412 - COVID “Booster”, Choosing Wisely Derm, Short-Course Antibiotics
Take 3 – Practical Practice Pointers©
From the Centers for Disease Control and Prevention
1) Additional Doses of COVID-19 mRNA Vaccines
The Advisory Committee on Immunization Practices recommended last week that people who are moderately to severely immunocompromised (up to about 2.7% of the US population) receive a third dose of an mRNA vaccine (Pfizer or Moderna) to best protect them against COVID-19.
This recommendation comes after some studies have suggested that, in outbreak situations, vaccinated but immunocompromised individuals are more likely to be hospitalized with COVID-19 than those with well-functioning immune systems who are vaccinated. These folks are also more likely to spread the virus to close contacts when they become infected. Other small studies in different immunocompromised populations have shown that a third dose results in antibody production in about 33-50% of those who had not produced any antibody in response to the initial series.
Those considered moderately-to-severely immunocompromised are:
- Receiving active cancer treatment for tumors or cancers of the blood
- Received an organ transplant and are taking immune suppressant medicine Received a stem cell transplant within the last 2 years or are taking medicine to suppress the immune system
- Moderate or severe primary immunodeficiency (such as DiGeorge syndrome, Wiskott-Aldrich syndrome)
- Advanced or untreated HIV infection
- Active treatment with high-dose corticosteroids or other drugs that may suppress your immune response
- For those here at Carilion Clinic, our infectious disease consultants have added some criteria and have provided some more specificity:
- Immunosuppressing medications: Anti-TNF therapy, JAK inhibitor, Interleukin inhibitors, B‑cell depleting therapies. This include, but are not limited to, rituximab (Rituxan); secukinumab (Cosentyx); dupilumab (Dupixent); tofacitinib (Xeljanz); infliximab (Remicade); and adalimumab (Humira).
- Corticosteroid doses of the equivalent of 10 mg of prednisone per day for three weeks or greater.
- Patients receiving hemodialysis
Antibody testing has not been shown to be helpful to prospectively understand immunity to COVID-19, so it is not recommended to determine the need for additional doses.
Offer another mRNA vaccine 4 weeks after the second dose of an mRNA vaccine series. It is acceptable to switch products if necessary (e.g., a Pfizer third dose is OK if the patient got a primary Moderna series). The side effects are anticipated to be like second-dose side effects. In the studies, there were no serious adverse events attributable to either vaccine reactions or transplantation rejection episodes.
There is not yet a recommendation for an additional dose for patients who have gotten a Janssen (J&J) vaccine. There are no recommendations for any other group to receive additional doses or for anyone to have more than 3 vaccines currently. To date, the vaccines do well in covering the variants up through delta, but this is being closely monitored.
It will be helpful in implementing this recommendation that the CDC listed specific criteria for the definition of moderate to severe immune compromise. Biologic therapies for autoimmune diseases differ in their immune suppression effects – advise patients to discuss these with their prescribing clinician. This is a recommendation without a lot of evidence of effectiveness but is being made in response to an epidemiologic finding of breakthrough infections in these populations. Watch for more revisions to vaccine recommendations as the pandemic continues to evolve.
- CDC. COVID-19 Vaccines for Moderately to Severely Immunocompromised People [Internet]. CDC. 2021 [cited 2021 Aug 16]. Link
A Twofer From Choosing Wisely and the AAP Section on Dermatology
2) Tinea Capitis, Tinea Corporis, Candida, and Diaper Dermatitis
Do not treat tinea capitis with topical medications only:
Tinea capitis, a dermatophyte infection of the hair shafts of the scalp, is treated with antifungal agents. Topical treatments cannot penetrate the hair shaft itself, which is where the infection lies; thus, monotherapy with topical medications is insufficient to effectively treat the infection. This insufficient treatment can lead to increased health care costs resulting from multiple visits and the prescribing of ineffective medications.
For this reason, when tinea capitis is suspected or is diagnosed, systemic treatment is warranted, most commonly with off-label griseofulvin or terbinafine. Terbinafine is effective for most types of tinea capitis and is less expensive than griseofulvin with improved compliance because of a shorter required course of treatment. Topical treatments such as ketoconazole shampoo and selenium sulfide shampoo may be used adjunctively to decrease carriage of viable spores, thus possibly decreasing the time to cure and decreasing shedding of the organism, which decreases risk of transmission of infection to other individuals.
Although combination topical antifungal/corticosteroids have been approved for the treatment of tinea corporis, candidiasis, and diaper dermatitis, we recommend against use of these agents.
