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lnfestious Disease High Value Care Recommendations The American College of Physicians, in collaboration with . Early localized Lyme disease usually presents within multiple other organizations, is engaged in a worldwide 4 weeks of infection and is characterizedby erythema initiative to promote the practice of High Value Care (HVC). migrans (Etvt) at the site of tick attachment; patients with The goals of the HVC initiative are to improve health care EM and a compatible exposure history do not require outcomes by providing care of proven benefit and reducing confirmatory laboratory testing and should receive oral costs by avoiding unnecessary and even harmful interven- doxycycline. tions. The initiative comprises several programs that inte- . Post-Lyme disease syndrome (fatigue, arthralgia, myalgia, grate the important concept of health care value (balancing and impairment of memory or cognition) can last for clinical benefit with costs and harms) for a given interven- years, even after appropriate treatment; prolonged anti- tion into a broad range of educational materials to address biotics are not effective in treating this condition. the needs of trainees, practicing physicians, and patients. . Urine culture is not recommended in womenwith uncomplicated cystitis but is indicated in pyelonephritis, HVC content has been integrated into MKSAP 19 in several complicated cystitis, recurrent urinary tract infections, important ways. MKSAP 19 includes HVC-identified key patients with multiple antibiotic allergies, and in patients points in the text, HVC-focused multiple-choice questions, with a suspected resistant organism. and, in MKSAP Digital, an HVC custom quiz. From the text and questions, we have generated the following list of HVC . Pyuria accompanying asymptomatic bacteriuria is not an indication for urine culture or antimicrobial treatment. recommendations that meet the definition below of high value care and bring us closer to our goal of improving . Urine culture with susceptibility testing is required in acute pyelonephritis before initiation of empiric therapy; patient outcomes while conserving finite resources. follow-up urine cultures are only indicated in pregnant High Value Care Recommendation: A recommendation to women. choose diagnostic and management strategies for patients . Imaging studies are only necessary in patients with in specific clinical situations that balance clinical benefit pyelonephritis and fever for more than72 hours, in per- with cost and harms with the goal of improving patient sistent bacteremia, or when complications are suspected. outcomes. . Screening for and treating asymptomatic bacteriuria before nonurologic surgical procedures is not recom- Below are the High Value Care Recommendations for the mended (see Item 49). Infectious Disease section of MKSAP 19. . In women with recurrent cystitis, self-treatment with a . Uninfected diabetic foot wounds should not be cultured first-line, short-course regimen (such as nitrofurantoin) or treated with antibiotics. is an appropriate initial strategr (see Item 36). . Diagnostic studies to identi$r a causative organism are o Test of cure is not recommended in patients with not routinely indicated in outpatients with community- Chlamgdia trachomaf is infection except in pregnancy; acquired pneumonia (CAP) but should be considered however, patients should be retested for possible repeat in non-ICU hospitalized patients when this information infection after 3 months or at their next medical visit. would change management; diagnostic studies should be . Because of its low cost and specificity, plain radiography performed in all patients admitted to the ICU with CAP. is recommended as an initial imaging test for suspected o Patients with community-acquired pneumonia requiring osteomyelitis; if radiography is negative, MRI, with and hospitalization can be treated with the standard inpatient without intravenous contrast, should be obtained. regimens regardless of a documented aspiration event . In patients with vertebral osteomyelitis and positive (see Item 7). blood cultures for a typical pathogen, bone biopsy is o Most patients with hospital-acquired pneumonia only generally not indicated (see Item 28). require treatment for 7 days; exceptions include patients . Oral antibiotics (such as doxycycline) with high bioavail- who have bacteremia, have a metastatic infection, show ability have been shown to be noninferior to intravenous slow response to therapy, are immunocompromised, or antibiotics for the management of osteomyelitis (see have pyogenic complications (see Item 107). Item 87). . In adults with community-acquired pneumonia whose . In patients with classic fever of unknown origin (fever symptoms have resolved within 5 to 7 days, routine >38.3'C [100.9 "F] for >3 weeks that remains undiag- follow-up chest imaging is usually not necessary. nosed after careful extensive evaluation and two visits in

