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An ongoing dialogue on HIV/AIDS, infectious diseases,
December 11th, 2016
About a million years ago — in other words, probably sometime during my ID fellowship — I asked transplant ID guru Bob Rubin how various ID guidelines came together, including one on antifungal therapy he had just led.
“You lock a bunch of experts in a hotel conference room,” he said. “Provide them plenty of food and coffee. Then you hide the key until they come up with something, especially if there’s a deadline .”
Having participated on a couple of guidelines committees, I can attest that the process has changed just a bit since Bob provided me that memorable story. Conference calls, web-based presentations, and numerous shared documents with extensive “track changes” peppered throughout now dominate the process, along with frequent reminders about grading both the strength of the recommendations and the quality of evidence.
And, since we’re ID doctors, we of course try to outdo each other in obsessive attention to detail — emphasis on obsessive. While everyone makes a big noise about editing and shortening the final document, if that means eliminating one key reference, tell that to its champion — especially if they authored or co-authored the paper. It’s going in!
On the topic of guidelines, you might have noticed that the Infectious Diseases Society of America (IDSA) has been on quite a roll over the past year. They’ve been churning out new guidelines at a blistering pace, often in collaboration with other medical societies. So here’s a look back on IDSA’s hard work over the past 12 months, each one highlighted with at least one notable and/or interesting recommendation, and also (just for bragging rights) the number of references (all thoroughly read, no doubt):
- Candidiasis. Last updated in 2009, these revised guidelines cover diagnosis, prevention, and treatment. A selected key recommendation: An echinocandin is recommended as initial therapy, with transition to fluconazole if the isolate is susceptible. Number of references: 560 — impressive!
- Antibiotic Stewardship. The first of its kind! A selected key recommendation: Rapid viral testing for respiratory pathogens is recommended to reduce the use of inappropriate antibiotics. Number of references: 225 — you have to think this will grow in the next iteration.
- Aspergillosis. Prevention, diagnosis, and treatment of this difficult-to-treat opportunistic infection. A selected key recommendation: Serum and bronchoalveolar lavage galactomannan can accurately diagnose invasive aspergillosis in high risk patients; the panel disagreed about using PCR. Number of references: 655! Wow, that might be hard to beat.
- Hospital-acquired and ventilator-associated pneumonia. Retires the term “health-care associated pneumonia”, often abbreviated (and spoken) as “H-CAP” — will be hard for many to break that habit. A selected key recommendation: Duration of therapy should be 7-days (follows the rules!), not 8-15. Number of references: 364. Middle of the pack.
- Coccidioidomycosis. What a mouthful that fungal disease is, which must be why most people just say “cocci.” A selected key recommendation (actually two this time): No antifungal treatment for an asymptomatic pulmonary nodule (not even a bit of fluconazole?), while duration of azole therapy for coccidioides meningitis is lifelong. Number of references: 219 — a relatively “low” number, maybe because cocci’s geographic distribution isn’t very wide. Nah, 219 references is still a lot.
- Treatment of drug-susceptible tuberculosis. The winner for the most number of organizations involved in developing and endorsing these guidelines — I counted 9 (just read the start of the abstract). A selected key recommendation: Initial adjunctive corticosteroid therapy should not be routinely used in patients with tuberculous pericarditis. Number of references: 531 — would be top of the pack if you added the other TB Guidelines (which are next).
- Diagnosis of tuberculosis. First update on this topic in 17 years, so long overdue. A selected key recommendation: Use an interferon gamma release assay (IGRA) to assess for latent TB in place of the tuberculin skin test (TST) in most clinical settings. I’m ok with that! Number of references: 241 — hey, it’s just diagnosis after all.
- Leishmaniasis. Diagnosis and treatment of cutaneous, mucocutaneous, and visceral disease. A selected key recommendation: Use a reference laboratory to perform culture and PCR in an effort to identify the infecting parasite to the species level, which may have implications for management. Number of references: 503, which exceeds the number of cases of leishmaniasis I have seen by 498.
That’s 8 Guidelines, and a total of 3,298 references. Hard at work, IDSA!
Of course no listing of IDSA Guidelines these days is complete without the invaluable HCV guidelines, which I’ve praised (and use) often. They’ve changed so frequently since their inception that they have their own special site, and aren’t really “published” anywhere else — at least not in a traditional medical journal. On the plus side, this allows the HCV Guidelines greater flexibility, with modifications on an as-needed basis (three times in 2016 alone) for important changes in the field — a nod to the DHHS HIV Guidelines, which have a similar structure. On the minus side, there’s no real peer review, and I’m sure some of the writers of the guidelines (especially those seeking academic promotion) wouldn’t mind a byline discoverable in PubMed.
And they don’t number their references, so someone else has to count. Kind of like guessing the number of pennies in a big jar to win a prize.
Finally, here are some bears playing with a pink balloon. Just because.
