It’s hard to believe that it is time to ring in the New Year already!
In 2010, we did indeed learn valuable lessons from influenza A(H1N1). In many hospitals, the national mandate for health care workers and influenza vaccine became a reality. The new palivizumab guidelines and the use of hepatitis A and 13-valent pneumococcal conjugate vaccine have been implemented, and we continued to see a decline in meningococcal and rotaviral infection. Clindamycin resistance rates have increased, although we have not seen the rise in vancomycin intermediate or resistant Staphylococcus aureus, the prospect of which made me wonder if this drug would become pass?
By Dr. Mary Anne Jackson
For the upcoming year, I think we will be seriously talking about the following topics:
• HPV completion rates for teenage girls. Dr. Lee E. Widdice of Cincinnati Children’s Hospital and colleagues noted that only 14% of 3,297 girls completed their vaccine on time, and only 28% within a year of starting the vaccine. The rate of on-time vaccine completions was significantly less for nonwhites, raising concern for the impact of this health care disparity on the epidemiology of cervical cancer (Pediatrics 2010 Dec. 13 [doi:10.1542/peds.2010-0812]).
My partner, Dr. Christopher Harrison, and other investigators in the National Institutes of Health–based vaccine evaluation and treatment units across the country are looking at whether the immunogenicity of vaccine is adequate in teens who receive their doses later than recommended. Additional research into the health care disparity issues should be targeted in future studies.
• Is the epidemiology of RSV changing? It’s late December here in Kansas City, and we have seen only a modest number of infants hospitalized with bronchiolitis. The onset of respiratory syncytial virus across most of the Unites States is usually in early to mid-November (MMWR 2010;59:230-3).
Dr. Denise Bratcher and I looked at 10 RSV seasons in our institution, and the average onset was indeed Nov. 5 (except in one season when disease began in mid-January). Although there is some season-to-season variability, 2010 was a remarkably slow year for us in terms of RSV disease. Could prevention of influenza with wide scale use of influenza vaccine be impacting RSV rates? I think this is possible, and it will need to be monitored.
• Judicious use of antibiotics will be front and center in the office setting. Practitioners will increasingly be scrutinizing their use of antibiotics to ensure appropriate use by making the correct diagnosis and using the most narrow-spectrum efficacious drug available.
If you want to evaluate antibiotic use in your practice, start with streptococcal pharyngitis. Ensure that you are doing streptococcal testing in the appropriate patient, using amoxicillin as your first-line drug and determining who has a valid penicillin allergy and really requires an alternative agent. Of those who self-report a history of allergy, 90% are not allergic (JAMA 2001;285:2498-505). Taking a careful history of the exact reaction to penicillin is the easiest approach to the exclusion of true penicillin allergy.
• No more tuberculin skin testing in patients older than 5 years? Interferon-based tuberculin testing (a simple, albeit expensive, blood test) has proved especially valuable for the older patient who has either just come to the United States (and previously received BCG vaccine), has returned from traveling overseas to a TB-endemic country, or is beginning work in a health care field.
There is a significant upside to these new tests, although I suspect we will learn more as they become routine and are used on a large scale for the evaluation of health care personnel. However, they have produced indeterminate results in a small subset of health workers. Most have no risk factors for TB, but the indeterminate result engenders considerable angst and additional testing in some cases. As we learn more about the reliability of such tests as a population-screening tool, I suspect we will see additional recommendations.
• Is MRSA going away? It seems that we are seeing fewer children presenting to our emergency department with skin and soft-tissue abscesses, and fewer patients presenting to our infectious disease clinic with recurrent infection. It is hard to say whether this observation is real or imagined, or if practitioners are just getting used to doing the evaluation and treatment of such patients themselves. Certainly the number of children we treat for more serious skeletal infection does not seem to be decreasing. The evidence-based MRSA-management guidelines from IDSA (Infectious Disease Society of America) – which will cover everything from neonatal pustulosis to invasive infection – should be out soon. They are worth the read, all 105 pages of them.