May 16th, 2016

Lots of College Graduations ID Link-O-Rama

For those of us living and working in Boston, we are most definitely smack dab in the middle of college graduation season — which means traffic is crazy, restaurants are booked, and energetic young adults are everywhere wearing gowns and funny hats.

In other words, a good excuse for an ID Link-o-Rama:

  • FDA advises against use of fluoroquinolones for uncomplicated infections. Specifically, this means sinusitis, bronchitis, and uncomplicated urinary tract infections — in other words, conditions that often would get better without any treatment at all. FDA was in a tough position with this one. On the one hand, you have the fact that all antibiotics have side effRED SQUIRREL PICects — are quinolones really worse? On the other, you have personal reports like this. And not just a few of them. And, in case you’re wondering, this FDA statement is huge — very likely to be practice-changing, and something that has been in the works for years. Hope we see studies one day that give an estimate of incidence and mechanism.
  • Guidelines for evaluation and treatment of (non-Lyme) tick-borne infections updated. So what’s the best treatment for anaplasmosis, ehrlichiosis, and Rocky Mountain Spotted fever when your patient has a (maybe) contraindication to doxycycline — for example, the patient is younger than 8 years? Answer: Doxycycline! And what about the alternatives? Didn’t you hear me? DOXYCYCLINE! There are alternatives, just none of them — chloramphenicol, rifampin, quinolones — very good.
  • Some smart people have known about Zika for years. I had the opportunity to interview Duane Gubler, a specialist in vector-borne infectious diseases, about Zika — and in his self-effacing way, he let on that he’s known about it for much longer than any of us. Great perspectives also on what it will take to contain it in the USA and globally, and an important side comment on Yellow Fever. Here’s a massive and comprehensive review on Zika on which he was senior author, if you can’t get enough.
  • Clinical differences between Zika, dengue, and chikungunya summarized. Here’s a handy table we should all commit to memory.
  • The HIV “care cascade” in the USA isn’t nearly as terrible as we thought. Specifically: 86% diagnosed, 72% retained in care, 68% on antiretroviral therapy, and 55% virally suppressed as of 2011, and it’s probably even better now. Of course, these updated data are much less newsworthy than the previous discouraging estimates — how long before these updated data are cited in place of these now famous (and much more attention-grabbing) figures?
  • Deaths from opioid overdoses now exceed those from car accidents — by a lot. After a weekend of rounding on several patients with life-threatening infections from injection drug use, I wonder: Are these horrible infections counted among the casualties? For the record, I have never seen so many serious IDU-related bacterial infections, in particular among “kids” (ages 18-29).
  • Over-the-counter loperamide is increasingly being used by people addicted to opioids. All of us HIV specialists have had patients on these drugs for years at a time, mostly (we thought) to counteract the toxic effects of certain antiretroviral agents. Now it appears that there is an important “off label” reason for the chronic use. Watch for the same issue with diphenoxylate/atropine (Lomotil).
  • Are workforce limitations holding back treatment of HCV? As stated nicely in this editorial, “managing HCV remains entrenched in the domain of hepatologists, gastroenterologists, and infectious diseases specialists located primarily in urban referral centers.” Given the simplicity, efficacy, and safety of HCV treatment, the authors argue for expansion of treatment to non-specialists and non-MDs. Makes sense — but until that happens, keep sending HCV cases to us ID docs, we love treating HCV!
  • Elvitegravir as a single-agent will no longer be available as of February 2017. (Information came as a “Dear Doctor” letter, so no link … somehow it snuck onto this “Link-o-Rama”!) Not surprisingly, hardly anyone is on elvitegravir (fewer than 50 patients nationally), which means that 99.9999% (that’s an estimate) of elvitegravir use is in coformulations, which will of course still be available. While stopping sales of elvitegravir alone is understandable based on the low utilization, even better would be removal of older toxic antiretroviral agents, such as didanosine, which can cause life-threatening side effects. I bet there are more than 50 people nationally on that drug!
  • British red squirrels are getting leprosy. For years the red squirrels have been in decline due to the brash American gray squirrels, and now this! The horror. Remember, the English take their animals very seriously — some have said that this is where they channel all those warm emotions that they are so reluctant to use with people.

To wrap up in a totally different direction, some of my best friends and colleagues love musicals — me, not so much (would prefer good seats at a baseball game, thank you).

Regardless, I did think The Lion King was pretty spectacular, so enjoy!


(H/T to Rochelle Walensky and Raphy Landovitz for the video, Reuters for the squirrel pic.)

5 Responses to “Lots of College Graduations ID Link-O-Rama”

  1. Loretta S says:

    Wondering what your take on the FDA warning about fluoroquinolones is, Paul. Do you think it will result in more ID consults? The feeling among the fellow primary care providers I talk with is that this is going to be a big problem. The FDA is fuzzy on the meaning of “For patients with these conditions, fluoroquinolone should be reserved for those who do not have alternative treatment options.” What does it mean that a patient does not have alternative treatment options? They’ve been on 3 other antibiotics in the last year for their chronic sinus infections? Or does it mean they have allergies to all the other potential antibiotics? Or the C&S for a UTI showed a bacterium that only responds to an FQ? (I can’t think of a time when I’ve seen that, to be honest.) There are other scenarios, but you get the drift. And what does this mean for prescribing for COPD exacerbations, where an FQ is commonly-prescribed?

    Not surprisingly, fear is something I am also hearing. As in, “Oh, great. So every time I prescribe an FQ, I have to imagine myself on the witness stand getting hammered by a lawyer. Nope, not going to let that happen.” Yeah, fear of lawyers and malpractice suits drives a lot of medical thinking, I know. A whole other topic.

    So I would be curious about your take as an ID doctor. I regard the FDA statement as extraordinary, and it sounds like you do, too?

  2. Tom Boo says:

    Hakuna Truvada video cute and catchy but would be confusing if it was used in Swahili-speaking countries! Hakuna mean “absence of” or “there isn’t any”, so it makes no sense (everyone seems to know that hakuna matata means no problem or no worries).

    • david says:

      That’s true about the video. At the beginning I really wondered why they were so happy when an important drug like truvada is not available. Beautiful video though

  3. Erika says:

    As an HIV surveillance professional, I have to say – be careful! That paper is an estimate, while the CDC figures are based on total numbers. Both have weaknesses. I don’t think it’s right to say that the care cascade is or isn’t anything, since all the data have problems – maybe that an alternative estimate is now available that suggests a rosier picture.

  4. Chaz says:

    Even if these HIV cascade data are not as bad as you thought, they are still pretty bad for an industrialised nation

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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