Journal Club
In this feature, a panel of IDSA members identifies and critiques important new studies in the current literature that have a significant impact on the practice of infectious diseases medicine.
- Integrated Stepped Treatment for Alcohol Use Disorder in People Living with HIV
- Atypically Manifested Bacteremia and Mortality in the Elderly
Click here for the previous edition of Journal Club. For a review of other recent research in the infectious diseases literature, see “In the Literature,” by Stanley Deresinski, MD, FIDSA, in each issue of Clinical Infectious Diseases.
Integrated Stepped Treatment for Alcohol Use Disorder in People Living with HIV
Review by Lauren Richey, MD, MPH, FIDSA
Alcohol use disorder causes significant morbidity and mortality among people living with HIV, yet integrated treatment within HIV clinics that includes both medications and counseling is rarely available. A recent Lancet HIV study tested an integrated stepped approach to treating this disorder within five Veterans Affairs HIV clinics. Adults living with HIV who met criteria for alcohol use disorder on their yearly AUDIT-C screen were invited to participate. They were randomized to the integrated stepped alcohol treatment (ISAT) or treatment as usual (TAU), which entailed referral to substance abuse treatment services. As this was an effectiveness trial, recruited patients were not seeking treatment or incentivized to attend any of the treatment sessions.
The ISAT interventions included three steps; the first was addiction physician management with a focus on alcohol treatment medications, consisting of eight sessions over 24 weeks. At week 4, patients with heavy drinking (five drinks per day for men) in the past 14 days were stepped up to four additional sessions of motivational enhancement therapy provided by a psychologist. At week 12, patients with continued heavy drinking were referred for a higher level of addiction treatment (intensive outpatient or inpatient treatment). The primary outcome was drinks per week over the past 30 days at week 24.
One hundred and twenty-eight patients were randomly assigned. For the primary outcome, ISAT participants averaged 10.4 drinks per week, and TAU participants averaged 15.6, although this difference was not statistically significant. ISAT participants were significantly more likely to receive alcohol treatment medicines at weeks 4 and 24. Session attendance varied from as high as 65 percent for the first to 7 percent for the last. Adequate attendance, defined as 30 percent or more of the sessions, resulted in a statistical decrease in drinks per week at week 24 (7.7 vs 15.6).
Overall the intervention resulted in increased receipt of medications and counseling for alcohol use disorder as well as formal alcohol treatment services. Results were improved among patients attending the sessions. This study shows that integrated alcohol treatment can result in increased use of cessation medicines and addiction treatment, however, more work needs to be done to improve adherence to the treatment sessions.
(Edelman et al. Lancet HIV. Published online: May 17, 2019.)
Atypically Manifested Bacteremia and Mortality in the Elderly
Reviewed by Michael T. Melia, MD
Elderly patients are less likely than younger patients to exhibit typical signs and symptoms of infection, and bacteremia has been associated with greater mortality risk in older adults. In a recent manuscript in The American Journal of Medicine, the authors investigated whether atypical manifestations of bacteremia in patients ≥ 75 years of age are associated with greater mortality risk.
Investigators undertook a prospective, observational study of consecutive bacteremic patients at two French hospitals. “Typical” bacteremia included temperature ≥ 38.3°C or < 36°C, chills, or systolic blood pressure < 90 mm Hg. If none of these signs was present, the bacteremia was “atypical.” Mean patient age was 85.4 ± 5.8 years; 47 percent were women. Most (80.8 percent) patients lived at home. Assistance from others was common; 69.7 percent had domestic help.
Of the 151 patients, 119 (78.8 percent) had typical bacteremia, and 32 (21.2 percent) atypical. The majority (106, 65.0 percent) of episodes were caused by Gram-negative pathogens. Cumulative day 7, 30, and 90 mortality rates were 7.9, 22.0, and 40.0 percent, respectively. After adjusting for potential prognostic factors, atypical bacteremia was associated with death at days 7 (odds ratio 4.46, 95 percent confidence interval [CI] 1.04-19.24) and 90 (odds ratio 3.76, 95 percent CI 1.30-10.92). There were no significant differences between time of blood culture collection and initiation of antibiotic therapy between patients with typical and atypical infection (30.4 versus 18.2 hours, P = 0.06). On multivariate analysis, patients with atypical bacteremia were more likely to be diabetic and have Staphylococcus aureus as the culprit pathogen.
The finding that bacteremia is associated with increased mortality is neither novel nor surprising. What is interesting about this manuscript is the finding that patients with Staphylococcus aureus bacteremia were more likely to have atypical presentations, arguing against the commonly-heard mantra, “The patient would be sicker if this were all due to Staph.” The study also provides a useful reminder of the poor prognosis associated with bacteremia in older adults.
(Hyernard et al. Am J Med. Published online: June 1, 2019. )