An ongoing dialogue on HIV/AIDS, infectious diseases,
February 23rd, 2014
A Lower Dose of Efavirenz Works Just Fine — and Why This Matters
As we heard last year in Malaysia, and now published in The Lancet, 400 mg of efavirenz is just as effective as the standard 600 mg dose.
The proportion of participants with a viral load below 200 copies per mL at week 48 was 94·1% for efavirenz 400 mg and 92·2% for 600 mg (difference 1·85%, 95% CI −2·1 to 5·79). CD4 T-cell counts at week 48 were significantly higher for the 400 mg group than for the 600 mg group (mean difference 25 cells per μL, 95% CI 6—44; p=0·01).
The 400 mg dose was better tolerated, too. For the record, these data are far more convincing than prior dose-reducing strategies with other antiretrovirals (stavudine, zidovudine, ritonavir come to mind). The results of the study were no doubt outstanding.
So these results have huge implications internationally, where efavirenz-based regimens are the default first-line choice for essentially all treatment naive patients. A lower dose will make treatment cheaper, coformulations easier, the pills smaller, and the sun will shine brighter, too.
Here in the USA? As of today, these data are of limited value, and here’s why:
- As first-line therapy, efavirenz is overwhelmingly given as part of coformulated TDF/FTC/EFV (Atripla), which as you know includes 600 mg. Decreasing to 400 mg means increasing the number of pills, both because this splits up the coformulation and because EFV comes in 200 mg capsules.
- If we’re after similar efficacy and better tolerability, there are several other non-efavirenz first-line options that do the same thing, and are easy to take, too — notably TDF/FTC/rilpivirine, TDF/FTC/elvitegravir/cobicistat, and TDF/FTC or ABC/3TC + dolutegravir.
- Until a generic version of efavirenz is approved, there’s not all that much benefit from a cost perspective — though I do hear that TDF/FTC/EFV pricing has been going up.
- The 400 mg dose is not FDA approved for treatment.
So for now, I stick with my opinion about the waning of the efavirenz era — a drug which has been on an extraordinary run dating back its approval in 1998.
However, if the 400 mg dose does get FDA approved, and if there are future coformulations with EFV using this dose, and if these data are confirmed to lower toxicity while maintaining virologic efficacy, then efavirenz might make a comeback.
But it’s a long shot.
February 13th, 2014
Jeter is Retiring, and Certain ID Doctors Are Getting Old(er)
It’s safe to say that most of the perspectives on Derek Jeter’s retiring from baseball will not be written by ID doctors, so let me seize the opportunity.
And since it’s always risky to dwell on players from a certain team while living in Boston — I have friends for whom a central component of their identity is Hatred for the Yankees — this will be less about Jeter’s retirement and more about how the news made me feel.
In a word — old.
You see, I was at the game when Jeter hit his first major league home run — opening day in Cleveland, April 2 1996, weather a balmy 38 degrees. That was a remarkable year on many fronts, both personal and professional, as my daughter was born, Boston experienced its snowiest winter ever, HIV became suddenly treatable (How About That!), and well, the Yankees won the World Series, in part thanks to their rookie shortstop.
So what was it like to be an ID doctor 18 years ago? Let’s take a look at the Wayback Machine, and I caution those of a certain age that this is guaranteed to make you feel downright ancient:
- You were still doing gram stains in a hospital lab that was on the patient floors.
- Aminoglycosides were a regular part of “triples” — you know, amp, gent, clinda.
- Amphotericin B had no liposomal formulation, and was co-administered with all kinds of magic potions (diphenhydramine, meperidine, hydrocortisone, pixie dust) to make it better tolerated.
- Erythromycin was used as an actual antibiotic — sometimes even intravenously.
- Ritonavir was used as an actual antiretroviral, and the dose was 600 mg twice daily (yes kids, you read that right).
- Severe C diff was extremely uncommon, and almost never happened in an outpatient.
- Community-acquired MRSA might be presented at an ID case conference given its rarity.
- There was hardly any vancomycin-resistant enterococcus — good thing, too, since there was no linezolid.
