Thread by @Josh_S_Davis

Here again are my #Top10 Infectious Diseases papers of 2022. Not in order (alphabetical by first author). Non-COVID (because >120,000 COVID papers in 2022). Have to be at least one of: Paradigm Shifting, Practice Changing or Dogma Challenging #IDtwitter 🧵

1. Cheetah Trial, Lancet Vol 400, Nov 2022
Cluster RCT, 81 hospitals and 13,301 pts having surgery. Compared with usual care, routine change of gloves and instruments before wound closure reduced the 30-day SSI incidence from 18.9% to 16.0% (adjRR 0.87 [0.79-0.95], p=0.003)

Was done in 7 African countries. Unclear if applicable in high income countries, but probably is. SSI rate in high-income countries similar to control arm of this trial.
Pending further data, routine glove and instrument change before closure should become routine globally

2. Blom et al INFORM trial, BMJ vol 379
140 adults with prosthetic hip joint infection requiring revision were randomised to one-stage or two-stage revision
In terms of mean WOMAC score (a PROM), one-stage was better than two-stage at 3 months, but no different at 12 months.

3. Feuerstadt NEJM; 386:220
182 adults with CDAD post Rx (and with >=3 prev episodes) were randomized to receive SER-109 (oral purified Firmicutes spores) or placebo PO daily for 3 days. CDAD recurrence after 8 weeks was significantly less (12% versus 40%)

Might replace the need for FMT in high-risk patients, thus avoiding its risks
?Safer than faecal products like PR Rebyota (FDA approved Nov 2022)
Will prob be recommended post Vanco/Fidaxo for selected (or all) patients
Need to see real-world data

4. Futier BMJ; vol 379: e071476
At 11 French hospitals, 960 pts pre colorectal surgery randomised to IV+PO AB prophylaxis (ornidazole 1g PO x 1 12h pre-op + cefoxitin 2g IVI 30’ pre-op) or IV+placebo. SSI at 30 days=13% vs 22%, favouring intervention (-8.6%, CI -13.5% to -3.8%)

Adds to and simplifies previous observational studies and RCTs showing benefit of PO AB prophylaxis (often with >=2 drugs, plus post-op doses).
Addition of a long-acting PO nitroimidazole (e.g. tinidazole) should be routine in colorectal surgery (probably + bowel prep as well)

5. Harding et al BMJ; 376: e068229
8 UK centres, 240 women w/ recurrent UTIs randomised to methenamine hippurate or antibiotics for 12 months. AB-treated UTIs occurred in 0.89/person-year in AB group vs 1.38 in hippurate group, difference 0.49 (90% CI 0.15-0.84), non-inferior

Baseline rate=6.5 UTIs/person/year. Although hippurate less effective than antibiotics, it was non-inferior; both were very effective (both reduced incidence UTIs from 6 to about 1 per year). Hippurate should be routinely offered 1st line before resorting to AB prophylaxis

6. Lawrence et al NEJM; 386: 1109
844 HIV +ve adults with cryptococcal meningitis in Africa (median CD4 count=26) randomised to a single large dose of L-AmpB (10mg/kg) plus 14 days of 5FC+Fluconazole, OR “standard care” (7 days ABDC 1mg/kg/day + 5FC, then 7 days fluconazole)

Mortality at 10 weeks=24.8% (L-AmpB) versus 28.7% (SOC; difference -3.9%, upper bound non-inf margin=+1.2%). Also less AEs in single dose group. Likely also should apply to HIV +ve people with C.neoformans in high-income countries. Should not be applied to C.gattii meningitis

7. Larsen Nature; 602: 135
Cross-sectional microbial genomic study of swabs from 276 hedgehogs across 10 European countries + NZ, found MecC-MRSA in 101 of them (suggesting co-evolution). Phylogenetic analysis found several lineages with MRCA from 1800-1950.

A separate analysis of the common hedgehog dermatophyte, Trichophyton erinacei, revealed that it produces Penicillin G, accounting for natural selection pressure on S.aureus.

This refutes narrative that methicillin resistance emerged shortly after methicillin became available
Accords with other evidence that all resistance mechanisms already exist in nature
Thus all new antibiotics need to be used very carefully since resistance is inevitable

8. SUDDICU trial, JAMA; 328(19):1911
Cluster cross-over RCT in 19 Australian ICUs, where 5,982 ventilated patients were randomised (at ICU-level) to receive SDD (PO+NG tobramycin, nystatin and colistin while intubated + 4 days of IV ceftriaxone) or standard care.

In-hospital mortality was 27.0% in the SDD group and 29.1% in controls (OR 0.91, 95% CI 0.82-1.02). New MRO acquisition, positive blood cultures and total antibiotic use were all significantly less in the SDD group.

SDD almost certainly reduces mortality in ventilated patients, but with a small effect size (~2% absolute mortality reduction)
No adverse signal on MRO acquisition but important questions remain
You could use this trial to justify whatever your a priori opinion was on SDD

9. Smith, NewSkin Prep Trial, Annals of Surgery
3-arm RCT. 3,213 adults having surgery randomised to pre-op skin prep with alcohol-betadine (AB), alcohol-chlorhexidine (AC), or aqueous betadine (AqB). In terms of SSI, AB non-inferior to AC, and was not superior to AqB

Major guidelines recommend AC, based on data from small, heterogeneous and/or industry-sponsored studies.
AqB cheaper (vs chlorhexidine) and safer (vs ETOH) and statistically non-inferior so should be included in guidelines as equal first choice

10. Thornhill NEJM: 387: 679
Before April 2022, monkeypox (now “Mpox”) was rare and sporadic outside Africa. Since then, a worldwide outbreak is ongoing. This article describes the clinical features of 528 infections across 16 countries over the first 8 weeks of the outbreak.

As of 8/12/22, there were 144 cases in Australia, >21,000 in Europe and >29,000 in the USA.
New pandemics happen when and how we least expect it!