HIV and ID Observations

A few ID/HIV tidbits to contemplate as we go from slipping on ice and snow to dodging the mud:

• Beta-lactam therapy alone is non-inferior to regimens that also cover “atypicals” for hospitalized patients with pneumonia. These results challenge a dogma that has been present for a couple of decades — namely, that all patients admitted with community-acquired pneumonia should get either a quinolone or a beta-lactam plus a macrolide. But is one study done in the Netherlands enough to change clinical practice?
• Flurry of recent papers on the cost effectiveness of HCV therapy:  One, two, three, and four, to be exact. Bottom line? A huge oversimplification goes like this — from a societal perspective, the new treatments are for the most part cost-effective and expensive. And, of course, from an individual perspective — meaning you are the individual being treated, or the prescriber — they are a no-brainer.
• Related: Entertaining and informative discussion of HCV pricing, and what’s going on behind the scenes from longtime ID/HIV clinician, researcher, and educator Mike Saag. When it comes to this market, what’s the opposite of transparent?  Highly recommended, especially for fans of Get Smart. And if you want some additional info on the world of “Pharmacy Benefit Managers”, read this. (Thanks to Mike for the link)
• “Fourth Generation” HIV screening tests that detect both antigen and antibody can still miss acute HIV. Remember, the duration of p24 antigen detectability during acute HIV is relatively short. Important to think about this limitation, especially when evaluating patients for PrEP — we should have a low threshold to order HIV RNA.
• The outbreak of injection drug use (IDU)-related HIV in Indiana is a stark reminder of how quickly HIV can spread with the right mix of bad ingredients — rising rates of opiate addiction, poverty, and lack of access to clean needles. Notably, in the rest of the US this mode of HIV transmission has become quite rare — here in Boston, I haven’t seen a newly acquired case of HIV from IDU in years. Bad time for complacency on this issue.
• Watch out for ciprofloxacin-resistant shigella in returning travelers. As noted in the report, “shigella is transmitted easily from person-to-person”, which is something of an understatement since some people can get sick after ingesting fewer than 100 bacteria.
• The air near beef cattle feed yards carries antibiotics, antibiotic resistance genes, and resistant bacteria. Yuck, good idea to stay up-wind. Remember, 80% of our national use of antibiotics goes to livestock. Will the programs announced this week by Obama actually reduce this use?
• I recently learned that two of the HACEK organisms have new names: Haemophilus aphrophilus is now Aggregatibacter aphrophilus, and Actinobacillus actinomycetemcomitans is now Aggregatibacter actinomycetemcomitans. Wow. The mnemonic “HACEK” still works, however, standing for Haemophilus species, Aggregatibacter species, Cardiobacterium hominis, Eikenella corrodens, and Kingella species. I’m convinced some of us chose ID as a specialty just so we could know information like this.

Hey, it’s Holy Week. Colored (sometimes green) eggs and ham! Peeps! Matzo balls and brisket! Jelly fruit slices! For those of a less traditional spiritual bent, enjoy this: