HIV and ID Observations

This is a very valuable pear.

Once upon a time, the annual meeting of the Infectious Diseases Society of America (IDSA) wasn’t much of a research conference.

It consisted mostly of review sessions on topics deemed worthy of an update or a refresher, led by noted experts in the field. They would cite the latest literature on endocarditis, or mycoplasma, or prosthetic joint infections, or malaria, or transplant infections, or HIV complications, or sternotomy infections following cardiac surgery.

(I kid you not about that last one … to each their own, I guess!)

Some of this was good stuff — cutting edge and exciting — but some was frankly kind of tedious. You went because it was “good for you”, kind of like eating kale if you don’t like kale.

And pretty much all of it was led by white men of a certain age — which is my age now, give or take a decade, good grief.

My, how times have changed, and emphatically for the better.

The IDSA meeting, re-branded “IDWeek” a few years ago, now mixes in original research with not only these terrific review sessions (you can still skip the one on sternotomy infections), but also challenging case presentations, entertaining debates, policy updates, and awards.

Importantly, presenters, participants, and awardees all increasingly reflect the diversity of our field, making the meeting feel much more inviting and collegial — a very welcome change.

There’s so much going on no one can cover it all, certainly not me. So here’s a sampling of some (emphasis on some) of the interesting research presentations from last week, a “Mini” Really Rapid Review™ of the conference. Use the comments section to chime in with your favorites.

• 20% of outpatient antibiotic courses are prescribed without a visit, and 46% without even an infection-related diagnosis. These data (from former colleague Jeffrey Linder) are discouraging, but not surprising — it’s much easier for clinicians to respond to patient complaints with action (here a prescription for antibiotics) than a recommendation for watchful waiting. Antibiotic prescribing is also associated with higher patient satisfaction. We need to keep getting the word out that these are not benign drugs!
• Daptomycin plus IV fosfomycin is better than daptomycin alone for MRSA bacteremia. There is in vitro synergy between daptomycin and fosfomycin against MRSA (who knew?), which motivated this randomized controlled trial. The results are tantalizing, with most  endpoints significantly favoring the combination. Credit to the investigators for studying something so common and so serious, but for which we have so little good comparative data. (IV fosfomycin is not available yet in the USA.)
• Preemptive therapy for CMV in high-risk donor seropositive/recipient seronegative liver transplant recipients reduced the incidence of CMV disease more than prophylactic therapy. Participants were followed with weekly CMV viral loads, so this strategy requires quite a bit of monitoring and care coordination. Still, the study is very likely to change clinical practice in some transplant centers. (FYI, every time I write “preemptive” I need to confirm the spelling.)
• Fetal exposure to efavirenz during pregnancy increased the risk of “neurologic conditions” among HIV-negative children. This observational study of 3,747 children also showed a trend toward more such conditions (microcephaly, febrile seizures, seizure disorders, ophthalmologic disorders, others) with dolutegravir. Since boosted PIs may increase the risk of premature birth (and have the worst GI tolerability), the unfortunate fact remains that we still don’t know the safest HIV treatment for pregnant women.
  

  “MRSA? Campylobacter? So sorry, I didn’t mean it.”

• Therapy dogs benefit pediatric oncology patients, but may transmit MRSA. Fortunately, a decontamination procedure involving chlorhexidine-based shampoo before the visit, and chlorhexidine wipes on the fur during the visit, reduced this risk. I say benefit-risk ratio favors keeping the dogs involved, but acknowledge I’m highly biased! (Go ahead — click on the picture.)
• Dogs (actually puppies) were also responsible for a large outbreak of highly drug-resistant campylobacter. Extensive use of “prophylactic” antibiotics by breeders and a pet store chain provided the selective pressure. So don’t blame the pups.
• Women are underrepresented in publications and achieving the rank of full professor in academic ID. Imbalance is greater in ID than in other specialties, including cardiology, endocrinology, and hematology — can we speculate why that would be? (Study led by one of our ID fellows, he wrote, beaming with pride.)
• For healthcare workers caring for patients with viral respiratory infections, there was no difference in their incidence of lab-confirmed influenza or viral respiratory infections whether they used N-95 or standard medical masks. Hugely important negative study — N95 masks are expensive, uncomfortable, require fit testing, and are just generally a huge pain.
• A longer duration of surgical antibiotic prophylaxis did not reduce surgical site infections but increased adverse events. Tell your surgical colleagues this the next time they want to continue antibiotics postoperatively for a few days “just in case.”
• Clinical outcomes of ID consultations done by telemedicine were comparable to in-person consults. The field of telemedicine is exploding, driven by ever-improving technology, shared electronic medical records, what’s best for the patient and — importantly — mutually agreeable financial benefits for both consultant and consulting clinicians. It really can’t get off the ground in a fee-for-service, RVU-based system, where in-person visits still are an ID doctor’s only billable service. Outstanding session here given by representatives from successful programs.
• All-cause mortality is significantly increased in adults with pulmonary non-tuberculous mycobacterial infections. This large (43,394!) Medicare database study confirmed what we ID doctors and pulmonary specialists already know — that these NTMs are serious infections that deserve way more attention. Better treatments can’t come soon enough!
• A small randomized study found similar outcomes — and shorter lengths of stay — when patients with substance use disorder received OPAT. This contentious topic was debated further here; shout out to my colleagues for this excellent recent comprehensive review.

There was plenty more, of course — read the many responses to this query!

Hi Twitter Friends, I'm going to do a "Mini Really Rapid Review" of #IDWeek2018, looking for suggestions of what to cover. Fire away! Links appreciated. p.s. will explain the significance of the pear later. pic.twitter.com/oMk0PU9B5Z

— Paul Sax (@PaulSaxMD) October 6, 2018

As for the pear, it cost a staggering $4.64 in my hotel lobby. Remember when San Francisco was affordable? I don’t either.

At least I saved money on the flight out there.