Category Archives: Infections

Seasonal Influenza Flu – How often do side effects occur?

Lately I have been approached several times about the incidence of fever post vaccination. Data suggests that it is a rare and benign issue at best. In a placebo controlled trials it was no more frequent than in the control group.

Placebo-controlled trials demonstrated that among older persons and healthy young adults, administration of TIV is not associated with higher rates for systemic symptoms

Therefore the presence of low grade fever or the concern for fever should not be a contraindication for vaccination.

Also of interest is the recurring concern for Guillian-barre. In this series there were no cases in over 4 million doses administered.

This is link to the 2010-11 summary of the reported adverse reactions to influenza vaccination.

Influenza vaccination reduces MI and stroke in elderly- a published study

Just another reason to have the elderly vaccinated every year with Influenza vaccine along with appropriate 23-valent pneumococcal vaccine (when is pneumovax given?).

This prospective study in Hong Kong observed readmission rates among 36,000 elderly patients. The study found statistically significant decrease in the number of deaths, pneumonia, strokes and myocardial infarctions among the studied population.

One may ask “What does a vaccine have to do with prevention of stroke or MI?”. The reasons are that this population is at risk for these stressful infections. The burden of these conditions (sepsis) can further stress a compromised elderly patient and can “push” them into a stroke or and MI. These vaccine may not even completely prevent the illnesses themselves but by reducing the stress of the illness can go a long way in reducing morbidity and mortality from other conditions such as MI and strokes.

Also of note that very few if any “side effects” that are often cited in the lay media were seen. If there were more side effects it should have been seen in the higher hospitalization rate. In fact the vaccinated group had lower death and hospitalization rates.

For more information read the reference:

1. Hung, Ivan F N, Angela Y M Leung, Daniel W S Chu, Doris Leung, Terence Cheung, Chi-Kuen Chan, Cindy L K Lam, et al. 2010. Prevention of acute myocardial infarction and stroke among elderly persons by dual pneumococcal and influenza vaccination: a prospective cohort study. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 51, no. 9 (November): 1007-16. doi:10.1086/656587. http://www.ncbi.nlm.nih.gov/pubmed/20887208.

Drug Safety and Availability > FDA Drug Safety Communication: Increased risk of death with Tygacil (tigecycline) compared to other antibiotics used to treat similar infections

Drug Safety and Availability > FDA Drug Safety Communication: Increased risk of death with Tygacil (tigecycline) compared to other antibiotics used to treat similar infections.

A must read notice published by the FDA. It appears that there is a trend towards statistical inferiority of tigecycline when compared to standard therapy with regards to ventilator associated pneumonia. It is also notable that it did not show better outcomes in any category when compared to standard therapy.

This by no means indicates that tigecycline is an inferior drug but merely that it is about as good as other standard therapy on the market. Yes; it is a broader coverage drug similar to imipenem. But contrary to popular belief among my fellow colleagues, broader coverage drug not always equate with better drug or even a better outcome.

Keeping the coverage appropriate to the condition being treated using a drug that achieves appropriate serum levels at the site of the infection under the conditions currently present (pH, low O2 concentrations, neutropenia) will achieve optimal results.

No increase in Gullain Barre incidence with H1N1 2009 vaccination-says CDC

The preliminary results from the last H1N1 2009 vaccination season are in. So far no excess cases have been reported with the vaccine when compared to previous vaccination years. More people developed Guillain Barre without vaccination than with the vaccine (total numbers). The rate of cases per 100,000 population were slightly greater in those with vaccination than those without vaccination (0.8 per 100,000 persons greater). These results are consistent with the expected safety profile as seen in previous years.

No statistically significant association between GBS and 2009 H1N1 vaccination has been seen

More information on the history of Guillain Barre and vaccinations

Preliminary Results: Surveillance for Guillain-Barr√© Syndrome After Receipt of Influenza A H1N1 2009 Monovalent Vaccine — United States, 2009–2010.

IDSA and SHEA have new guidelines on clostridium difficile

Clostridium difficile has gone from being just a nuisance or an everyday major problem today. Research has been ongoing to look for better treatment plans and strategies for dealing with relapses. The Infectious Disease Society of America (IDSA) and The Society for for Healthcare Epidemiology of America (SHEA) have released updated guidelines in the May 2010 issue of Infection Control and Hospital Epidemiology.

