HIV and ID Observations

In honor of spring (March 20), and the very important National Puppy Day (March 23), here are a bunch of ID and HIV-related recent items for consideration, contemplation, and perusal:

• A life-threatening case of tetanus in an unvaccinated boy highlights the personal and financial cost of the anti-vaccine movement. How deeply embedded are these false beliefs? The parents still aren’t vaccinating their children.
• Prophylaxis for Mycobacterium avium complex is no longer recommended for people who start ART immediately, regardless of CD4 cell count. Have been advocating for this change long enough to write, “I told you so, nah nah.” Bet it takes a while to extract this from medical school curricula, where somehow MAC prophylaxis has assumed importance way beyond its actual usefulness.
• Travel advice about Zika has dramatically changed. This is a sensible policy shift — ongoing transmission is now exceedingly rare, even the regions hardest hit by Zika back in 2015-16. Still, the information may cause ongoing confusion — sensible discussion here.
• What is it like for an unvaccinated adult to get measles? This personal account makes it clear that it’s no picnic — measles is no mild “viral syndrome.” Once again, so impressive when people use their own adversity to try and effect change — thank you!
• And along a similar theme, thank you to this teenager who has publically sought vaccines for himself — even though his parents remain anti-vaxxers, and have publicly criticized him.
• ID consultation improves outcomes and saves money for people receiving outpatient parenteral antibiotic therapy (OPAT). From the abstract:  “ID consultations during OPAT are associated with large and significant reductions in the rates of ED admission and hospital admission … as well as lower total healthcare spending.” Here’s a bold idea — let’s ask insurance companies and other payers to pay ID doctors for this important service, which right now is often done gratis!
• In community-acquired pneumonia, starting treatment that includes combination therapy directed at Pseudomonas aeruginosa is associated with higher mortality. Retrospective studies like this one can be tripped up by unmeasured confounders — such as whether those who received combination therapy were sicker in ways that could not be accounted for — but given the absence of data supporting combination therapy, here one must assume that less is more.
• Playing in the dirt improves the gut microbiome and reduces the risk of allergies. How’s that for prematurely drawing conclusions about the clinical implications of a mouse study? You’re welcome. Still — it wouldn’t surprise me a bit if it turns out to be true.
• Medical history buffs and antibiotic geeks will appreciate this detailed account about antibiotic development, bacterial resistance, and vancomycin. Even though it’s 240 pages (!) long, rest assured that the “font” is large, it’s double-spaced, and once you start reading, it’s hard to stop! I like this sentence about the 1950s: “The antibiotics aureomycin, terramycin, tetracycline, and chloramphenicol formed the closely related group known as broad-spectrum antibiotics.” Ha. (H/T to Dr. David Aronoff for this find.)
• This sensible review finds no evidence that patients with sacral pressure ulcers need long-term treatment for underlying osteomyelitis. This does not mean withholding antibiotics from cases where there is evidence of acute infection (fever, purulent drainage, surrounding cellulitis), but is does mean that empiric 6 weeks of IV antibiotics for an equivocal MRI finding is of questionable value. A good read for everyone who does inpatient ID consults.
• These ID doctors argue that our specialty should have a voice in the “This Is Our Lane” movement to reduce gun violence in our country. Certainly survivors of gun violence frequently have numerous infectious complications, especially those with spinal cord injuries. That the authors come from Louisiana — a state with a particularly high rate of firearm related deaths — adds to the importance of their message.
• A couple of additional studies add to the the evidence that persistent low-level viremia in HIV may mean something clinically — but we still don’t know what to do about it. In this paper, 50-199 was associated with subsequent failure; in this one, the problem level didn’t kick in until > 200. I’m convinced that for those that are 100% adherent to meds, it doesn’t mean much; for those that have low-level viremia due to irregular adherence, it does! For more on this topic:
• Here’s a new explanation for detectable HIV in patients on suppressive therapy — “repliclones”. These are large cell clones carrying intact proviruses, and don’t represent replication in the traditional sense — but can contribute to low-level detectable virus. (The RRR™ of CROI 2019 was two weeks ago; I should have highlighted this study.) A good further description of the study is here, along with what it means for cure research.
• This politician takes his kids to chicken pox parties, and this one believes that antibiotics work against measles. Hmmm … trying to think of something funny to write, but words completely escape me. And that’s rare.
• A second-year medical resident put together this informative and entertaining “Tweetorial” on MRSA precautions. Should be required reading for any institution considering the need for contact precautions for this organism. Wondering if he’s going into ID, seems like a natural!