December 4th, 2016
A selection of ID/HIV questions that have been dogging me over the past year, some longer:
- Why is there no reliable, readily available PCR diagnostic test for malaria? Seems especially ironic since the one for babesia has become so commonly used. Does the Binax antigen test make it unnecessary?
- Why aren’t we actively recommending Zika testing for couples who return from endemic areas and are interested in conceiving? A negative test would make a low-likelihood but serious outcome (congenital Zika) even less likely. They could still wait the recommended six months if they want.
- What is the right abbreviation for Pneumocystis pneumonia? Is it “PCP” (PneumoCystis pneumonia) or “PJP” (Pneumocystis jirovecii pneumonia)? Have heard smart people use both; I prefer the former.
- Once there are more manufacturers of generic daptomycin and the price drops, how long before it’s used more than vancomycin? If we never have to monitor vancomycin levels again, there should be a small celebration.
- In the big new HIV vaccine study just starting, how many participants will also be receiving PrEP? Here’s the study design of HVTN 702, and PrEP clearly is allowed. I suspect it won’t be available to most of the participants, otherwise it could make it hard to discern whether the vaccine actually works.
- Does anyone really know the full meningococcal vaccination recommendations without looking them up? For the 99% of us who don’t, here they are. This is an old bugaboo, inspired by the new recommendation to give meningococcal immunization to all HIV patients.
- Could the headlines be any more misleading about how many patients contracted HIV or HCV from the dentist who used his own equipment? Here’s an example — you have to read it carefully to make sure you see the “May” in there. But gotta sell papers/get clicks (and I just contributed to the latter).
- Speaking of, is this the headline of the year? I think we have a winner, folks — “GOVERNMENT DRONES WILL SHOOT VACCINATED M&MS AT PRAIRIE DOGS.” The disease, for the record, is the “sylvatic plague.” You have to read the full story to believe it. And just wait for the anti-vaxxers to protest.
- If primary care clinicians had a rapid diagnostic test that could tell patients definitively that they had a specific viral respiratory tract infection, would this decrease the use of outpatient antibiotics? They could say, “Mr. Smith, your test came back, and you have rhinovirus.” I say “Yes it will”; my colleague Jeff Linder (a primary care internist who studies antibiotic overuse) is skeptical.
- Will broadly neutralizing antibodies (“bNAbs”) ever have a role in HIV treatment? Not based on this study. Admittedly it’s early in bNAb research, but to date I’m not getting the bNAb enthusiasm.
- We have penicillin G, and penicillin V, but what about the other letters? Hat tip to John Cafardi for this one.
- Wouldn’t it be useful if ID doctors had some formal training in wound management? Big gap for many (most?) of us.
- What percentage of non-occupational HIV post-exposure prophylaxis courses are unnecessary? I’m estimating 99.9994%, but that train seems to have left the station, with no going back.
- Why did the new makers of crofelemer change the name from (the absurdly wonderful) Fulyzaq to (the less remarkable) Mytesi? And here’s an artist’s rendition of a Mytesi, in case you were sad about the extinction of Fulyzaq.
- In Lyme-endemic areas, why is there no recommendation to give a single dose of antibiotics to children with tick bites? Odd that we use this strategy in essentially all adults, and almost no children — it’s as if we were applying drinking-age criteria to this completely unrelated issue.
- Why is a CSF exam recommended in all patients with optic or otic syphilis? Treatment is the same (IV penicillin) regardless of the results. Have been asking this question for years.
- What fraction of HIV viral load tests that come back “VIRAL RNA DETECTED BUT BELOW THE QUANTIFIABLE RANGE OF THE ASSAY” are clinically important? Boy that must be rare. The ratio of (Emotionally important to patient)/(Clinically important to patient) must be nearly infinite.
- What’s it like to have an oral carbapenem? Someone from Japan might know.
Ok, time for a couple of quick non-ID ones:
- When will the Washington Redskins change their offensive name? Or the Cleveland Indians get rid of their unfunny mascot?
- When will the torture of choosing a password be replaced by something easier and more reliable? Here’s one recent example. Arrghh.
Hey, it’s National Influenza Vaccination Week! Check your party schedule carefully.
November 25th, 2016
Every so often, one of my regular readers (which must number at least a dozen at this point, including my extended family, dog, and cat) asks me where I come up with ideas.
The answer, of course, is that there are infinite sources of inspiration in the field of Infectious Diseases — the difficulty is choosing what fascinating topic will be the target of this week’s cogent and definitive analysis.
Or, I can just steal something, which is what I’ve unabashedly done with the Cartoon Contest, modeled after the more established version from The New Yorker.
And here’s the winner of the summertime contest, an outdoor scene that might bring back fond memories of warm breezes, long days at the beach, and dining al fresco:
We’ll give Philip Morganelli the top prize on this one, though he’ll need to share the generous honorarium with John Lee, who introduced the whole “carbon footprint” theme and might have provided Philip some inspiration.