Many clinicians are unaware that the combination products contain a relatively high-potency topical steroid. For treatment of tinea corporis, the application of a topical antifungal agent alone is recommended. If symptoms such as severe pruritus require concomitant application of a topical steroid, a separate low-potency agent can be prescribed, allowing for a tapering course that should be limited to less than 2 weeks. A separate topical antifungal cream can be continued longer until the infection is cleared. This will reduce the risk of systemic absorption of the topical steroid.
Combination products are often used for treatment of diaper dermatitis. In most patients, diaper dermatitis is an irritant contact dermatitis from stool that will usually respond to barrier diaper creams/ointments alone. Combination products, if applied with every diaper change, can result in skin atrophy, striae, and systemic absorption of the relatively high-potency topical steroids. It is instead recommended that barrier products be applied with every diaper change in this circumstance and a second low-potency topical steroid be applied, as needed, no more than twice a day and tapered as soon at the dermatitis is under control.
These provide a good reminder regarding common pediatric problems for which, depending on where and when we trained, we may have developed varying practices. The use of combination medications which include steroids is particularly important to note, given the potential harm that can be caused by these higher potency steroids.
Choosing Wisely and AAP Section on Dermatology. Released 27 January 2021. Link
From the American College of Physicians (ACP)
3) Appropriate Use of Short-Course Antibiotics in Common Infections
Antimicrobial overuse is a major health care issue that contributes to antibiotic resistance and causes unnecessary side-effects and potential allergic reactions. Such overuse includes unnecessarily long durations of antibiotic therapy in patients with common bacterial infections, such as acute bronchitis with chronic obstructive pulmonary disease (COPD) exacerbation, community-acquired pneumonia (CAP), urinary tract infections (UTIs), and cellulitis. It is estimated that up to 1/3 of outpatient antibiotic prescriptions in the US are considered unnecessary and/are continued for too long, particularly for bronchitis and sinusitis. The American College of Physicians recent published guidance for the appropriate use of antibiotics in common ambulatory infections. Recommendations include:
- Limit antibiotic treatment duration to 5 days when managing patients with COPD exacerbations and acute uncomplicated bronchitis who have clinical signs of a bacterial infection (presence of increased sputum purulence in addition to increased dyspnea, and/or increased sputum volume. Antibiotic choice is based on the most common bacterial etiologies, which include Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. Recommended therapeutic agents include aminopenicillin with clavulanic acid, macrolides, and tetracyclines.
- Prescribe antibiotics for community-acquired pneumonia for a minimum of 5 days. Extension of therapy after 5 days of antibiotics should be guided by validated measures of clinical stability, which include resolution of vital sign abnormalities, ability to eat, and normal mentation. Antibiotic choice is based on the most common bacterial etiologies, which include S pneumoniae, H influenzae, Mycoplasma pneumoniae, and Staphylococcus aureus, along with atypical pathogens (eg, Legionella species). Recommended therapeutic agents include amoxicillin, doxycycline, or a macrolide in healthy adults or, in patients with comorbidities, a beta-lactam with a macrolide or a respiratory fluoroquinolone.
- In women with uncomplicated bacterial cystitis, prescribe short-course antibiotics with either nitrofurantoin for 5 days, trimethoprim–sulfamethoxazole (TMP–SMZ) for 3 days, or fosfomycin as a single dose. In men and women with uncomplicated pyelonephritis, prescribe short-course therapy either with fluoroquinolones (5 to 7 days) or TMP–SMZ (14 days) based on antibiotic susceptibility.
- In patients with nonpurulent cellulitis, use a 5- to 6-day course of antibiotics active against streptococci (eg, cephalosporin, penicillin, clindamycin), particularly for patients able to self-monitor and who have close follow-up with primary care. These recommendations do not apply to patients with purulent cellulitis (eg, abscesses, furuncles, carbuncles) or suspected infection with MRSA.
These provide good reminders for common infections. There is often the belief that higher doses or longer duration is better, but there is now plentiful evidence that this is not the case. Remember as well that antibiotic therapy is generally not indicated for inflamed epidermal inclusion cysts and venous stasis dermatitis (see 2nd and 3rd references).
- Lee RA et al. Appropriate Use of Short-Course Antibiotics in Common Infections: Best Practice Advice From the ACP. Ann Intern Med. 2021 Apr 6. Link.
- Choosing Wisely and the American Academy of Dermatology. 19 Feb 2015. Link
- Choosing Wisely and the Infectious Disease Society of America. 23 Feb 2015. Link
Mark and John
Carilion Clinic Department of Family and Community Medicine
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