. James L. Madara, CEO of the American Medical Association, echoed Mr. Slavitt’s comments on the current, negative impact of EHRs on physicians’ practices. He noted that many physicians are spending at least 2 hours each workday using their EHR and may click up to 4,000 times per 8-hour shift.

Dr. Madara outlined three AMA goals to help restore the physician-patient relationship. The first is to restructure the medical school curriculum, which he said essentially is the same as it has been for 100 years. New generations of physicians should be taught how to deliver collaborative care that includes telemedicine, more ambulatory care, and home care. Community-based partnerships, he said, would become key to treating chronic diseases like diabetes and would have to be factored into reimbursement models. The AMA also seeks to improve health outcomes and ensure thriving physician practices.

Central to the AMA’s plan for the future: Helping physicians restructure practice via technology. He announced that the AMA is a founding partner in the Silicon Valley (Calif.) based Health2047, a company focused on supporting health IT and other entrepreneurs in their efforts to provide physicians with digital tools that improve patient outcomes, among other innovations.

With MACRA set to go into full effect in 2019, Dr. Madara said that a “daunting” level of change is about to take place. Citing the successful shift to ICD-10, he said he was optimistic there would be positive changes, largely brought about through incentives to the private marketplace and by dropping meaningful use.

Although having metrics in health care delivery is important, Dr. Madara said that, up to this point, “We kinda got it wrong” with quality measures that are more processed based, rather than evidence based. “It was really great to hear about the move from meaningful use to a more aggregated program.”

*Correction, 1/12/2016: A previous version of this story included an incorrect start-up date for meaningful use changes.

[email protected]

On Twitter @whitneymcknight

Antibiotic therapy for 7 days or less may be just as effective as longer courses of antibiotics for select inpatients with uncomplicated gram-negative bacteremia from urinary infections, based on a retrospective, single-center analysis by researchers at Maimonides Medical Center in New York.

Hospitalized patients whose temperatures returned to levels below 100.4º F within 72 hours of starting therapy appeared to do well on short-course (7 days or less) antibiotic therapy, Siddharth Swamy, Pharm.D., and his colleagues reported in a study in Infectious Diseases in Clinical Practice posted online Dec. 30, 2015. However, increased clinical failures were noted in patients with a delayed response to therapy, indicating that duration of therapy needs to be individualized for each patient.

The researchers reviewed 178 eligible cases of gram-negative bacteremia. The most common source of bacteremia was the urinary tract (53%), followed by catheters (14%), and unknown sources (14%).

Patients were treated with antibiotics for either 7 days or less (42 patients), 8-14 days (100 patients), or more than 14 days (36 patients). The patients in the study were comparable, with the exception of a higher percentage of patients in the short-course antibiotic group who no longer had temperatures above 100.4º F within 72 hours of initiating therapy. The respective percentage of patients who had defervesced in 72 hours or less was 79% for 7 days or less of therapy, 69% for 8-14 days of therapy, and 36% for more than 14 days of therapy (P = .0002). Overall clinical response rates were 79% for 7 days or less of antibiotics, 89% for 8-14 days of therapy, and 81% for more than 14 days of therapy. Microbiologic cure rates were 83%, 89, and 92%, respectively; the differences were nonsignificant.

However, persisting fever predicted clinical response: Among patients who defervesced after 72 hours, the short-course treatment group had a significantly decreased clinical response rate, compared with intermediate- and long-course treatment groups (11%, 65%, 70%, respectively; P = .03).

The most common infectious pathogens were Escherichia coli (46%) and Klebsiella pneumoniae (22%); most cases were low-inocula bacteremias and were related to urinary tract infections in 53% of the cases. Thus, the findings “are not necessarily applicable to high-inocula bacteremias, nonlactose-fermenting gram-negative organisms, or multidrug-resistant gram-negative organisms,” the researchers wrote.

[email protected]

On Twitter @whitneymcknight

Antibiotic therapy for 7 days or less may be just as effective as longer courses of antibiotics for select inpatients with uncomplicated gram-negative bacteremia from urinary infections, based on a retrospective, single-center analysis by researchers at Maimonides Medical Center in New York.