But I confess this contest turned out a bit differently than anticipated. With such an ID-oriented crowd, I figured the obviously very well-done burgers would generate plenty of funny captions about food safety. If you’re wondering what I mean, take a look at this most unappetizing food truck:
Concern about underdone burgers prompted my next door neighbors Ben and Carol to call the well-done hockey pucks favored by ID specialists “Madoff burgers”. It’s in honor of Dr. Lawrence Madoff, an ID doctor who works at the Massachusetts Department of Public Health, who periodically attends our neighborhood cookouts — you can guess Larry’s emphatic answer to the question, “And how would you like that done?” Perhaps he will be introducing his own line of crispy fast food soon.
Yet none of the top three captions chosen by our AHA (Advanced Humor Algorithm) had anything remotely to do with infectious food safety:
- “No thanks, I’m watching my carbon footprint.” (the now-famous Philip Morganelli)
- “Sorry, I was using fire in the belly as a figure of speech.” (JRMD)
- “No thanks. They always give me heartburn.” (Aaron Kassoff)
Perhaps I poisoned (ha) the ID entries by introducing the drawing with this gloomy sentence: “We must be vigilant to the ever rising threat of both foodborne pathogens and carcinogenic heterocyclic amines.” Come to think of it, that alone could have been a (very unfunny) caption.
This time, you’ll get no such leading leading statement — here’s the cartoon, let your inspiration run wild:
Post captions in the comments section (preferred), or if you’re shy, email them to me at firstname.lastname@example.org.
(Drawing by Anne Sax.)
November 20th, 2016
But with the (unsurprising) concession that I too felt that watching the election returns was akin to witnessing a slowly developing and incomprehensible train wreck, I remind you that the expression of gratitude is well known to make you happier. Plus, it’s the season.
So here’s a brief list of things in our fascinating field to be grateful for as you get the turkey ready. As a bonus, I’ve put a few non-ID ones at the end, because, well, why not?
- New diagnoses of HIV in the USA are down — really! After decades of HIV incidence being stubbornly stuck at the same level since the early 1990s, new diagnoses have declined 19% since 2005. Yes, 40,000 new diagnoses/year is clearly too many, and new infections are still too common in black men who have sex with men — but they are down in all other groups. Chalk this significant decline up to several important factors: 1) more testing; 2) more people on treatment; 3) more people on treatment that actually works; 4) more of those at-risk but negative on pre-exposure prophylaxis (PrEP). Ever the optimist, I predict further declines in HIV diagnoses in the years to come.
- Hospitals are mandated to have antibiotic stewardship programs coordinated with infection prevention efforts. Or, to put it more accurately, they must have these programs if they want to get paid by Medicare and Medicaid, which is quite the incentive. If that’s not enough, The Joint Commission, which accredits and certifies US hospitals, agrees. ID doctors have been warning about the risks of antibiotic resistance for years; these rulings really put some momentum behind antibiotic stewardship and infection control efforts, a tremendous opportunity to improve patient care — and for ID in particular to take a leadership role in making this happen.
- Access to hepatitis C therapy has vastly improved, and the remaining treatment challenges have been solved. I acknowledge that access isn’t the same in all states, but here most payers — including even Massachusetts Medicaid — have abandoned “fibrosis requirements” for HCV therapy, which were never defensible medically anyway. In fact, we can get approval for treatment for almost everyone, regardless of payer, because the costs of treatment are way down from the “sticker price” — enough so that HCV treatment is now considered “High Health System Value” by the Institute for Clinical and Economic Review, a group initially quite critical of HCV treatment pricing. And with the approval of velpatasvir/sofosbuvir and elbasvir/grazoprevir, two of the remaining challenges in HCV therapy — genotype 3 and patients with renal disease, respectively — are now checked off. Two ongoing issues are diagnosing patients before they have significant liver disease (a large proportion of those with HCV don’t know they have it), and the rare cases of treatment failure with resistance. Good news here, too — early diagnosis should improve with better therapy (see HIV example above), and the patients with treatment failure will have new options soon. You are hereby forgiven if you don’t know (yet) what voxilaprevir and glecaprevir/pibrentasvir are, though you will need to know soon.
- MRSA rates continue to decline. If you asked me in the mid-2000s to forecast the status of Staph aureus susceptibilities, I would have predicted that the MRSA USA300 strain was going to take over the world, laying waste to susceptible strains and causing painful abscesses, kind of like Godzilla stomping through downtown Tokyo. (What a terrible analogy. Sorry.) It was so bad I wrote this desperate post about MRSA almost 10 years ago. Fortunately, I was WRONG (not the first or the last time). While still common, MRSA has declined both in the hospital and the community settings. Not only that, but penicillin-sensitive strains seem to be making a comeback, somehow re-emerging from the pre-penicillin 1930s decade like a Lincoln Zephyr Coupe. Is that analogy better?
- The University of Liverpool HIV and hepatitis drug interactions resources are better than ever, and invaluable. When most people think of Liverpool, their first association is probably The Beatles, and second football (you know, what the rest of the planet calls soccer). ID doctors, however, might think of something else — the University of Liverpool gives us the very best resources for HIV and hepatitis drug interactions, and if you aren’t using them yet, start now — they will make your prescribing life so much easier. Note that the excellent web site and mobile apps have recently been redesigned, making them better than ever.
- Applications to ID fellowships are up. The final numbers aren’t in, but it does appear that a discouraging downward trend has, at least for this year, been reversed. Too soon to say if this will continue, but I can also say anecdotally that the applicants we had this year were excellent — smart, engaging, curious, interested in a wide variety of ID topics, and just the sort of people we want for the field.
- John Bartlett’s annual “What’s Hot in ID” lectures at IDSA/IDWeek. John’s can’t-miss lectures follow a logical game plan: he chooses the top 5-8 issues in Infectious Diseases over the past year, highlights the key studies, synthesizes the take-home messages, and — here’s the best part — he then says, “So I called [first-author of the paper] about this surprising result, and this is what he [or she] told me.” Pure gold — educational, entertaining, just fun — and this year’s talk was no exception, so I’m sad to report that he’s told me that this will be his last lecture at IDWeek. I’ve written about John before — thank you for teaching us so much!
Plenty of other topics I could have included, but here are a few non-ID items I’m also grateful for, just for fun:
- Wait Wait…Don’t Tell Me! The best (and funniest) way to get the news, especially since John Stewart left The Daily Show.
- The Cubs won the World Series. It had been a while (you might have heard that).
- An electric car is the Motor Trend Car of the Year, and it’s not even a Tesla. Surprise, it’s the Chevy Bolt, and Motor Trend says it can hear “the sound of the automotive world shifting on its axis”. I barely drive, but can only imagine how much better our planet would be without every car having an internal combustion engine.
- Television has never been better. An indisputable fact.
- Simone Biles and Usain Bolt. Amazing X 2.
- Bill Bryson’s books. All of them.
- Spiralized vegetables. Where did these come from?
- The Poscast. In which Joe Posnanski (my favorite sports writer) and comedy writer Michael Schur have long, pointless, and incredibly funny discussions.
- Asturias, by Isaac Albeniz. On the guitar, of course.
- Bailey, a lost dog in Brooklyn, was found. Just read the story.
What are you grateful for this year?
November 13th, 2016
(Note to readers: This will have nothing to do with the election — for obvious reasons. Yes, there’s a poll at the end, but your political views will not matter one bit. There, I feel better.)
Just received this email from a longstanding leader in HIV care and research:
I would like to ask for you a favor. I am preparing an elite controllers talk for the next GESIDA meeting that will take place in Madrid on December 2nd 2016 and I am doing a very short survey to international experts [thanks very much, Jose!]. I would appreciate very much if you can answers these 2 questions:
1) Would you treat with ART elite controllers (patients with CD4>500 and longstanding HIV VL<50 copies/mL)?
2) Please, explain your answer in 1-2 short sentences
Thanks again for considering my proposal and for your time.
This is a tough question, and if you’re wondering why, let me provide a bit of background for those who don’t do ID/HIV medicine regularly.
“HIV controllers” are those rare individuals who have HIV infection, but their immune systems somehow “controls” viral replication without the need for antiretroviral medications. How common is it? Estimates vary, but it’s certainly no more than 1% of those with HIV. (Here’s one representative study from France.) Rarity notwithstanding, every experienced HIV/ID clinician has seen at least one of these patients, and those of us doing this for a while have several, most of whom we’ve been following for years.
At the extreme end of the controller phenotype are people sometimes termed “elite” controllers, meaning we can’t detect HIV in their blood using even our current highly sensitive viral load assays — their results always come back “Target not detected” (in other words, “undetectable”), and their CD4 cell counts remain normal.
Not surprisingly, these elite controllers are the source of immense interest to researchers, who have long believed that these patients’ immunologic response to HIV — a usually progressive, lethal infection — might hold the clue for immunotherapy, or an effective vaccine, or both. Not only that, but their “elite” status allows them to board the plane first even when traveling coach, and grants them free WiFi and an automatic room upgrade when checking into fine hotels.
(Just wanted to see if you were listening.)
Back to the science: But all is not completely normal in these lucky HIV controllers. Some have elevated levels of immune activation and inflammation — perhaps a marker that their immune systems are working overtime to control HIV. Might this insalubrious inflammatory milieu cause lymphoid fibrosis? Or increase the risk of cardiovascular disease? One provocative study showed that HIV controllers were admitted to the hospital more often than HIV infected patients who were on antiretroviral therapy.
