An ongoing dialogue on HIV/AIDS, infectious diseases,
July 7th, 2019
In Praise of Experienced ID Fellows — and a Dozen On-Service ID Learning Units
My message — you were like them not so long ago; they didn’t suddenly all lose their brainpower when you graduated. This ungenerous opinion of house staff may be especially held by experienced fellows, as the accumulating workload of the year can lead to impatience.
The post might have felt a bit tough on current fellows, but that was not my intention. As I noted at the start (citing my own experience), it’s nearly a universal illusion, one we all have to get through.
So here’s the flip side of working with those experienced ID fellows — for us attendings, it’s wonderful.
I frequently attend on the inpatient ID service during the transition period between fellowship years, and once again it’s been an absolute joy to witness the expertise and confidence of these seasoned pros as they finish their fellowship year.
Their clinical instincts. Their remarkable growth in fund of knowledge. Their ability to assess, rapidly, not just “sick” vs. “not sick” — that starts with residency — but even more importantly, “sick from an ID problem” vs. “sick from something else entirely; the ID issue is secondary.”
The skills go on. The experienced ID fellows focus their diagnostic and therapeutic suggestions in ways that would have been impossible for them just months ago. They handle serious, difficult ID problems — Staph aureus bacteremia, a new HIV diagnosis, epidural abscess — with confidence and aplomb. They communicate with patients, family members, and consulting teams accurately and clearly, without excessive jargon.
As they present cases on rounds, I await their assessments with deep interest — as more often than not they have insights about diagnosis and treatment that are spot-on.
Plus — and this is a tough one — they recognize that the late afternoon or weekend consult may be highly appropriate, and not just an annoyance, no matter how busy the day.
So thank you, ID fellows who have just finished their first year — it’s been a blast.
And here’s a list of some of what we discussed on rounds — a dozen “Learning Units” for each day on service:
Day #1: Transmitted HIV drug resistance mutations in newly diagnosed people with HIV often have no clinical significance (e.g., L90M in PI is most common). Latest data from @CDCgov not yet published but summarized in this valuable poster from #CROI2019. https://t.co/KcCR66RVuw … pic.twitter.com/BgcTHFyqRS
— Paul Sax (@PaulSaxMD) June 26, 2019
Day #2: @IDSAInfo guidelines recommend dilated ophtho. evals in all non-neutropenic pts w/ candidemia, but this widely cited recent review found the practice to be of questionable yield. Do you still recommend it? @FungalDoc @GermHunterMD @FranciscoMarty_ https://t.co/YvT6JpSFuN
— Paul Sax (@PaulSaxMD) June 27, 2019
Day #3: The @KariusDx DNA sequencing test may assist in dx for difficult to culture pathogens (as in this case report of C. burnetii endocarditis); broader role in clinical practice still to be determined by sensitivity, specificity, and cost. https://t.co/8FZfFGzqte
— Paul Sax (@PaulSaxMD) June 28, 2019
Day #4: Dropped gallstones as a nidus for abdominal abscess, sometimes with actinomyces; can also cause empyema. https://t.co/SmUqg7SWTp
— Paul Sax (@PaulSaxMD) June 29, 2019
Day #5: The "inoculum effect" is a main reason to favor oxacillin/nafcillin over cefazolin in serious infections due to MSSA. But how then to explain the numerous observational studies demonstrating comparable (or better) outcomes with cefazolin? https://t.co/MqqqQJENkR
— Paul Sax (@PaulSaxMD) June 30, 2019
Day #6: Hantavirus pulmonary syndrome should be considered in patients with rural exposure (esp southwest USA) and pulmonary interstitial edema on chest radiographs in association with leukocytosis, thrombocytopenia, and hemoconcentration. https://t.co/4o5Vc855re
— Paul Sax (@PaulSaxMD) July 1, 2019
Day #7: In this retrospective series, 46 (38%) of 122 patients with pure aortic insufficiency requiring valve replacement had endocarditis. Study done in the pre-molecular diagnostics era — would it be different now? https://t.co/K5j1IHdYpN
— Paul Sax (@PaulSaxMD) July 2, 2019
Day #8: The risk of stroke is increased after herpes zoster, in particular within the first 3 months and after V1 HZ. Treat with acyclovir, though one wonders if this is beneficial in late-onset cases (where CSF PCR may be negative). https://t.co/TLGUxFdKtV
— Paul Sax (@PaulSaxMD) July 4, 2019
Day #9: The most common infectious causes of broncholithiasis are histoplasmosis and TB, but any granulomatous process can be responsible. Management highly variable depending on location and clinical symptoms. Good recent review: https://t.co/5No3zGLHQo
— Paul Sax (@PaulSaxMD) July 4, 2019
Day #10: P. acnes (now C. acnes) is an important cause of post-neurosurgical infection. Key points: 1) long duration of symptoms; 2) no fever; 3) nl wbc; 4) delayed presentation post surgery; 5) anaerobe, slow to grow. Good early case series: https://t.co/SYr5oWtGRR
— Paul Sax (@PaulSaxMD) July 5, 2019
Day #11: Despite some reports of resistance, doxycycline remains the treatment of choice for Mycoplasma hominis infection. Alternatives include quinolones and clindamycin. Azithromycin should be avoided. https://t.co/Of9DHpJVYe
— Paul Sax (@PaulSaxMD) July 6, 2019
Day #12. In a low TB prevalence setting (USA), a single negative Xpert MTB/RIF sputum test had a negative predictive value for TB of 99.7%; two tests 100%! This study has had a major impact on infection control policies in US hospitals. @ACTGNetwork https://t.co/cqNZFMn58B
— Paul Sax (@PaulSaxMD) July 7, 2019
What an outstanding group. Much gratitude to you all! https://t.co/RO7MkUbV3Y
— Paul Sax (@PaulSaxMD) July 3, 2019