HIV and ID Observations

Are doctors’ neckties causing infections?  That’s the implication of this Wall Street Journal piece:

The list of things to avoid during flu season includes crowded buses, hospitals and handshakes. Consider adding this: your doctor’s necktie. … A 2004 analysis of neckties worn by 42 doctors and medical staffers at the New York Hospital Medical Center of Queens found that nearly half carried bacteria that could cause illnesses such as pneumonia and blood infections. That compared with 10% for ties worn by security guards at the hospital.

This is old news, of course (yet somehow it warranted front page coverage in the WSJ, go figure).  In fact, the British went so far as to ban neckties for doctors entirely in 2006, stating a tie is an “unnecessary piece of clothing.”   (No comments about ascots, however.)

One problem with the cited study in the WSJ is that it does not link the wearing of neckties to actual infections in patients — and I don’t think any study has.  Meaning this:  do the patients of the necktie-wearing docs get more infections than the patients of MDs who dress more casually?

If not, then it’s just another study of this ilk:  “We cultured ________ [fill in the blank of some seemingly innocuous item -- computer keyboard, reflex hammer, clock radio], and found evidence of staph and coliform bacteria in XX%.  These results suggest that [insert item] should be sterilized prior to patient care.”

My hunch:  neckties may carry bacteria — see this company’s antimicrobial neckties for vivid proof — but they are not themselves causing nosocomial infections.

But since I could be wrong on this one, should we get rid of neckties in the hospitals and clinics just in case?

Let’s imagine you’re seeing a case of pneumonia, and you suspect (as is quite reasonable these days) that it is precipitated by H1N1 influenza.

What antibiotics do you choose for an outpatient?

(If someone is sick enough to be admitted — especially to the ICU — I’m assuming the all-guns blazing approach will be adopted.)

Even though some of these pneumonias have been only H1N1, bacterial superinfection can and does occur — most commonly with our old friend S. pneumoniae, somewhat less so with group A strep, S. aureus (including MRSA, of course), and H. influenza.

But since we hardly ever know exactly what species of bacteria we’re dealing with, how can you leave even one of these out?  That MRSA one in particular?

This past week I chose trimethoprim-sulfamethoxazole + high-dose levofloxacin — in addition to the oseltamavir.

Overkill?  These guidelines from Canada would suggest so, but I’m not so sure.  After all, most people with H1N1 do not get pneumonia at all (and hence do not need antibiotics), and not surprisingly this was not a person with a normal immune system.

Should be an interesting winter …

I was working with a medical intern in clinic this past week who is potentially interested in ID. After seeing our 3rd consecutive stable HIV patient, he asked me what I thought the next big challenge would be in our field — especially since HIV treatment has been “solved.”

“Solved” might be stating it a bit strongly — after all, we still have no cure, the drugs aren’t perfect, not everyone can get them, there’s no vaccine,  etc — but he had a point.  Many of the research questions on HIV treatment are now about moving things forward incrementally, and it’s hard to imagine an advance anytime soon along the lines of combination therapy in the mid 1990s, or even the second wave of newer treatments that become available in 2006-8.

So what’s the answer to his question?  I compiled a brief list, shown below in no particular order:

• Highly drug-resistant bacteria — MRSA, carbapenemase-producing gram negatives, etc.
• Influenza, obviously, plus other SARS-like respiratory viruses
• Hepatitis C, though we’ll have to take this back from the hepatologists — I doubt they’ll mind — with nearly a hundred novel treatments in development
• Infections associated with therapeutic immunosuppression — TNF blockers, other biologics
• Food safety
• Device-related infections
• Novel diagnostics — PCR, other amplification techniques, direct antigen detection methods, etc
• Finding the next infectious cause of some idiopathic or autoimmune disease — some helicobacter-like discovery regarding Crohn’s, or multiple sclerosis, or sarcoid

(Not on my list are issues specifically related to ID in resource-limited settings, because that’s not what I do.)

I’m sure I’m missing something, but it’s a start.

Remember the HIV vaccine trial press release?  The one announcing the first-ever positive result?

Then the backlash, with people questioning how the analyses were done, and reported?

Now, less than a month later, we have the scientific presentation and the paper appear on the same day.

Read all about it here and here.

If you want the view from 10,000 feet (why is that the chosen altitude for that cliche?), here it is:

• The vaccine strategy combines two vaccine generally thought to be ineffective on their own — canarypox ALVAC-HIV and glycoprotein 120 AIDSVAX B/E — in a “prime and boost” approach
• Over 16,000 patients are enrolled in Thailand in a placebo-controlled trial
• The “modified intention-to-treat” analysis, which excludes those who are found to be HIV positive at entry, shows a modest but statistically significant protective effect, reducing the infection rate by about 30%
• There is a trend towards a protective effect in the intention-to-treat and per protocol analyses
• In those who were vaccinated and became infected, there was no effect on CD4 cell count or HIV RNA

Numerous questions remain, many of them summarized in this accompanying editorial:  Why did it work when the individual strategies didn’t?  How durable is the protection?  How do the strains causing infection relate to those in the vaccine?  Did the per-protocol analysis fail to show a significant protective effect solely because of a smaller sample size?  Would the vaccine work if tested on higher-risk populations?  What effect will this study have on the ongoing vaccine development effort, both in the lab and in trials?