Ultimately, this raises the question Jose posed in his email — should we start HIV controllers on antiretroviral therapy? Ten years ago, the answer was easy — NO — and we told them this repeatedly. Your immune system is doing what our antiretrovirals set out to do, which is control viral replication. Not only that, it’s doing so without side effects. You’re lucky — you don’t need treatment.
But times most definitely have changed. In addition to the above data on immune activation and inflammation, HIV treatment is now so much safer. Plus, we have the results of the START study and HPTN 052, showing that HIV treatment is beneficial even to those with CD4 > 500, and that suppressive therapy makes people with HIV essentially non-contagious. As a result, all guidelines now explicitly state that HIV treatment is indicated for all people with HIV. Doesn’t that include HIV controllers?
The reason this isn’t so clear comes down to three remaining issues, all of them significant. Two are uncertainties from clinical science, the third an emotional one from our patients.
- For elite controllers, there’s no proof of clinical benefit or reduction in transmission risk. The START study showed that those with CD4 > 500 benefited from starting therapy rather than waiting until the CD4 fell to < 350. However, the median HIV RNA of study participants was 13,000, and while it’s not in the primary paper, only a small fraction of participants could have had HIV RNA < 500. Imagine how few (if any?) were “elite controllers”. Similarly, would HPTN 052 demonstrate a reduction in the risk of HIV transmission even among those who started the study with undetectable viral loads? Doubtful.
- Patients who start ART often have some residual abnormalities in immune activation and inflammation — will the same hold true for elite controllers? In patients on long-term suppressive ART, abnormalities in inflammatory and immunologic markers persist in many patients. Moreover, the number of elite controllers who have been treated with ART and studied intensively is very small, limiting our ability to make firm conclusions. This study looked at 4 such patients treated with TDF/FTC and raltegravir, showing a non-significant trend downward over 24 weeks of therapy. More such patients are being studied in ACTG A5308, which is an ongoing prospective clinical study of ART in HIV controllers (I’m on the study team) — but until we have those results, the benefits of ART even on surrogate markers for this population are unknown.
- Most HIV controllers don’t want to start treatment. We’ve been telling some of them for years — even decades — that they are special, and that they don’t need treatment since their immune systems are doing all the work. Not surprisingly, after hearing this for so long, it’s hard for them to hear otherwise, in particular since they still feel fine. It’s difficult to convey the benefits of HIV therapy by using the concepts of “T-cell activation” or (even worse), “%CD38+HLA-DR+ CD4+ T cells”.
Our experience with A5308 when we approached HIV controllers about participating was fascinating — even those who have been enormously generous to the research community, providing blood and tissue samples to numerous investigators for years, simply didn’t want to take HIV meds. One even told me he would prefer something more experimental than ART, such as an HIV vaccine or novel combination of cytokines.
OK, that’s enough — much more than the 1-2 sentences requested by Jose, sorry about that!
But it’s time to decide, please take the poll below (all are encouraged to participate). And this time (ahem), there’s no wrong answer.
November 6th, 2016
Infectious Diseases doctors will find this exchange familiar:
New person you’re meeting: What to do you do?
ID Doc: I’m a doctor.
New person: Oh — what kind?
ID Doc: A specialist in Infectious Diseases.
New person (making a face, or moving a few feet back, either to be humorous or truly frightened, or both): Yuck! Well I guess someone has to do it …
The stigma associated with Infectious Diseases is as much a part of the field as knowing why Pneumocystis carinii is now Pneumocystis jirovecii, and how to pronounce the drug class that includes linezolid and tedizolid. (Oxazolidinone.)
I mention this aspect of ID as it came up recently in the context of our shiny bells and whistles electronic health record. One of its many features (common to most EHRs) is that you can generate letters to patients to notify them of their lab results.
Here’s what the header to those letters looks like; I highlighted the key problems:
There are four issues with this image, three small, one big. The three small items first:
- That’s the old hospital insignia. Here’s the new one.
- The lower-case “b” in BWH. Hello, can we get a proofreader in here?
- For some reason it’s calling our practice “bWH Infectious Diseases Medicine”, which is a term used literally nowhere else — we’re the “Division of Infectious Diseases” to the rest of the world.
None of these is a big deal (though it is kind of ironic to see what you get for your billion dollars).
What is a big deal, however, is that many of our patients have made it abundantly clear to us that they don’t want any references to “Infectious Diseases” on materials mailed to them. Worse would be “Infectious Diseases” on the envelope’s return address — gosh, anyone could see that — but mentioning it at the top of a letter is also off limits. (For the record, our old EHR had an option to choose “generic BWH letterhead”, and we went with that as the default.) We’re also not supposed to say we’re calling from “Infectious Diseases” when leaving appointment reminders or other voicemail messages, so we don’t.
