HIV and ID Observations

Scene:  Medical Grand Rounds, 5 minutes before the start. Lecture is on coronary artery disease, which may have a link to Infectious Disease even if it isn’t actually caused by Chlamydia pneumoniae or CMV after all.

A well-regarded, experienced primary care physician (PCP) approaches.

PCP: Hi Paul, I have quick question*.

[*Curbsiders often use this exact phrase — and rarely does it correlate with whether the question is actually “quick”.]

Me:  Sure.

PCP: One of my patients has a urine culture that’s persistently positive for MRSA* — I’ve repeated it twice. Should I treat it?

[*Ah, our old friend MRSA. Odds of this question actually being “quick” have just plummeted.]

Me: Hmm, those results could be a sign of systemic infection, with secondary seeding of the GU tract.*

[*We ID doctors are probably — no, definitely — biased towards badness. Which makes us worriers. After all, why else do we get involved in a case?]

PCP: But he’s completely asymptomatic*. Do I need to treat it?

[*I am pretty sure, by his giving me this information, that he does NOT want to complicate matters by looking more deeply into the matter. But he’s slightly unsure about this approach, so he wants me to endorse his action. Or more accurately, his lack of action.]

Me: Then I bet it’s in his prostate — MRSA can cause prostatic abscess, or chronic prostatitis. You could get a prostatic ultrasound or pelvic CT to investigate further.*

[*At this point, our malpractice lawyers would like me to insert into the conversation defensive boilerplate language, such as, “I’ve given you some general information about a general patient, but I don’t know this case well enough for me to render specific medical advice. At your request or the patient’s request, I would be happy to become involved in evaluating him and see him for a formal consultation.” Which makes me wonder: Can you imagine if doctors actually did everything lawyers told us to do?]

PCP: Well, he’s 100 years old, and the family doesn’t want him leaving the nursing home unless it’s a true emergency.*

[*A perfect example of how you don’t get the whole story from a curbside consult. “Quick question”… yeah right.]

Me: I see.

PCP: And I’d like to avoid giving him antibiotics, since last year he had C diff twice and it nearly killed him.*

[*See above comment about not getting “the whole story.”]

Me: Got it.

The lights dim in anticipation of the lecture. Various doctors, many of them cardiologists, begin heading for their seats, readying themselves for the lecture. Time is running out!

PCP: So, what do you think I should do?*

[*I knew it would come to this. Hey, I’m trying to be helpful! Really!]

Me: I guess you’re weighing the risks of giving him antibiotics — and causing another case of C diff — with the risks of undertreating a potentially invasive infection, MRSA.*

[*Look, I know this is an incredibly obvious thing to say. But what else can I do?]

PCP: I could have told you that, and I’m no ID specialist.*

[*He didn’t actually say this, but he was probably thinking it.]

Me: Ask me about evaluating chest pain. That’s much easier.

The lecture starts. It is excellent.  But people immediately take out their smart phones and check their email and Facebook updates anyway.