Hospitalized patients whose temperatures returned to levels below 100.4º F within 72 hours of starting therapy appeared to do well on short-course (7 days or less) antibiotic therapy, Siddharth Swamy, Pharm.D., and his colleagues reported in a study in Infectious Diseases in Clinical Practice posted online Dec. 30, 2015. However, increased clinical failures were noted in patients with a delayed response to therapy, indicating that duration of therapy needs to be individualized for each patient.

The researchers reviewed 178 eligible cases of gram-negative bacteremia. The most common source of bacteremia was the urinary tract (53%), followed by catheters (14%), and unknown sources (14%).

Patients were treated with antibiotics for either 7 days or less (42 patients), 8-14 days (100 patients), or more than 14 days (36 patients). The patients in the study were comparable, with the exception of a higher percentage of patients in the short-course antibiotic group who no longer had temperatures above 100.4º F within 72 hours of initiating therapy. The respective percentage of patients who had defervesced in 72 hours or less was 79% for 7 days or less of therapy, 69% for 8-14 days of therapy, and 36% for more than 14 days of therapy (P = .0002). Overall clinical response rates were 79% for 7 days or less of antibiotics, 89% for 8-14 days of therapy, and 81% for more than 14 days of therapy. Microbiologic cure rates were 83%, 89, and 92%, respectively; the differences were nonsignificant.

However, persisting fever predicted clinical response: Among patients who defervesced after 72 hours, the short-course treatment group had a significantly decreased clinical response rate, compared with intermediate- and long-course treatment groups (11%, 65%, 70%, respectively; P = .03).

The most common infectious pathogens were Escherichia coli (46%) and Klebsiella pneumoniae (22%); most cases were low-inocula bacteremias and were related to urinary tract infections in 53% of the cases. Thus, the findings “are not necessarily applicable to high-inocula bacteremias, nonlactose-fermenting gram-negative organisms, or multidrug-resistant gram-negative organisms,” the researchers wrote.

[email protected]

On Twitter @whitneymcknight

Antibiotic therapy for 7 days or less may be just as effective as longer courses of antibiotics for select inpatients with uncomplicated gram-negative bacteremia from urinary infections, based on a retrospective, single-center analysis by researchers at Maimonides Medical Center in New York.

Hospitalized patients whose temperatures returned to levels below 100.4º F within 72 hours of starting therapy appeared to do well on short-course (7 days or less) antibiotic therapy, Siddharth Swamy, Pharm.D., and his colleagues reported in a study in Infectious Diseases in Clinical Practice posted online Dec. 30, 2015. However, increased clinical failures were noted in patients with a delayed response to therapy, indicating that duration of therapy needs to be individualized for each patient.

The researchers reviewed 178 eligible cases of gram-negative bacteremia. The most common source of bacteremia was the urinary tract (53%), followed by catheters (14%), and unknown sources (14%).

Patients were treated with antibiotics for either 7 days or less (42 patients), 8-14 days (100 patients), or more than 14 days (36 patients). The patients in the study were comparable, with the exception of a higher percentage of patients in the short-course antibiotic group who no longer had temperatures above 100.4º F within 72 hours of initiating therapy. The respective percentage of patients who had defervesced in 72 hours or less was 79% for 7 days or less of therapy, 69% for 8-14 days of therapy, and 36% for more than 14 days of therapy (P = .0002). Overall clinical response rates were 79% for 7 days or less of antibiotics, 89% for 8-14 days of therapy, and 81% for more than 14 days of therapy. Microbiologic cure rates were 83%, 89, and 92%, respectively; the differences were nonsignificant.

However, persisting fever predicted clinical response: Among patients who defervesced after 72 hours, the short-course treatment group had a significantly decreased clinical response rate, compared with intermediate- and long-course treatment groups (11%, 65%, 70%, respectively; P = .03).

The most common infectious pathogens were Escherichia coli (46%) and Klebsiella pneumoniae (22%); most cases were low-inocula bacteremias and were related to urinary tract infections in 53% of the cases. Thus, the findings “are not necessarily applicable to high-inocula bacteremias, nonlactose-fermenting gram-negative organisms, or multidrug-resistant gram-negative organisms,” the researchers wrote.

[email protected]

On Twitter @whitneymcknight