The guidelines are helpful in reviewing the current state of the art with regards to treating this problem. With the number of remedies and regimens it is important to decide what works and what does not have the science to back it up.
A few points to emphasize from this document that are relevant for day to day practice.

1. Stools should not be checked in asymptomatic patients: This sounds simple enough but unfortunately I get a call almost every week from the lab asking what they should do with a solid stool specimen sent to them for clostridium difficile assay. Stools will remain toxin positive and PCR positive in patients successfully treated for months. There is no value in retesting stools.

2. Repeat testing of stool for toxin during the same episode of diarrhea should not be done.

3. Gloves AND gowns are recommended for all healthcare workers and visitors. There is good evidence that this does reduce nosocomial transmission. This has remained standard practice but unfortunately is often the least adhered to.

4. Private rooms are preferred but if private rooms are not available, cohorting is acceptable with a dedicated commode for each patient.

5. Chlorine containing cleaning agents should be used to reduce spore transmission, there was no recommendations with regards to changing curtains etc.

6. Environmental culture for clostridium difficile is not recommended.

7. Probiotics: Primary use of probiotics to prevent clostridium difficile is not recommended. There are no trials that support the theory that it will prevent clostridium difficile.

8. Metronidazole still remains the first line of therapy it is also recommended for relapse. But should not be used for long term therapy due to risk of neurotoxicity.

9. Treatment of greater than two recurrences can be done with vancomycin with either tapering or pulse treatment. Jury still appears to be out with clear guidelines on what should be done with frequent relapsers.

10. Though is is still very frequently used there is no evidence that use of rifampin or cholestyramine reduces the risk of future recurrence. In fact cholestyramine may delay recovery as it bind to the antibiotics in addition to the toxin.

11. Some practitioners use rifaxamin for the treatment of clostridium difficile with PO vancomycin. The only study on this was small study of 8 patients, where rifaxamin was used immediately after finishing the course of vancomycin it reduced the number of future relapses in 7 of the patients. A very small study and difficult to base widespread use of the agent based on this alone.

12. There is no compelling evidence that use of probiotics are useful in prevention or treatment of clostridium difficile. These agents are widely used with the general feeling that it “cannot hurt”. I am not sure that there is any evidence of this either. In fact there are cases of fungemia due to this.

There is ongoing study in the area of use of immunoglobulin for the prevention and treatment of refractory clostridium difficile. Widespread use cannot still be advocated.

Clostridium difficile remains an important disease and there remains a need for better understanding of the treatment especially in those with frequent relapses and refractory disease.

Prevention of infections aboard cruise ships

Spring break is here many Americans will go on vacation and some will take a cruise.

Cruises have become increasingly popular over the years as a form of vacation. Cruise lines have responded to the increased demand by adding larger ships to meet the demand. On the darker side cruise ships have been plagues by risk of infection outbreaks due to the over crowding aboard ships. The cruise lines have appropriately responded to this fear of outbreaks by instituting appropriate precautions without interfering with the vacation mood. In fact we just got back from our own spring break cruise in the Caribbean sea on Royal Caribbean’s Oasis of the Seas, their newest and currently largest cruise ship. I noticed several precautions since the last time we took a cruise several years ago. (BTW:The cruise was fabulous. I highly recommend it!)

From an infectious disease perspective I not only have to congratulate the cruise line on a phenomenal job with the accommodations and entertainment but also the attention to infection control issues.

Most dreaded infection issues are the ones transmitted by either droplet leading to respiratory infections or by contact leading to diarrheal illnesses like norovirus outbreaks that often get media attention that the cruise lines dread.

With regard to respiratory infections the few obvious changes in newer ships is the larger airspaces in common areas. The dining halls, the theaters and the promenade all had higher ceilings than on older cruise ships allowing for greater air exchanges. There was information posted daily about respiratory infections, H1N1 precautions etc.