Non-ID clinicians might think this is an exaggeration, but I assure you it’s really the tip of the iceberg. I’ve had patients tell me that they don’t like the fact that our practice is called “Infectious Diseases” in the hospital directory, preferring that we be listed by some generic term — one suggested we go back to the plural, “Medical Specialties”, which is what our office used to be called when we shared clinical space with Renal, Pulmonary, and GI; another wanted the bland moniker “Brigham Associates” (to which I would always wonder, “associates with what?”). Some don’t even like sitting in our waiting room — this is very sad, when you think about it — even though they are coming to us for their own ID problem.
But think of how we’ve responded to our patients’ concerns:
- Many ID/HIV practices or inpatient services have various euphemisms that say nothing about the mission of the clinicians — Ward 86, the Moore Clinic, the 1917 Clinic are three famous examples.
- A terrific group of HIV/ID nurses I’ve worked with for over 20 years calls themselves “The Resource Team.”
- I know a famous hospital (yes, again that other one in Boston abbreviated with 3 letters) that frequently refers to HIV as “Z virus” — a longstanding tradition that greatly precedes (and has nothing to do with) Zika.
So back to our patient letters: I contacted our excellent IT liason to see if we could change the letterhead back to something that doesn’t say “Infectious Diseases”, and included our HIV Social workers in the email thread, thinking they would certainly amplify the importance of this change to our patients.
Surprisingly, I got this back from one of them:
Does any other department need to protect their patients by disguising the name of where they work? It’s as if we own stigma like our patients. In Social Work they call that “the parallel process”. It’s kind of a part of our own identity, our reality, and for some of us our pride in our specialization. I’ve been changed as a person because of it. Wow, really getting deep this morning!
Susan has a point. Imagine if “Dana-Farber Cancer Institute” or “Memorial Sloan Kettering Cancer Center” were asked by their patients not to include the word “Cancer” in their names. Or if a Cardiologist asked to remove his or her specialty from their hospital identification badge — I know one ID doctor who actually did this, as he didn’t want to make patients or hospital coworkers uncomfortable.
Makes you think. Are we doing more harm than good in treating our field with such exceptionalism?
October 29th, 2016
Let’s start with the clinical controversy, one that’s been bouncing around Emergency Rooms, outpatient practices, postgraduate courses, and medical journals for years. Specifically, are antibiotics helpful for skin abscesses that are adequately drained?
It’s still debated since of course most patients with this annoying problem will get better on their own provided the drainage is adequate. What do the antibiotics add, if anything?
Now, thanks to a superb clinical trial presented this past week in New Orleans at the annual IDWeek Meeting, we have some answers.
And though the study is important, there’s a good chance you don’t know about it, even if you attended IDWeek. First, just like the last time this group presented results of a different trial on at a national meeting, the abstract presentation took place in front of a only a handful of meeting participants.
Second, even if you wanted to come see the presentation, you might have been stymied by the vast travel distances inside the New Orleans Convention Center, which must be one of the longest indoor spaces on the planet. Safe to say that no one who attended this meeting finished a day with fewer than 10,000 steps, unless they brought along their hoverboards or Segways. Sometimes it felt like I was walking half the way to Baton Rouge.
(For the record, that first study ended up being a major paper in the esteemed New England Journal of Medicine. Justice!)
Anyway, here are some of the details of this new study:
- Adults and children with small skin abscesses were eligible provided they weren’t immunocompromised, diabetic, or systemically ill.
- They all underwent abscess drainage and cultures.
- Participants were randomized 1:1:1 to receive TMP/SMX, or clindamycin, or placebo for ten days. (Glad they followed the Golden Rule.)
- 786 subjects enrolled (505 adults and 281 children) at several sites around the country.
- 67% had positive cultures for Staph aureus; 74% of these isolates were MRSA.
- At a 10-day post-therapy visit, cure of infection was seen in 83.1% and 81.7% of clindamycin and TMP/SMX treated patients respectively — both significantly better than placebo (68.9%).
- TMP/SMX was better tolerated than clindamycin, with adverse event rates of 11% (TMP/SMX) and 22% (clindamycin). Placebo was 12.5% (guess that’s the “nocebo” effect). There were no cases of C diff or severe rashes.
- Clindamycin-treated patients had fewer relapses than those receiving TMP/SMX.
The droll presenter, Dr. Robert Daum, and the senior author, Dr. Chip Chambers, made a couple of other interesting observations. First, if the culture grew a Staph aureus resistant to clindamycin, responses were reduced. The good news is that this resistance was observed in only around 5% of isolates, a much lower percentage than typically seen in Staph aureus from hospitalized patients.
Second, if cultures were negative for staph, response rates were similar between all three treatment arms — meaning you could potentially stop antibiotics in select patients based on culture results (though important caveat, this strategy wasn’t tested).
