COMMENTARY

Auwaerter's Highlights From IDWeek 2019

Paul G. Auwaerter, MD

Disclosures

November 01, 2019

This transcript has been edited for clarity.

Hello. This is Paul Auwaerter, speaking for Medscape Infectious Diseases, at the Johns Hopkins University School of Medicine. I'd like to speak about four topics from IDWeek. They're quite random, but they impressed me with some useful messages.

Of course, there was a wealth of exciting developments and it's not possible to cover everything in only a few minutes. These are certainly biased and represent [my] interests that I thought might be helpful to those who didn't attend or hadn't made all of the sessions.

From Outbreaks to -Omics

First, to kick off the meeting, there was a high-level plenary set of talks by Francis Collins, director of the National Institutes of Health, and Pardis Sabeti, who is at the T.H. Chan School of Public Health at Harvard University. I think both utilize some of the exciting developments in the -omics revolution, specifically some of the genomics with metagenetic sequencing and the technologies that, as Francis Collins pointed out, allowed the cost of sequencing the whole human genome to fall from $100 million to $500—and, no doubt, it will fall further.

These techniques have led to more precise definitions of strains and the ability to follow outbreaks. Examples have included the Lassa fever outbreak, which was initially thought to have human-to-human spread in West Africa but instead was traced to the rodent population. Public health officials were able to give the proper messages and implement rodent control to staunch the Lassa fever outbreak.

It was also very helpful in tracing contacts in the Ebola outbreak in West Africa, to try to understand the spread and to help prevent spread into urban locations elsewhere on the continent.

Last, a more local example is at the National Institutes of Health, where an outbreak in the clinical building of a resistant Klebsiella was traced epidemiologically by the infection control group and Tara Palmore [and Julie Segre], with the use of such precise genetic analyses of the organisms.

CRISPR-Cas technologies can introduce genetic material signals and others that can advance a number of approaches to both treatment and control of infectious diseases. I think there will be much more excitement in this area in future years.

The Resurgence of Syphilis

Gail Bolan from the Centers for Disease Control and Prevention spoke about sexually transmitted diseases. For those who work in cities, it's no surprise that syphilis has had a great resurgence since the year 2000, which was the low point in the United States.

Increases are probably due to many factors, including social dynamics, decreased core public health infrastructure funding, the availability of PrEP (pre-exposure prophylaxis)—which may have led to benefits in terms of reducing the spread of HIV but have perhaps allowed other STDs that are not immediately life-threatening to spread—and testing difficulties, especially in syphilis, where many people are not yet completely aware of the testing algorithms and what they mean.

A 270% rise in congenital syphilis has occurred as a result. Also, some of the techniques borrowed from elsewhere in terms of understanding social networks have been very helpful in improving understanding of spread and the impact of the disease, and notification of sexual partners. I think these are things that public health will certainly help and may even reach further back into community practice settings to help patients prevent spread to others.

Influenza

Last year, IDSA (Infectious Diseases Society of America) had a guideline for influenza prevention and treatment. Meagan Fitzpatrick and Kathleen Neuzil from the influenza center at the University of Maryland made some very strong arguments that influenza really is one of the most serious infections that occur annually, resulting in many deaths, hospitalizations, and loss of work. These are all things that most infectious disease physicians understand well.

It's important to note that the influenza vaccine has received some bad press in the sense that the degree of coverage and efficacy in the past few years has been in the 40%-50% range, though sometimes lower or as high as 60%. Although it may not be 100% protective, Meagan Fitzpatrick made the point that if you use mathematical models where an influenza vaccine might have 43% coverage in terms of vulnerable populations in the United States and the vaccine has merely 20% efficacy—which is not very good at all—this would still prevent 21 million infections, 130,000 hospitalizations, and 62,000 deaths.

The most effective transmitters of influenza are children aged 5-19 and adults in the 30-39 years age range. Effective immunization in these areas, even with a vaccine that's not perfect, still has dramatic health benefits. This is an important message that we can convey to our patients, especially in primary care or to those who may be vaccine hesitant.

There are increasing data that have shown benefit in the over-65-years population from the high-dose influenza vaccine in terms of being more effective, although any vaccine is better than none if patients cannot get the high-dose vaccine. Other data suggest that recombinant vaccines for influenza may be more effective than egg-based strategies, so this may be something to consider as we look to additional developments.

Of course, we need better influenza vaccines. A universal vaccine would be fabulous, and there will also be some growing interest in new antivirals. I think in 1-2 years we will have more information about potential combination strategies in antivirals for influenza.

A Spirited Debate on Treating Staphylococcal Bacteremia

Patty Wright from Vanderbilt and Vance Fowler from Duke University School of Medicine gave quite spirited pro and con debates about whether uncomplicated staphylococcal bacteremia can be treated with oral drugs. At the end of the day, both decided that it could be possible if you had uncomplicated S aureus bacteremia, although Dr Fowler made the appropriate point that this is very difficult to find because most patients have complications or comorbidities.

If you do have a patient who is relatively healthy, has no obvious sores, and clears the bacteremia, there could be a role, but it's devastating to have consequences of staph return and perhaps develop problems such as endocarditis, mycotic aneurysms, epidural abscess, and so on.

I think the audience was persuaded that although there could be opportunities in the future, until better data show us otherwise, intravenous therapy is probably here to stay for most cases of S aureus bacteremia.

These were just a few things I took interest in at IDWeek 2019. I hope you find it interesting. If you don't attend IDWeek, it's always great to go and see colleagues.

I personally always go to sessions that I wouldn't normally attend for my own work in tickborne disease, to better understand some aspects related to general infectious diseases, HIV, transplant oncology, and public health. Thanks very much for listening.

Paul G. Auwaerter, MD, is an infectious diseases specialist at the Johns Hopkins School of Medicine, with expertise in tickborne illnesses. He has published more than 100 original manuscripts, 30 textbook chapters, and four books, and has been a Medscape contributor since 2008.

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