lnfestious Disease High Value Care Recommendations The American College of Physicians, in collaboration with . Early localized Lyme disease usually presents within multiple other organizations, is engaged in a worldwide 4 weeks of infection and is characterizedby erythema initiative to promote the practice of High Value Care (HVC). migrans (Etvt) at the site of tick attachment; patients with The goals of the HVC initiative are to improve health care EM and a compatible exposure history do not require outcomes by providing care of proven benefit and reducing confirmatory laboratory testing and should receive oral costs by avoiding unnecessary and even harmful interven- doxycycline. tions. The initiative comprises several programs that inte- . Post-Lyme disease syndrome (fatigue, arthralgia, myalgia, grate the important concept of health care value (balancing and impairment of memory or cognition) can last for clinical benefit with costs and harms) for a given interven- years, even after appropriate treatment; prolonged anti- tion into a broad range of educational materials to address biotics are not effective in treating this condition. the needs of trainees, practicing physicians, and patients. . Urine culture is not recommended in womenwith uncomplicated cystitis but is indicated in pyelonephritis, HVC content has been integrated into MKSAP 19 in several complicated cystitis, recurrent urinary tract infections, important ways. MKSAP 19 includes HVC-identified key patients with multiple antibiotic allergies, and in patients points in the text, HVC-focused multiple-choice questions, with a suspected resistant organism. and, in MKSAP Digital, an HVC custom quiz. From the text and questions, we have generated the following list of HVC . Pyuria accompanying asymptomatic bacteriuria is not an indication for urine culture or antimicrobial treatment. recommendations that meet the definition below of high value care and bring us closer to our goal of improving . Urine culture with susceptibility testing is required in acute pyelonephritis before initiation of empiric therapy; patient outcomes while conserving finite resources. follow-up urine cultures are only indicated in pregnant High Value Care Recommendation: A recommendation to women. choose diagnostic and management strategies for patients . Imaging studies are only necessary in patients with in specific clinical situations that balance clinical benefit pyelonephritis and fever for more than72 hours, in per- with cost and harms with the goal of improving patient sistent bacteremia, or when complications are suspected. outcomes. . Screening for and treating asymptomatic bacteriuria before nonurologic surgical procedures is not recom- Below are the High Value Care Recommendations for the mended (see Item 49). Infectious Disease section of MKSAP 19. . In women with recurrent cystitis, self-treatment with a . Uninfected diabetic foot wounds should not be cultured first-line, short-course regimen (such as nitrofurantoin) or treated with antibiotics. is an appropriate initial strategr (see Item 36). . Diagnostic studies to identi$r a causative organism are o Test of cure is not recommended in patients with not routinely indicated in outpatients with community- Chlamgdia trachomaf is infection except in pregnancy; acquired pneumonia (CAP) but should be considered however, patients should be retested for possible repeat in non-ICU hospitalized patients when this information infection after 3 months or at their next medical visit. would change management; diagnostic studies should be . Because of its low cost and specificity, plain radiography performed in all patients admitted to the ICU with CAP. is recommended as an initial imaging test for suspected o Patients with community-acquired pneumonia requiring osteomyelitis; if radiography is negative, MRI, with and hospitalization can be treated with the standard inpatient without intravenous contrast, should be obtained. regimens regardless of a documented aspiration event . In patients with vertebral osteomyelitis and positive (see Item 7). blood cultures for a typical pathogen, bone biopsy is o Most patients with hospital-acquired pneumonia only generally not indicated (see Item 28). require treatment for 7 days; exceptions include patients . Oral antibiotics (such as doxycycline) with high bioavail- who have bacteremia, have a metastatic infection, show ability have been shown to be noninferior to intravenous slow response to therapy, are immunocompromised, or antibiotics for the management of osteomyelitis (see have pyogenic complications (see Item 107). Item 87). . In adults with community-acquired pneumonia whose . In patients with classic fever of unknown origin (fever symptoms have resolved within 5 to 7 days, routine >38.3'C [100.9 "F] for >3 weeks that remains undiag- follow-up chest imaging is usually not necessary. nosed after careful extensive evaluation and two visits in xilt

the ambulatory setting), no further testing or treatment . Hand hygiene is the foundation of infection prevention; is indicated (see ltem 67). the World Health Organization has identified fwe key hand . Fluid replacement is the mainstay of treatment for trav- hygiene moments (before touching a patient, before clean elers' diarrhea; azithromycin and fluoroquinolones are or aseptic procedure, after body fluid exposure risk after recommended only in severe disease. touching a patient, and after touching patient surroundings). . Most uncomplicated Salmonello infections in adults o Catheter-associated aqymptomatic bacteriuria is common younger than 50 ye:rs resolve within l week and require and generally does not require treatment. only supportive care; when empiric treatment is indi- . Candiduria in a patient with a catheter frequently rep- cated for those with more severe or invasive disease, resents colonization and rarely requires treatment. fluoroquinolones (such as ciprofloxacin) are most likely o Antimicrobial- or antiseptic-coated catheters have not to be effective. shor,rm benefit for short-terrn or long-term catheteriza- o Enterotoxigenic Escherichiq coliinfection is usually a tion, are more expensive, and, in some cases, cause more self-limited illness that resolves without treatment after discomfort for patients. approximately 4 days; hydration and empiric antibiotic . Reconfinnation of the diagnosis of herpes simplex virus therapy with fluoroquinolones, azithromycin, or rifaximin infection before treatment is not needed in the setting of are recommended in travelers when symptoms restrict a consistent clinical presentation (see Item 44). activities. . Avoiding unnecessaqr antibiotic use, simpliffing unnec€s- . Diarrhea caused by C-ampylobacterusually resolves sary oombination therapy, avoiding double anaerobic crov- spontaneously (see Item 57). erage, converting intravenous to oral agents, stneamtining . Prop$axis and immunization are preferred over treating de-escalation, and minimizing therapy duration are import- active infections after transplantation. ant components of antimicrobial stewardship programs.

