AGA Releases Position Statement on Management of Hepatitis C

The demand to manage hepatitis C virus (HCV) infection has increased over the past decade, and current predictions are that HCV-associated morbidity and mortality rates will escalate in the next 20 years. The American Gastroenterological Association (AGA) has released a review and position statement on the management of HCV infection. The report was published in the January 2006 issue of Gastroenterology.

Routine screening is not necessary for asymptomatic adults with a low probability of infection. Persons in high-risk groups (e.g., injection drug users, immigrants from countries with high rates of infection) should be tested for HCV.

Potential candidates for antiviral therapy include patients who have a reactive enzyme immunoassay for antibody to HCV and those with HCV RNA or compensated liver disease. Elevated alanine transaminase and aspartate transaminase levels are not required for therapy.

Preferred therapy for previously untreated patients with HCV infection consists of a weekly subcutaneous injection of pegylated interferon alfa and oral ribavirin (Rebetol) taken daily. Pegylated interferon is considered the best treatment for patients with indications for antiviral therapy but who have contraindications to ribavirin. Two pegylated interferon alfa preparations are available: pegylated interferon alfa-2a (Pegasys), which is administered at a fixed 180-mcg dose, and pegylated interferon alfa-2b (PEG-Intron), which is administered at a dose of 1.5 mcg per kg.

HCV RNA levels should be monitored using the same quantitative amplification assay at baseline and 12 weeks. An early virologic response (i.e., a reduction in HCV RNA levels of at least 2-log10 within the first 12 weeks of therapy) is a valuable clinical milestone. Without the early virologic response, the chance of sustained virologic response is 3 percent or less. During therapy, clinical and virologic monitoring should be performed at intervals of once per month to once every three months.

Treatment recommendations may vary for other patients, including those with cirrhosis, acute hepatitis C, hematologic disorders, end-stage renal disease, extra-hepatic disease, and human immunodeficiency virus, as well as patients who are injection-drug or alcohol users, have had a liver transplant, or have relapsed or did not respond to previous HCV therapy. Treatment is not recommended for patients younger than three years.

CDC Releases Report on Early- and Late-Onset Neonatal GBS Infection

In 2002 the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics recommended universal screening of pregnant women at 35 to 37 weeks’ gestation for rectovaginal group B streptococcus (GBS) colonization; intrapartum antimicrobial prophylaxis was recommended for carriers. To assess the impact of this strategy, the CDC analyzed data from 1996 to 2004 from the Active Bacterial Core surveillance system. The report was published in the December 2, 2005, issue of Morbidity and Mortality Weekly Report and is available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5447a2.htm.

The data represented approximately 337,000 live births in 1996 to approximately 427,000 live births in 2004. GBS found in children between zero and six days of age was defined as early onset, and disease found in children between seven and 89 days of age was considered late onset. The CDC found that the incidence of early-onset GBS infection in 2004 decreased 31 percent from 2000 and 2001, the period just before the universal screening was implemented. The incidence of late-onset GBS infection remained the same from 1996 to 2004.

Although the absolute difference between blacks and whites in the incidence of early-onset infection declined 68 percent from 1993 (before the prevention guidelines were released) to 2003, racial disparities still exist. In 2004, the rates of late-onset GBS infection per 1,000 live births were 0.83 for blacks, 0.28 for whites, and 0.19 for infants of other races. Similarly, the rates of early-onset disease per 1,000 births were 0.73 for blacks, 0.26 for whites, and 0.15 for other races.

In both early- and late-onset GBS infection, the fatality ratio was highest for preterm infants (23 percent of infants with early-onset infection and 9 percent of those with late-onset infection). Of term infants, 4 percent with early-onset infections died, whereas no infants with late-onset infection died. Continued examination is needed to evaluate the effects of the 2002 guideline revision on early-onset infections and to determine the long-term effects of intrapartum use of antimicrobial agents on neonatal GBS infection.