- If you wanted a quinolone to treat community-acquired pneumonia, you were out of luck — levofloxacin wasn’t approved until December 1996.
- If your patient needed indinavir, he/she needed to get it from a single mail-order pharmacy called “Statscript.”
- No echinocandins, oseltamivir, tigecycline, cefepime, daptomycin.
- Some days you spent half of your time on rounds looking for X-rays. These were actual films, viewed on a light box — or, if you were in the radiology department, on those noisy contraptions that rotated light boxes. (What did they do with those things?)
- These numbers/letters meant nothing: HLA-B*5701, HPTN 052, K65R, E138K, CCR5, CXCR4, Q80K, PrEP, TDF.
- Target vancomycin trough level: 5-10.
- Some people were actually taking ddC — which, despite the medical “information” from Dallas Buyers Club, was a pretty horrible medication.
- Best place for drug information was often the “PDR”. If you’ve never heard of it, don’t ask.
I could go on like this all day, but why not finish on a high note?
February 5th, 2014
Electronic Medical Records, Eye Contact — and Dogs
A few thoughts on the importance of eye contact during patient care, no doubt inspired by my puppy’s first birthday, and his insistent and adoring (at least that’s how I see it) gaze:
- Long piece in the New York Review of Books — all doctors subscribe, of course — by Arnold (Bud) Relman, describing his experience as a 90-year-old who survives a fall. Riveting, moving, and typically curmudgeonly stuff from the ex-Editor-in-Chief of the New England Journal of Medicine. But this line deserves emphasis: “During the day I was visited on rounds by teams of physicians. They spent most of their time outside my room, studying and discussing the data on their mobile computers.“
- How do interns spend their time in the era of electronic medical records? Let’s look at the data — “Interns spent 12% of their time in direct patient care, 64% in indirect patient care, 15% in educational activities, and 9 % in miscellaneous activities. Computer use occupied 40% of interns’ time.“
- Or, for a more poetic description, read Abraham Verghese’s brilliant description of the “iPatient”: “On my first day as an attending physician in a new hospital, I found my house staff and students in the team room, a snug bunker filled with glowing monitors … the demands of charting in the electronic medical record (EMR), moving patients through the system, and respecting work-hour limits led residents to spend an astonishing amount of time in front of the monitor.”
- One of my colleagues in General Medicine, Jeff Linder (who parenthetically does some nice ID-related work too), found that the number one barrier to use of electronic medical records during an outpatient visit was loss of eye contact with patients — which does not surprise me a bit.
- The solution? Get a medical scribe to join you in the exam room so you can actually look at the patient while taking the history. This is the money quote from this wonderful New York Times piece: “For decades, physicians pinned their hopes on computers to help them manage the overwhelming demands of office visits. Instead, electronic health records have become a disease in need of a cure, as physicians do their best to diagnose and treat patients while continuously feeding the data-hungry computer.” FYI, after reading this piece, every single colleague of mine wants a scribe now.
- The hospital periodically receives patient surveys from these guys. The leading complaint, of course, is parking — this is Boston, after all. But in the Top Five Complaints is also something along the lines of, “That doctor seemed more interested in the computer than in me.”
- Department of Oversharing: I recently saw a doctor for an eye issue, and he was very competent and nice. He spent 90% of the visit (aside from the exam part) entering what I was telling him into his electronic medical record. The computer was situated far to his left, so he was facing away from me the entire time; I could have put on this hat, he never would have noticed.
OK, so I’m nearly done. Except to comment that we used to be able to take notes while facing our patients, and that this allowed a kind of organic eye contact that seems all but impossible in the electronic medical record era. Note that I won my 8th Grade Typing Competition (72 words/minute, thank you), so don’t blame inadequate keyboarding skills.
And since this started with a dog (dare you to click on the image above) and eye contact, I might as well say that they run rings around both cats and us electronic medical records-obsessed doctors when it comes to this skill.