the ambulatory setting), no further testing or treatment . Hand hygiene is the foundation of infection prevention; is indicated (see ltem 67). the World Health Organization has identified fwe key hand . Fluid replacement is the mainstay of treatment for trav- hygiene moments (before touching a patient, before clean elers' diarrhea; azithromycin and fluoroquinolones are or aseptic procedure, after body fluid exposure risk after recommended only in severe disease. touching a patient, and after touching patient surroundings). . Most uncomplicated Salmonello infections in adults o Catheter-associated aqymptomatic bacteriuria is common younger than 50 ye:rs resolve within l week and require and generally does not require treatment. only supportive care; when empiric treatment is indi- . Candiduria in a patient with a catheter frequently rep- cated for those with more severe or invasive disease, resents colonization and rarely requires treatment. fluoroquinolones (such as ciprofloxacin) are most likely o Antimicrobial- or antiseptic-coated catheters have not to be effective. shor,rm benefit for short-terrn or long-term catheteriza- o Enterotoxigenic Escherichiq coliinfection is usually a tion, are more expensive, and, in some cases, cause more self-limited illness that resolves without treatment after discomfort for patients. approximately 4 days; hydration and empiric antibiotic . Reconfinnation of the diagnosis of herpes simplex virus therapy with fluoroquinolones, azithromycin, or rifaximin infection before treatment is not needed in the setting of are recommended in travelers when symptoms restrict a consistent clinical presentation (see Item 44). activities. . Avoiding unnecessaqr antibiotic use, simpliffing unnec€s- . Diarrhea caused by C-ampylobacterusually resolves sary oombination therapy, avoiding double anaerobic crov- spontaneously (see Item 57). erage, converting intravenous to oral agents, stneamtining . Prop$axis and immunization are preferred over treating de-escalation, and minimizing therapy duration are import- active infections after transplantation. ant components of antimicrobial stewardship programs. xlY

lnfestious Disease Central Neruous System pharyngitis, maculopapular rash, and cough. A CSF lympho- cytic pleocytosis with normal glucose and mildly elevated lnfestions protein levels is typical (Table 1). Enterovirus PCR confirms the diagnosis. Treatment is supportive with a benign clinical Meningitis course. A positive Gram stain result for bacteria or yeast is seen in Herpesviruses can cause meningitis year round and only 5% of patients with community-acquired meningitis. include herpes simplex virus (HSV) types 1 and 2, varicella- Meningitis with a negative Gram stain result is a diagnostic zoster virus (VZV), cytomegalovirus, Epstein-Barr virus, and and management challenge because the differential diagno- human herpesvirus 6. Of the herpesviruses, HSV-2 is the most sis includes urgent treatable causes, such as bacterial or common cause of viral meningitis that can sometimes recur fungal meningitis. Bacterial cultures of cerebrospinal fluid (recurrent benign lymphocytic meningitis, also calted Mollaret (CSF) or blood are needed for antimicrobial sensitivity meningitis). ttre CSF findings resemble enteroviral meningitis. studies in suspected bacterial meningitis, but results are Outcomes for HSV-2 meningitis are generally favorable with- insufficiently timely to differentiate bacterial from viral out requiring acyclovir therapy. meningitis. In situations of clinical uncertainty, rapid diag- VZV can cause encephalitis, aseptic meningitis, myelitis, and nostic techniques such as polymerase chain reaction (PCR) a vasculitis presenting as a stroke. Vesicular lesions clue the diag-

