HIV and ID Observations

In no particular order, 20 things I’ve found interesting lately — a mix of ID (mostly), language quirks, clinical stuff, even tennis, and an apology (#21) at the very end. Bonus videos embedded because we all need a break.

1. Isn’t it amazing how, over time, an antibiotic once considered “broad spectrum” later becomes the drug we use after the term “narrowed?” Example:  “He was on meropenem, but his cultures came back with just Strep mitis, so we narrowed him to ceftriaxone.” Fair enough — it’s narrower than meropenem — but it’s crazy that ceftriaxone is now a “narrow” antibiotic!

2. Someone who claims incorrectly to be knowledgeable about healthcare — but has nonetheless risen to position of power and influence — said that “50 percent of revenues to most pediatricians come from vaccines”. What the …? You might as well say that they get the other 50% by charging for the stickers they hand out at the end of the visit. In fact, pediatric practices take on financial risk and incur high up-front expenses to have vaccines available; for some, providing and administering vaccines can lose money.

3. On the topic of pediatrics, childhood hospitalizations last year from mycoplasma did indeed sharply increase, accounting for half of hospitalized children with pneumonia. We also saw way many more cases in adults, including many with those strange off-target presentations (rashes, neurologic disorders, hemolysis). While cyclic variations in mycoplasma incidence are expected due to waning immunity, this past year saw a bigger increase than usual.

4. I’m not gonna lie — it has always amused me that many people (including me!) highlight certain comments with, “To be perfectly honest…” What does this imply about when we don’t say this? That we’re not being honest? And yes, “I’m not gonna lie”, “truth be told,” “truthfully,” and the rest of the bunch all fall into the same category.

5. A patient I’ve been following for years had a CD4 nadir of 3 at the time of their HIV diagnosis in 2010; it’s now over 2000, an astounding increase. Meanwhile, a similar patient I saw recently has had virologic suppression for almost as long, and the absolute CD4 count still can’t quite crack 100. This variation in immune response to antiretroviral therapy is one of the unsolved mysteries in HIV medicine.

6. Learned recently that pair of words that is used in a fixed order in an idiomatic expression is called an “irreversible binomial.” You know — wet and wild, mac and cheese, wear and tear, rock and roll. The first ID one that came to mind? Glucan and galactomannan — fungal diagnostics aficionados will agree, no one says it the other way

7. The continued universal susceptibility of Treponema pallidum and group A strep to penicillin remains a great gift to humankind, one we should be grateful for every day.

8. We complain about electronic medical records a bunch, but let’s face it — they have made a whole lot of things better than back in the pre-digital age. Near the top of the list? The ability to review radiographic studies without having to trek to a reading room, where the films may or may not be available. It’s especially great since we can now use Teams or Zoom to review the images with our radiologists, with them highlighting the areas of greatest interest.

9. How does anyone ever learn English?

10. We’ve had BCID (Blood Culture Identification) testing in place for around a year now; it rapidly identifies the bacteria in positive blood cultures, and tests for genetic determinants of common resistance mechanisms, too. Trust me — once you have this in place, you can’t imagine ever going back.

11. Even a year after my rant, and over a decade since generic tablets hit the market, some clinicians still think linezolid is too expensive. That’s because patients go to pharmacies, get told their insurance won’t cover it, and aren’t told they can just pay out-of-pocket at a reasonable price. Even worse, one large chain still charges a crazy high price, presumably for the branded version. Because they can? It’s madness.

12. I used to pride myself on knowing all of the FDA-approved cephalosporins, including obscure oral formulations. Confessing right here that the blizzard of recently approved and late-stage compounds (most of them cephalosporin-beta lactamase inhibitor combinations) has challenged this party trick. Let’s see — there’s already ceftazidime-avibactam, ceftolozane-tazobactam, cefepime-enmetazobactam, and cefidericol; coming soon will be cefepime-zidebactam and cefepime-taniborbactam. Wow.

13. By the way, in addition the cephalosporins, I can also name the fluoroquinolones that were withrawn due to safety issues — temafloxacin, sparfloxacin, gatafloxacin, grepafloxacin, and trovafloxacin. Branded Zagam, Trovan, Raxar, Tequin, they sounded like action figures fighting it out in an animated science fiction movie. Fun times!

14. Which reminds me: A resident recently told me they couldn’t go into ID because it required “too much memorization” — antibiotics and microbiology, specifically. My reply: it’s not like you become an endocrinologist by spontaneously deriving the hormonal feedback loops. Every specialty has its learning curve. Memorization follows interest.

15. Since the topic of party tricks came up (Name that cephalosporin! That discontinued quinolone!), I often find myself watching videos of card tricks with amazement, admiring the talent of people with a large repertoire. This guy, who says he has a million such tricks, is my favorite of many such magicians — something about his very regular-sounding voice makes him tremendously appealing:

16. Since those were Keith Haring playing cards — you noticed, right — I must cite that IAS 2025, the 13th IAS Conference on HIV Science, happened this week in Kigali, Rwanda. Not surprisingly, there were several presentations on disruptions in patient care resulting from recent policy changes and budget cuts by the USA — disruptions that will lead to more HIV infections and more HIV-related deaths. Sad to see this proud chapter in US foreign policy come to an end.

17. The letters to the editor at NEJM protesting the Sounding Board written by Drs. Vinay Prasad and Martin Makary on vaccines for COVID-19 make fascinating reading, as does Prasad’s and Makary’s response to the correspondence. It’s remarkable how a group of intelligent, experienced, and well-meaning people can look at the same body of evidence in medicine and come up with starkly different interpretations. I think both sides having valid points.

18. Related, what I’d really like to see is Prasad — who is a strong advocate of evidence-based medicine — take aim at some of the quite outlandish statements we’ve heard about the epidemiology and causes of autism, or the perils of seed oils. Hey, why not? He’s never been shy about voicing his opinion in the past.

19. My favorite new phrase mobilized by our ID fellows when coming up with a treatment plan for an ID consult? Course it out. “He’s improved on cefepime day 3 empirically for pneumonia; I think we can course it out with 4 more days and sign off.” Love that phrase — “course it out” — now a part of our service lingo. Plus, 3+4 = 7. Because of course it does.

20. Congratulations to Jannik Sinner, who blitzed his way past Carlos Alcaraz in this year’s Wimbledon final, as well as Iga Świątek, who “bageled” Amanda Anisimova, 6-0, 6-0. But the best single point of the competition? I’d give the nod to old-timer (38!) Novak Djokovic who, on his way to a semifinal finish, pulled this one off in an earlier round;

21. I was hard on Djokovic in the past when the guy refused to get the COVID-19 vaccine, comparing him to a bully athlete from my school days, but he has really grown on me. In my defense, the world was crazy those first two years of the pandemic; I wasn’t always so tolerant. Which is why I was delighted to read a piece entitled Novak Djokovic, I Was Wrong About You, as it summarizes my current views on him perfectly.

So my apologies, Novak!