Because this tweet seemed to strike a nerve among so many;.

Suppose its #tweetorial time to evaluate the evidence supporting, or not, the use of contact precautions (CP) to prevent the transmission and infectious complications of #MRSA https://t.co/BdwLxvQ4f6

— R Logan Jones, MD FACP (@rloganjonesmd) February 5, 2019

• We hear a ton about overtreatment of bacteriuria in the elderly, but might we sometimes be undertreating them? The study found no antibiotic therapy for UTIs was associated with a significant increase in bloodstream infection and all-cause mortality. The paper has already stirred up extensive controversy among antibiotic stewardship-types, not surprisingly.
• And in case you’re wondering, yes there are new guidelines for management of asymptomatic bacteriuria. To those who don’t practice medicine, let me assure you — this is not always an easy assessment to make, especially in the elderly in particular those with cognitive impairment! It’s still not quite clear what we should do with worsening incontinence, or when patients only note cloudy or “bad smelling” urine — a limitation acknowledged in the paper.
• Think of infection with Mycoplasma hominis and (in particular) Ureaplasma urealyticum in immunocompromised patients with unexplained hyperammonemia. That these organisms are so difficult to culture and also harbor unpredictable resistance patterns makes diagnosis and management tricky.
• ID has significant disparities in academic achievement and faculty rank by sex. Fascinating paper by one of our fellows (Dr. Jennifer Manne-Goehler), with perhaps the most interesting part being that the disparity is greater in ID than cardiology — why might that be? It is particularly important to understand these disparities in ID since women account for more than 50% of those entering our field.
• Rabies prophylaxis after a cat bite can cost you a lot. There’s nothing wrong with the medical management here; it’s the way our very peculiar healthcare system adjudicates the cost of care. In this example, a woman received a bill for $48,512 after a two-hour visit to an emergency room, which included shots of rabies immune globulin plus the vaccine, and a dose of an antibiotic. “My funeral would have been cheaper,” she said.
• United HealthCare is offering patients two $250 prepaid debit cards every 6 months to “offset medical expenses” if they go on certain less expensive HIV regimens. Consider this the converse of the “co-pay cards” provided by the pharmaceutical industry for brand-name drugs. The main problem I have with these programs is lack of transparency — here, what is United HealthCare making off this deal? Odds are it’s more than the cost of those debit cards, especially if those cards are used for services provided by United HealthCare anyway. Further information on this program from IDSA’s perspective is here,
• On the topic of drug costs, here’s authoritative and interesting review of drug pricing in ID. All the favorites are covered, from the shocking HCV drug prices to the mind-boggling pricing of generics such as pyrimethamine, albendazole, and even penicillin. The senior author is my long-time friend and colleague Dr. Rochelle Walensky — who appears to be far less cynical about that United HealthCare plan than I am!
• If you want a quick update on investigational antifungal agents, start right here with this summary. Wow, that’s quite a pipeline! And thank you, Dr. Andrej Spec (@FungalDoc), who was rewarded for this great work by receiving a commission (from me) for a full review paper.
• San Francisco has a poop on the streets problem. And no, it’s not just dogs and puppies — it’s also human feces on the street, the result of stark disparities of wealth readily apparent when walking around that city. From the piece:  “An infectious-disease specialist … has compared certain parts of San Francisco—where contaminants include a proliferation of discarded needles—to slums he’s studied in the developing world. The slums were cleaner.” Thanks to Dr. Monica Gandhi for first alerting me to this problem!

Too bad it’s another year until National Puppy Day returns.

Until then, enjoy this: