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An ongoing dialogue on HIV/AIDS, infectious diseases,
October 18th, 2013
Back to School: Top Questions from “ID in Primary Care”
We hold an annual post-graduate course entitled “Infectious Diseases in Primary Care”. In this 2.5 day course, we ID doctors do our best to address the concerns of clinicians on the front lines — those doing primary care.
And each year, we get some great questions. Like these:
- Question: I work at a university health center, and each year we have several hundred visiting students from countries that routinely give BCG immunization. We continue to do PPDs (tuberculin skin tests, TSTs) because they are cheaper, but there are tons of positives. Should we switch to an IGRA (interferon gamma release assay)?
Answer: If ever there were an indication to use IGRAs over TSTs, this is it! Think of the potential money, time, and aggravation you’d ultimately save. Once you switch to IGRAs for those with a BCG history, here’s what you won’t have to do: 1) track down the people who don’t return to have their skin test read; 2) explain to the BCG-immunized with the reactive skin test that we don’t consider BCG in this country when we interpret TSTs (Note: No one who’s received a BCG believes us; they think we’re out of our minds.); 3) get a chest X-ray in those with reactive TSTs from BCG alone; 4) prescribe unnecessary preventive therapy for that same group. Sounds like a good trade off to me. Read more here.
- Question: For skin infections, shouldn’t we double the dose of trimethoprim-sulfamethoxazole [that's not what he said -- he said "Bactrim"] to two double-strength tablets twice daily?
Answer: I’m not sure where this one came from — and it’s a widely held belief — but as far as I know, there are no definitive data supporting a double dose of TMP-SMX for skin infections. Plus, some of the toxicity of TMP-SMX is dose-related, and those “double-strength” tablets are gigantic. Notably, this randomized study used the standard dose (1 DS twice-daily), and this one used variable weight-based dosing. If someone knows why the higher dose is anecdotally so popular, let me know! Which reminds me — what should we call this drug? I generally frown on using trade names unless absolutely necessary, but “Bactrim” (or the less-commonly-used “Septra”) are vastly superior to the mouthful that is the generic name. Some say “cotrimoxazole”, but what is that? Please weigh in by voting in the poll below, and providing your comments.
- Question: Do you need to check serologies before giving the zoster vaccine if someone says they never had chicken pox as a kid?
Answer: Nope — the good news is that per the zoster vaccine guidelines, we can consider anyone born before 1980 in the United States to be varicella immune. And the last time I checked, everyone older than 60 (for whom the vaccine is indicated) was born before 1980, though you may wish to double-check my math.
- Question: Do you recommend repeat testing for C diff after the patient has been treated?
Answer: Certainly not if he/she is improving, as a repeat positive with any of the myriad C diff tests out there is quite common shortly after C diff treatment, and treating improving/resolved C diff with antibiotics is a bad move. So when would you check again? I find repeat C diff testing helpful in someone with a recent episode who’s now having vague symptoms (e.g., not a florid relapse), as a negative result suggests that it’s probably post-infectious GI issues (alteration of normal flora would be the broad generalization of what causes this) rather than a relapse of C diff.
- Question: When is next year’s course? I’d love to attend.
Not sure — some time in October, we’re working on finalizing the dates now.October 1-3, 2014. And we guarantee the New England weather will be perfect and the Red Sox will be in the playoffs.