HIV and ID Observations

Home IV antibiotics are not fun — just look at her face. (Image: Pixabay)

Having just completed a stint doing inpatient ID consults, I came away impressed with three things:

1. Staph aureus remains the Ruler of Evil Invasive Pathogens in the hospital setting.
2. You can “jinx” a holiday season by saying it’s usually quiet on Christmas. This year it sure wasn’t quiet, hoo boy.
3. Some surgeons aren’t ready to accept the evidence about oral antibiotics being just as good as intravenous (IV) for their patients with severe infections.

Note I wrote some surgeons — not all. But with apologies to authors of the POET and OVIVA studies, and in particular to Dr. Brad “Oral is the New IV” Spellberg, who has been a leader in this space, I bring you now a blended version of several conversations I had with surgical colleagues when I recommended oral antibiotics for their patients:

Me: I heard from your resident that you wanted a PICC line for Mr. Smith. Did you see our consult note?

Surgeon: Thanks for following him. No, didn’t read it — what did it say?

Me, not at all surprised that the attending surgeon didn’t read our Masterpiece: We recommended that he go home on trim sulfa, one double-strength tablet twice daily. (I might have said Bactrim. Ok, I did.) The organism is susceptible, and it has excellent oral absorption. That way we can spare him the PICC line and all the risks and hassles of home IV therapy.

Surgeon: This was a very severe infection — I’d prefer we be as aggressive as possible in treating it.

Me: Understood. But there’s literature now showing that oral antibiotics are comparable to and safer than IV. I’m especially comfortable in recommending it when there is a high GI-absorption option like Bactrim, a susceptible bug, and there has been source control, as in this case.

Surgeon: Thanks for sharing that — I’m not up on the ID literature, but this infection threatened to get into the joint (or bloodstream or CNS — it’s a generic conversation). In the OR, we drained frank pus*, and had to copiously** irrigate the site with 3 liters of sterile saline.

(*I always felt bad for people named “Frank” when I hear this expression.)

(**Surgeons frequently use the word “copiously” when they irrigate infections. And how do they decide on the number of liters to use?)

Me: Yes, I understand it was bad. But it sounds like you got it all — that’s probably the most important thing. Another thing, he’s taken Bactrim before, and we know he tolerates it well.

Surgeon: Maybe use orals for a milder infection, but not for an infection this severe. I told him after the surgery he’d be going home on IVs. If we use oral antibiotics and it fails, I’d feel bad we didn’t attack this as hard as possible with IV antibiotics.

Me: Ok, we’ll set up the home antibiotics.

Surgeon: Great, thanks so much. Really appreciate your help.

Me: No problem. He’ll go home on 6 weeks of IV colistin.

(That’s an ID joke, ha ha. It really was ceftriaxone.)

A few comments about this exchange.

• It’s entirely friendly. We both want what’s best for the patient.
• The surgeon has already made up his mind before consulting us that IV is preferred over oral antibiotics.
• There is deep anxiety about oral antibiotics not being “aggressive” enough with a “severe” infection, with the concern about an error of omission rather than commission. Meaning, a bad outcome by doing less outweighs concerns about a bad outcome by doing more, which is why I bolded this sentence, and repeat it here:  “If we use oral antibiotics and it fails, I’d feel bad we didn’t attack this as hard as possible with IV antibiotics.”

This last point gets to the core of this debate. Surgeons, who by their very nature are quite active in their day-to-day practice, may not comfortable with what they consider a less invasive approach. Intravenous antibiotics are more challenging, more intensive, typically reserved for inpatients or critically ill people, hence (they think) they must be better.

This is a particularly tough nut to crack. And I get it — if an infection is severe, don’t we want to treat it as aggressively as possible?

The problem with this line of thinking is that it ignores good clinical evidence (including randomized trials and well-done observational studies); it does not factor in the risks, hassles, and cost of IV therapy; and it forgets the important principle Brad often cites, which is that the bacteria don’t care how the antibiotic got there — just that it got there.

In some ways, we’ve fostered the surgeon’s view by taking on the management of home IV therapy — often called Outpatient Parenteral Antimicrobial Therapy, or OPAT — as a core responsibility of us specialists in Infectious Diseases. After all, who knows antibiotics better than we do?

But this has insulated them from the problems. If we had each surgeon manage OPAT for their patients, it would open their eyes about misplaced monitoring labs, clotted and infected lines, upper extremity DVTs, failed home deliveries of medications, confused care providers at home, capricious vancomycin levels, and miscellaneous other mess-ups that are an unwelcome part of home IV therapy.

I have a hunch that if Dr. Orthopod P. Neurosurgeon had to manage these and myriad other OPAT issues, they’d be quite willing to consider an oral option if we told them a good one existed.