Diarrheal outbreaks can quickly turn a vacation cruise into a nightmare adventure at sea, especially with the greater number of older persons on cruise ships who may be very susceptible to become very ill. If an effort to control this the cruise ships installed waterless hand sanitizer at the entry points to the ship and to the dining halls. They had staff reminding guests to use them. I was pleasantly surprised to see (non scientific observation) that the compliance rate among passengers was very high. I did not see the opposition from anyone that usually accompanies this kind of added inconvenience. Children, adults all seemed to participate and understand why this is needed. Of course the usual buffet controls were also in place such as sneeze guards, single use of plates and flatware etc.

It is very easy for corporations to go overboard (pun intended) with precautions in a knee jerk effort to control outbreaks at sea. These kind of measures prove to be counter productive in the long run. They create more inconvenience, greater cost, greater customer dissatisfaction without much hard science that they are getting anything for it. I did not see any of these problems on this particular cruise. Whoever is advising them is doing a good job.

All these precautions go a long way in making a successful vacation.
Hats off to Royal Caribbean cruise lines for the effort. We do appreciate it.

Successful vaccination season at our hospital

We have almost completed data collection from this years influenza vaccination season. participation has been higher among healthcare associates when compared to previous seasons at 68%. Despite the improvements it is still too low to see the true benefit of herd immunity.
The most frequent reason to refuse inoculation is fear of complications. Of the 1900 doses given this year there were only 8 reported complication. Sounds like a lot at first but 7 of these were merely pain at the site of injection, yes we tracked even issues as minor as that. The remaining one felt faint and was taken to the ER only to be released back to work two hours later. No one called in sick in the subsequent weeks related to the vaccination. And there was no Gullian barre either!
Overall a successful vaccination season but hope to do better next year.

CDC releases H1N1 2009 Monovalent safety data

The Centers for disease control (CDC) released safety data on the current season H1N1 monovalent vaccine. Based on data collected a total of 82 adverse events were reported per million doses. This is in comparison to 47 cases per million doses seen in the seasonal influenza vaccine. At first this may seem much higher but the proportion of serious adverse effects was about the same.

Of the 3,783 adverse events reported in the 438,376 doses monitored, 204 adverse effects were categorized as serious (ending in death, hospitalization, disability) similarly 283 serious events were reported for seasonal influenza vaccination.

Of the 13 deaths that were reported nine had underlying illneses. One death occurred after a motor vehicle accident. There were no common conditions or causes of death in the 13 deaths.

With regards to Guillain Barre there were a total of twelve possible cases were reported. Of these only 4 actually met the definition of Guillain Barre.

Overall the number of adverse effects appear to be few and most of them of minor consequences. This is similar to the data published in the New England Journal of Medicine earlier. There are of course limitations in the data especially not being able to detect very rare associations but they will be after all “very rare”.

The healthcare community especially has done a remarkable job with H1N1 given the short time available to mount a response to the impending threat.

source MMWR

Influenza cases finally dropping- an update

The past few weeks are finally beginning to show a declining trend in the number of cases with influenza like illness (ILI) presenting to the ER . The last wave appears to have peaked the week of Oct 12-18 when we saw about 17% of visits to the ER having an ILI. The week of Nov 9-15 had 6% of visits with ILI. This week may be even lower. This is a welcome relief from the peak levels of mid Oct.

Nationally the same declining trend appears to be taking place with fewer states reporting active H1N1.

Does this mean that the season is over or that vaccination is not necessary? The answer is no to both.

Influenza does come in “waves”. We had a wave over spring break and another in Oct. We may get another wave in the next month or so. Having enough herd immunity through vaccination can minimize the wave by decreasing the number of susceptible individuals in the community. Remember the vaccination is of greater benefit for the community than for the individual. We all go a long way in protecting those who cannot protect themselves. So those who have not gotten their vaccinations should still do so.

On a side note; We are continuing to have intensive care hospitalizations due to influenza related complications. This week we have two otherwise healthy individuals between the ages of 45-50 with severe pneumonia related complication in the ICU. Both cases have been ill for over a month before seeking medical help. Both would have been infected during the last wave of influenza. Neither of them were vaccinated.

Remember even though the wave may have past. There are still people that may still be suffering from delayed complications.