Answers to some of these questions may be forthcoming.  Regardless, the surprising results of this study serve as a reminder of just how mysterious the immune system remains — despite some incredibly smart people working on it with lots of resources.

Because if you asked the vaccine cognoscenti to vote a little over a year ago on which strategy in clinical trials would end up with a positive result — the “prime and boost” one published today or the adenovirus vector approach –  the latter would have won in a landslide.

My two favorite newspapers (New York Times and Wall Street Journal — sorry, hometown paper) have just covered opposite ends of a topic on the edges of ID practice — namely, colonic micro-organisms.

Too few?

Too many?

Wrong type?

In the Times, a review of the probiotic debate:

Probiotics are live micro-organisms that work by restoring the balance of intestinal bacteria and raising resistance to harmful germs… So what health problems can probiotics really help? After gathering at a Yale workshop to review the available evidence, a panel of 12 experts concluded that there was strong evidence that several probiotic strains could reduce diarrhea, including that associated with antibiotic use. Several studies have also suggested that certain probiotics may be useful for irritable bowel syndrome.

I suspect the “experts” were gathered specifically because they had interest in this topic, and hence may be predisposed to a favorable review of the data.  Still, there might be something to it, and I’m  crazy about yogurt — full summary of their report here, which was published in 2008.

Far more fringey, however, is the whole “colon cleansing” craze, covered in the WSJ:

The typical American diet of processed foods, pharmaceuticals, stress and lack of exercise is clogging up our lower intestinal tracts, leaving them inflamed and lined with waste—and leaking toxins into the body that cause problems ranging from headaches and chronic fatigue to arthritis and cellulite. All that “stubborn fecal matter” also contributes to bulging bellies and expanding waistlines, cleansing proponents claim.

Eliminating the buildup, either with supplements or laxatives, or by flushing the colon with warm water—a practice known as “hydrotherapy” or “colonics”—can dramatically improve a person’s health and well-being, proponents claim …

Gastroenterologists pooh-pooh [I did not make that up!] many of these claims …

What follows is a very thoughtful review — and a clear debunking — of what seems to be a major form of quackery out there.  For example, here are the claims of one such service:

Colon cleansing benefits intestinal tract problems, absorption, bowel disease, constipation, digestive system, parasites, yeast infection. Helps control blood pressure, restores pH balance, restores proper digestion, reduces bad odors.  Colon cleansing also clears intestinal blockage, relieves bloating, helps purify blood, kills bad bacteria, viruses. These are just of few of the many benefits one can receive by cleaning the intestinal tract.

The problem, of course, is the scientific data backing up these claims are pretty much non-existent.  But hey, it’s just $25 for the “Oxygenated Colon Cleanser,” and $35 for the “Super-Oxygenated.”  FREE SHIPPING!

Ultimately, I think one of the gastroenterologists quoted in the WSJ piece really nails it here:

“There is a degree of obsession that goes along with this,” says Dr. Landzberg… Even “natural” laxatives, such as the plants senna and cascara, can harm the bowel, Dr. Landzberg says, adding, “The public has grown increasingly wary of the side effects of pharmaceuticals. I would like to see people bring that same degree of healthy skepticism to ‘natural’ products.”

Wise words indeed.

As every card-carrying ID specialist knows, hardly anything is more common these days than patients with — and questions about — MRSA.

And one question I’ve been hearing increasingly these days is “Could I be getting my recurrent infection from Rufus?”

To which the answer is, unfortunately, yes.

(I had a dog named Rufus.  No offense intended to people out there actually named Rufus.)

Now along comes this article in the New York Times, which no doubt will stimulate the economy by prompting massive sales of hand-sanitizers, plus a flurry of trips to the vet to have Otto cultured.

(That’s Otto — our cat — in the picture, FYI.)

The article is self-explanatory — pets get MRSA, they can spread it to their owners and back — but did they have to put this caption under the picture of the dog?

INFECTION Don Graff of Belle Mead, N.J., with his English setter, Sunny. The dog contracted MRSA after a spider bite [emphasis added] but was given medication and has improved.

Spider bite!  If there’s one thing this medical writer should have figured out in her background research for the piece, it’s that MRSA infections are frequently mistaken for spider bites.

And I’d bet good money that Sunny (the English setter) never had one — for which I’m sure he’s quite relieved.

The alphabet soup that characterizes HIV therapeutics has always been one of its quirky challenges — for example, who could possibly know that 3TC, CBV, TZV, EPZ, and LAM all refer to drugs that are (or contain) lamivudine?

This drives our ID fellows nuts, and is certainly a strong deterrent to non-HIV specialists to learning the field.

(Maybe that’s why they pay us the big bucks… oh wait.)