Central Neruous System pharyngitis, maculopapular rash, and cough. A CSF lympho- cytic pleocytosis with normal glucose and mildly elevated lnfestions protein levels is typical (Table 1). Enterovirus PCR confirms the diagnosis. Treatment is supportive with a benign clinical Meningitis course. A positive Gram stain result for bacteria or yeast is seen in Herpesviruses can cause meningitis year round and only 5% of patients with community-acquired meningitis. include herpes simplex virus (HSV) types 1 and 2, varicella- Meningitis with a negative Gram stain result is a diagnostic zoster virus (VZV), cytomegalovirus, Epstein-Barr virus, and and management challenge because the differential diagno- human herpesvirus 6. Of the herpesviruses, HSV-2 is the most sis includes urgent treatable causes, such as bacterial or common cause of viral meningitis that can sometimes recur fungal meningitis. Bacterial cultures of cerebrospinal fluid (recurrent benign lymphocytic meningitis, also calted Mollaret (CSF) or blood are needed for antimicrobial sensitivity meningitis). ttre CSF findings resemble enteroviral meningitis. studies in suspected bacterial meningitis, but results are Outcomes for HSV-2 meningitis are generally favorable with- insufficiently timely to differentiate bacterial from viral out requiring acyclovir therapy. meningitis. In situations of clinical uncertainty, rapid diag- VZV can cause encephalitis, aseptic meningitis, myelitis, and nostic techniques such as polymerase chain reaction (PCR) a vasculitis presenting as a stroke. Vesicular lesions clue the diag- for common viruses and arboviral serologies can reduce use nosis but may be absent (zoster sine herpete). \rZV encephalitis of clinically unnecessary cranial imaging or antimicrobial and vasculitis may present with a hemorrhagic CSE, VZV may be therapy. detected in the CSF without clinical signs of meningitis or encephalitis, and patients with primary varicella or zoster do not Viral Meningitis require lumbar puncture (LP) unless they have clinical signs of Enteroviruses are the most common cause of viral meningitis, central nervous system (CNS) involvement. Immunocompromised usuallypresenting between May and November in the Western and older adult patients are at higher risk of VZV meningitis and Hemisphere, with symptoms including headache, fever, encephalitis. The diagnosis is confirmed by VZV PCR of the CSE nuchal rigidity, photophobia, nausea, vomiting, myalgia, and therapy is intravenous acyclovir.

for common viruses and arboviral serologies can reduce use nosis but may be absent (zoster sine herpete). \rZV encephalitis of clinically unnecessary cranial imaging or antimicrobial and vasculitis may present with a hemorrhagic CSE, VZV may be therapy. detected in the CSF without clinical signs of meningitis or encephalitis, and patients with primary varicella or zoster do not Viral Meningitis require lumbar puncture (LP) unless they have clinical signs of Enteroviruses are the most common cause of viral meningitis, central nervous system (CNS) involvement. Immunocompromised usuallypresenting between May and November in the Western and older adult patients are at higher risk of VZV meningitis and Hemisphere, with symptoms including headache, fever, encephalitis. The diagnosis is confirmed by VZV PCR of the CSE nuchal rigidity, photophobia, nausea, vomiting, myalgia, and therapy is intravenous acyclovir. TABLE 1" Typical CSF Findings in Patients with Viral and Bacterial Meningitis CSF Parameter Viral Meningitis" Bacterial Meningitis Opening pressure <250 mm H2O 200-500b mm H2O Leukocyte count 50-1 000/pL (50-1 000 x 1 06/L) 1 000-5000/pL (1 000-5000 x 1 06/L)' Leukocyte predominance Lymphocytesd Neutrophils Glucose level >45 mg/dL(2.5 mmol/L)" <40 mg/dL (2.2 mmol/L)r Protein level <200 mg/dl(2000 mg/L) 1 00-500 mg/dL (1 000-5000 mg/L) Gram stain Negative Positive in 60%-90%s

TABLE 1" Typical CSF Findings in Patients with Viral and Bacterial Meningitis CSF Parameter Viral Meningitis" Bacterial Meningitis Opening pressure <250 mm H2O 200-500b mm H2O Leukocyte count 50-1 000/pL (50-1 000 x 1 06/L) 1 000-5000/pL (1 000-5000 x 1 06/L)' Leukocyte predominance Lymphocytesd Neutrophils Glucose level >45 mg/dL(2.5 mmol/L)" <40 mg/dL (2.2 mmol/L)r Protein level <200 mg/dl(2000 mg/L) 1 00-500 mg/dL (1 000-5000 mg/L) Gram stain Negative Positive in 60%-90%s Culture Negative Positive i n 7 0o/"-857"h CSF = cerebrospinal fluid. "Primarily nonpolio enteroviruses (echoviruses and coxsackieviruses) and West Nile virus between June and October; herpes simplex type 2 year round bValues exceeding 600 mm H2O suggest the presence of cerebral edema, intracranial suppurative foci, or communicating hydrocephalus. .Range may be <100/pL(100 x 106/L)to >10,000/pL(10,000 x 106/L). dNeutrophil predominance occurs in 25o/" of viral meningitis cases, usually early in infection and more likely in young children with enteroviral infection. 'Amildhypoglycorrhachia(30-45 mg/dLl1 .7-2.5 mmol/Ll) canbeseeninviral infectionssuchasherpessimplexvirusandWestNilevirus. The CSF-to-plasma glucose ratio is <0.40 in most patients. gThe likelihood of a positive Gram stain correlates with the number of bacteria in the CSF. hThe yield of positive results is significantly reduced by previous administration of antimicrobial therapy. 1