The 2014 Hit Parade: Infectious Disease Stories of the Year

John Bartlett's Annual Review

John G. Bartlett, MD


December 09, 2014

In This Article

Epidemics, C difficile, and More


We have experienced an "epidemic of epidemics." One particularly worrisome epidemic is infection with enterovirus D68, which causes severe upper respiratory infections in children (> 1100 cases in 47 states), and enterovirus 71, which causes a relatively rare but serious polio-like syndrome (68 reported cases).[17,18]

Another newly experienced epidemic is Chikungunya, with more than 800,000 cases in Caribbean countries; 6600 cases in US travelers; and some endemic transmissions in Florida, indicating that it will probably be endemic in some southern states, especially with global warming.[19] This bad virus leads to severe arthralgic symptoms that can last months. There is no treatment; prevention is mosquito control.

Stool Transplant for C difficile Infection

Stool transplant has been proven effective for relapsing C difficile infection. The procedure has received much recent attention from the lay press as well as the FDA, when the agency decided that stool used in this fashion is a drug and under their control. Also of interest is the recent commercial source of screened specimens through OpenBiome ($250 per treatment) and the use of orally administered capsules.[20]

It now appears that stool transplantation is the most effective method to treat the patient with multiple relapses (the current IDSA guidelines recommend considering this approach after at least two relapses), and no significant differences in outcome have been demonstrated for specimens inserted by mouth, endoscope, or enema.[20]


This $173 million annually National Institutes of Health Human Microbiome Project is now beginning to deliver. Not much has yet been translated to practical applications, but three points are of possible interest:

A large series of elegant studies of cardiovascular disease show that lecithin (steak and eggs) consumption by human volunteers results in conversion by gut flora to products that promote atherosclerosis, and that this pattern can be reversed with antibiotics.[21] The effect is short-lived, owing to gut overgrowth by resistant bacteria.

Antibiotics appear to promote obesity, an observation that may dissuade some from antibiotic abuse. This is the reason that 80% of antibiotic use in the United States is in farming—the cows, pigs, and chickens get fatter.[7]

The work of Dickson and colleagues[22] on the lung microbiome indicates that standard teaching that the lower airways are sterile is erroneous. The lung microbiome extends from the nares to the alveoli, and "lung dysbiosis" may account for some acute exacerbations of chronic bronchitis.

Nosocomial Infections

The CMS approach to monitoring efforts to prevent healthcare-associated infections has changed. Previous criteria were process-based: for example, the "6-hour rule," which specified that the first dose of antibiotics should be administered to patients in the emergency department with community-acquired pneumonia within 6 hours of registration.

That rule is now gone, and systems of monitoring and payment are now tied to outcomes, with five major targets: ventilator-associated pneumonia, central line bacteremia, surgical-site infection, C difficile infection, and catheter-associated urinary tract infection (CAUTI). Each of these infections, except CAUTI, costs an average of $11,285-$45,814 per case, and collectively they account for about 80% of the 23,000 yearly deaths attributed to nosocomial infections in US hospitals.[8,23] Targeting these healthcare-associated infections is part of the effort to "save lives and money," and penalties will be reflected in hospital reimbursements from the major payer: CMS.


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