And while we’ve grown comfortable with the abbreviations for the 3 oldest drug classes — NRTI, NNRTI, and PI — what are we to do with integrase inhibitors?  Some candidates:

• “II” — sounds funny when you say it (”eye-eye”), and could be confused with “eleven” depending on the font
• “INSTI” — for “integrase strand transfer inhibitor”; I’ve already seen this one around a lot, but have also seen it written “InSTI” (lower-case n), which is hard to type
• “INI” — for “INtegrase Inhibitor”; same upper vs lower-case issue as “INSTI”, and saying “INI” always has an anatomic (especially umbilical) connotation to it

Still not sure where we’ll end up with this one, but I suspect “INSTI” will rule the day.

A few ID/HIV items to cover before summer “unofficially” ends (Sept 1?  Kids back at school?  Labor Day?):

• Will US Public Health officials recommend infant male circumcision to prevent HIV?  They might be considering such a move, but I suspect it will not be strongly promoted.  After all, none of the studies demonstrating its efficacy have been done in developed countries, and the pattern of the US epidemic — predominantly gay men and women of infected male partners — excludes the very group circumcision has been shown to protect:  circumcised heterosexual men.  Look for lots of CDC-ese in these guidelines, with terms such as “consider” and “might choose” and “be offered.”
• Getting lots of questions from my patients about the H1N1 vaccine.  Some decent interim answers here.  When available?  (Don’t know yet.)  Who will get it?  (The young, pregnant women, those at risk for severe flu)  Will there be enough?  (Maybe.)  Will the regular flu vaccine still be needed?  (Yes.)  Will this season’s flu vaccination programs/clinics/sites be civilized affairs with minimal panic, anger, waiting lines, frustration?  (I hope so, but the media will do their best to portray the situation otherwise.)
• Anyone see this movie on chronic Lyme?  Would love to hear your impressions.  I have not seen it — but this will definitely be a Netflix choice when it a appears on DVD.  (Note that I did not link to Netflix; I’m a big fan, but they are the most egregious purveyors of annoying pop-up ads in the universe right now.)
• How’s this for a new definition of contagious?  Be reassured:  my little teaser photo has been thoroughly autoclaved.

Enjoy the sunshine …

This might seem bizarre, but one of the reasons I chose to go into Infectious Diseases as a field was the names of the diseases (and often the micro-organisms that caused them) sounded so darn cool.

For example, if you were a science fiction writer you could hardly come up with a better-sounding name for a mysterious disease than “toxoplasmosis.”  Or its full name, “Toxoplasma gondii”.

Major Pribulon, I’d advise against taking your Colonial Defense Armada into Sector 18, Ambrilla Zone — I hear reports of a widespread outbreak of TOXOPLASMOSIS.

Wow, that sounds scary.

Anyway, from the only toxoplasma diagnostic reference lab in the United States — the one at Stanford, founded by Jack Remington, now headed by Jose Montoya — comes this fascinating paper on risk factors for acquiring toxoplasmosis in this country.  It’s a case-control study using 148 newly-acquired cases from their serology lab, comparing them with 413 negative controls.  Here are the significant risks:

• eating raw ground beef or rare lamb
• eating locally cured, dried, or smoked meat
• working with meat
• drinking unpasteurized goat’s milk
• having 3 or more (!) kittens
• eating raw oysters, clams, or mussels

Interesting that having 1 or 2 kittens was not a risk factor, and neither was gardening.  Raw shellfish consumption is one I hadn’t heard before; there are several plausible explanations:

Oysters, clams, and mussels are filter feeders that concentrate T. gondii, as has been shown under experimental conditions. Sea otters in California have been found to be infected with T. gondii, and it is likely that they are often infected by eating mollusks, which filter T. gondii from seawater. The seawater in California is thought to be contaminated by T. gondii oocysts that originate from cat feces, survive or bypass sewage treatment, and travel to the coast through river systems.

And don’t forget:  stay out of the Ambrilla Zone, Sector 18.

Over on the CID web site, they have the revised version of the “IDSA Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus”. It’s a great document, filled with useful references and a particularly strong table where to find other consensus guidelines (diabetes, hyperlipidemia, mental health, others).

My vote for what will be most commonly-cited part of the guidelines it Table 5 (Recommended Baseline Lab Tests) — though Table 9 (Vaccines) could be a close second.

Some potential areas of controversy:

• No recommendation for routine screening for osteoporosis
• No recommendation for routine anal pap smears in MSM
• LP for all patients with late-latent syphilis or syphilis of unknown duration

Regarding the bone density, I suspect this will will be recommended one day, though agree for now it’s premature.

However, I’m sure there are many who will be surprised that the anal paps are not routinely recommended.  Solid quote:

Anal cytologic screening (ie, anal Pap smears) in HIV infected women and MSM is not considered to be the standard of care at this time but is being performed in some health care centers. Additional studies of screening and treatment protocols for anal dysplasia are in progress to clarify this issue.

Seems that it is done uniformly at clinics that have enthusiasts, or zealots — plus a high-resolution anoscopy plus biopsy protocol.  (”If you’re at Disneyland, you go on the rides.”)   We don’t really know yet whether this screening prevents cancer.

For the LP issue — I know it’s in the STD Guidelines, but do you really LP all such cases in your HIV patients?