The results of this study add to a growing body of evidence that antibiotics do in fact improve outcomes even for drained skin abscesses, swinging the pendulum further back in the direction of using them for this indication. Whether you and your patient think that this net 10-15% increase chance of cure is worth the risks of antibiotics will probably depend on the case — but at least now we have the data to make an informed decision.
And boy, do my feet hurt.
October 20th, 2016
Once again, we’re giving our “Infectious Diseases in Primary Care” post-graduate course in beautiful Boston — where the weather is perfect, the air crisp and clear, and we are all watching with excitement as the few remaining baseball teams and presidential candidates make a mad dash to the end of their respective races.
(You might have heard something about that.)
As in the past, we get a boatload of excellent questions from our participants, most of whom are highly experienced primary care clinicians. Note that not all of these questions have a definitive answer, so if you have an opinion or want additional clarification, please weigh in!
Off we go:
- One of my patients had a positive tuberculin skin test, but didn’t believe it, so I sent a [insert brand name here for your interferon gamma release assay of choice, which I hate typing]. That came back as negative. The blood test is more accurate, isn’t it?
We get this one every year, so might as well start off with it! The problem here is that there is no “gold standard” for diagnosing latent tuberculosis — it’s easy when they both agree, but sometimes the TST is positive but not the IGRA, sometimes the reverse, and neither test has 100% sensitivity. The main advantage of the IGRA is that it is less prone to false-positive results from either BCG or non-tuberculous mycobacteria. In the case when you have a discordant result, go with the one that you think makes the most sense based on the likelihood of lifetime TB exposure — and don’t forget to use the invaluable Online TST/IGRA Interpreter to help guide your decision! If the stakes are particularly high (e.g., about to get TNF inhibitors), act on the positive result. Read more on this topic here. And to reiterate, typing the brand names of IGRAs is NO FUN AT ALL, but here goes: QuantiFERON-TB Gold In-Tube and T-SPOT.TB. Good grief.
- My patient doesn’t want to get the zoster vaccine since she’s afraid of getting a live-virus vaccine. Should I just wait until the inactivated vaccine comes out and then immunize her?
Sure, it’s reasonable to wait. The inactivated zoster vaccine has been tested in multiple prospective clinical trials (for example this recently published study in adults 70 or older), and is highly effective at reducing the risk of zoster, and also quite safe. Currently under FDA review, it will probably also require vetting by the American Committee on Immunization Practices (ACIP) before insurance plans will cover it. The current live-attenuated zoster vaccine is also safe and effective, but since zoster immunization is hardly urgent, if your patient wants to wait, that’s probably the way to go. Hey, I heard the vaccine may carry the nifty brand name “Shingrix”. I make fun of lots of brand names on this site — Fulyzaq, R.I.P. — but got to give credit when the marketers come up with a good one, and “Shingrix” is emphatically one of those.
- Do we really need to get a chest X-ray on a young patient with suspected pneumonia? Why not just treat them based on physical findings?
The primary reason to get a CXR is that the optimal antibiotic choice depends on what part of the lung is involved — levofloxacin, for example, is particularly effective in the left lung. (That was a joke. Ha.) Actually, my colleague Mary Montgomery fielded this one, so I’ll let her answer: “It’s important to get a CXR in order to avoid giving unnecessary antibiotics for acute bronchitis, which gets better without them — most are viral. We used to think that any radiation exposure was worse than antibiotics, but as we are learning more about the microbiome and antibiotic resistance the risk equation is changing. The radiation risk from one CXR is equivalent to 10 days of natural background radiation. (For comparison a mammogram is equivalent to 7 weeks of natural background radiation and a PET-CT is equivalent to 8 years!) And every antibiotic dose risks changing the microbiome, causing antibiotic resistance, or leading to C diff.”
- How do I choose between the multiple flu vaccines available?
Choosing among the current flu vaccine options is like trying to choose a breakfast cereal in a large US supermarket — there’s simply too much choice, and that’s without the live intranasal vaccine this year. Regular dose, high dose, trivalent, quadravalent, adjuvanted, eggless, mercury-free — pretty soon they’ll be offering them with free WiFi and a breakfast buffet. The ACIP won’t put their money down on any single vaccine brand, essentially saying “Get any of them — they all work.” Note the latest entry to this dizzying array of options — a recombinant egg-free quadravalent vaccine. I suspect the various Guidelines Committees are awaiting more definitive efficacy data, especially on the high-dose vs regular dose option — until then, we a study showing somewhat better response rate to the high-dose vaccine in the elderly. Some think this is enough to use the high-dose in the elderly, others don’t.
- I heard the flu season last year didn’t peak until March — is that because we’re vaccinating people earlier in the year, and their antibody protection wears off in late winter?
While there is evidence that antibody titers decrease over time after influenza immunization, this is not the reason the season peaked in March last year. Flu season peaks change year to year, usually falling somewhere in the northern hemisphere between December and March. As to why it varies like this, only the people who can predict the severity of the upcoming flu season can tell you. (Big secret: They don’t know that either.)
- I saw someone in my office recently who told me he was on a plane for 3 hours next to man who was coughing the whole time. He’s worried he might have been exposed to TB. How long should I wait before testing him?
You should test him now, to establish a baseline — especially if you don’t have a prior negative one on file. Since it takes 2-8 weeks to generate an immune response to TB after exposure — and it’s the immune response we’re measuring with both the TST and the IGRAs — guidelines suggest waiting 8-10 weeks after exposure for the second test. Remember that converting from negative to positive has a greater urgency for preventive treatment, as the risk for active disease is much greater in the first few years after acquiring TB. And while most people who are coughing a lot on planes do not have tuberculosis, I’m going to propose that airlines have the equivalent of negative air flow rooms for their coughing passengers. Can’t be too sure, right?
- I take care of patients in a capitated healthcare system, and we’re grappling what to do about hepatitis C treatment. It’s just so expensive!
If you agree that curing HCV before there’s significant liver fibrosis, cirrhosis, hepatic decompensation, cancer makes sense — and of course you do, it’s medically irrefutable — then we have to prescribe these treatments for our patients. The good news is that the cost is way down from the crazy “SIM-SOF” days of 2014, when curing a single patient of HCV could easily cost > $100,000. There are now numerous options for therapy, in particular for genotype 1, all of them more than 95% effective and many consisting of just one pill a day for 12 weeks. This wide range of choices has had the expected effect on pricing, with deep discounting off of “average wholesale price” now the expectation for all insured patients, whether their coverage is private or government payer. So if you haven’t looked into it for a while, you’ll likely be pleasantly surprised — estimates of current cost/cure are roughly $20-40,000/patient, depending on the regimen and the payer. Still a lot of money, but think of what we’re getting in return!
- Can you please continue to put fun videos on your blog?
Gladly. Meanwhile, if you have some questions appropriate for this course, post them in the comments section below, we’ll do our best to answer. And next year’s course looks like it will be October 25-27.
(Hat tip to Joe Posnanski for the video.)
October 9th, 2016
One of our medical school’s most beloved teachers gives a wonderful lecture on how to give an effective presentation. He offers many invaluable tips for a successful talk, such as 1) Show up early; 2) Know your audience; 3) Don’t read your slides; 4) Never include a slide that you need to preface by saying, “I know you can’t read this, but …”
He also cites certain “off limit” topics that could alienate you from your learners, hence best avoided if possible.
Here’s the list:
But to an ID/HIV specialist, Topic #1 is simply unavoidable. Sorry. And since we’re less than a month from wrapping up one of the most bizarre presidential races in U.S. history, Topic #2 is front-and-center in everything we do these days, and where we’re going to venture today.
The motivation is a New York Times piece published last week entitled, “Your Surgeon Is Probably a Republican, Your Psychiatrist Probably a Democrat.”
Which prompted me to offer this observation (and lightly edited figure):
So if I might edit the title, it could be, “Your Surgeon Is Probably a Republican, Your Psychiatrist Probably a Democrat, and Your ID/HIV Doctor Probably Hasn’t Voted Republican Since Lincoln.”
(Actually, that’s not quite true — but you get the idea. And it’s Psychiatry right above ID in the figure, obscured by the highlight I added.)
So now that I’m deep into these dangerous political waters, I’m wondering why we’re at the bottom of this graph. Or at the top, if you flip the question.
Two quick thoughts inspired by the article:
- ID/HIV doctors support the “safety net” culture of healthcare. Think about our AIDS Drug Assistance Program (ADAP) and Ryan White Care Act — arguably among the most successful national health programs in the country. (For the record, ADAP was the topic of the second-ever post on this site way back when, triggering all kinds of prickly comments. Glad the nice people at NEJM Journal Watch didn’t pull the plug right then and there.) And consider organizations such as Partners in Health or Médecins Sans Frontières. Or the vast number of ID doctors who devote their energies to global health, or to emerging infectious diseases, or to life-threatening outbreaks, or to diseases that disproportionately strike the poor or disenfranchised (tuberculosis, malaria, HIV, HCV, cholera, parasitic diseases), or to working in “free” clinics for sexually transmitted infections. Somehow these efforts register as more Blue than Red, don’t they?
- Money. Hey, this isn’t the first time we ID/HIV docs have been at the bottom of a figure — remember 2014, when we ranked last in salary? Things have improved for us since then, fortunately, but even with these salary gains, we’re hardly in surgical specialty territory. So there’s a strong correlation (higher salary, more likely Republican), but it’s hard to argue that this relatively low pay directly causes Democratic leanings — unless you conclude that highly paid doctors resent high taxes (which after all pay for those safety nets) more than we do.
But it’s probably more complicated than just these two factors, so would be interested in your thoughts.
And just for fun, let’s make it 3 for 3 on those prohibited topics …