Enjoy more dog magic in this nifty documentary:
January 30th, 2014
Unanswerable Questions in Infectious Diseases: Persistent MRSA Bacteremia
Ok, here’s a favorite of adult ID specialists everywhere — a real tough one. The case goes something like this:
Older person, many medical problems. Probably is on hemodialysis, with the vascular surgeons having some difficulty with access. There’s diabetes, of course, and cardiovascular disease, and oh yeah, a mechanical aortic valve that’s around 10 years old. Some toes are missing from prior surgical treatment of osteomyelitis.
Now? Fever and mental status changes have brought him/her to the hospital, and 100% of the umpteen blood cultures done since admission are positive for MRSA. They remain positive even though the MIC to vancomycin is 1.0 and the trough concentration of the drug is 18.
Since starting on vancomycin, the patient has improved somewhat, but continues to have fevers and, yes, positive blood cultures. Lots of them — it’s been days. Vancomycin MIC is checked again, and it remains unchanged. Maybe even it’s 0.5 this time. An exhaustive search for a removable focus of infection has yielded nothing — no abscess, no valvular vegetations/root abscess, no spinal osteomyelitis, clots. A cardiac surgeon has been consulted, and passes on the opportunity to replace the valve, thank you very much. The dialysis AV fistula is functioning, for now, but is not red or draining.
So the question is this:
With persistent MRSA bacteremia despite “appropriate” vancomycin therapy, should the antibiotics be changed?
Lots of options out there. Linezolid. Daptomycin. Ceftaroline (off label, of course). Combination therapy, with the idea that more should be better, naturally. You could add gentamicin (really?), or rifampin (biofilms!), or do a vancomycin/beta-lactam combination.
Let’s hear from you — vote on these options (as I said, there are lots of them this time), then comment away.
January 21st, 2014
Unanswerable Questions in Infectious Diseases: The Positive Cultures for Candida in an ICU Patient
OK, gang. You did such a bang-up job on Question #1 that I can’t resist getting another consult.
Here’s the case: Patient in intensive care, has been there for some time — at least a week, probably weeks. Perhaps he/she had surgery (especially abdominal surgery) that didn’t go well, or has severe cardiovascular disease, or multiple trauma from an MVA, or suffered a large intracerebral hemorrhage or stroke. There have been several antibiotic “courses” directed at fevers of too many origins.
Each day you see the patient, and each day there’s a fever — generally 100.5 or a bit higher. Normotensive. Nothing obvious on exam. Labs show a WBC of 11-15 — in other words, not normal but not horribly abnormal either. LFTs are fine.
All bacterial cultures are unrevealing. Several sputum cultures, however, are positive for Candida; a urine culture (from a foley catheter) is positive also. If the patient has an abdominal drain, it has a few yeast in there too. Imaging is non-specifically abnormal — some pleural effusions, but no obvious pneumonia; CT shows no abscess.
So here’s the question:
Should patients in the ICU be given systemic treatment for Candida spp. if they have positive cultures from multiple sites other than blood?
If you want to research the question, here are a couple of randomized trials here and here, concluding yay and nay, respectively.
Or just go ahead and vote, and have at it in the comments section.
January 15th, 2014
Unanswerable Questions in Infectious Diseases: The Abdominal Collection and Duration of Antibiotic Therapy
Each time I attend on the inpatient service, the number of questions for which we just don’t have a definitive answer continues to amaze me. And here’s the most remarkable part — many of them come up all the time!
In that spirit, I will post a series of these quandaries, and you, the brilliant readers, will offer your answers or, barring a definitive answer, your individual approach.
Let’s start with this one:
How long should we continue antibiotics in someone with infected abdominal collection and a percutaneous drain?
You know the situation — peritonitis from perforation, or diverticular abscess, or a surgical mishap, and now the interventional radiologists have kindly placed a drain into the infected collection. (Or, more commonly, multiple drains into the multiple collections.) The patient, once critically ill, is improving — albeit slowly — and the resident, surgical PA, and surgeon all want to know the answer to the above question.
Low grade fevers — 99.5 F or so — continue. There might be an ongoing anastomotic leak, there might not. There is no plan for more surgery. White blood cell count is down from 25K to 15K. Platelets are slowly rising.
Yes, this is a specific variant on the age-old “How long should we treat?” question. I’ve opined on this before, but now we’re getting specific. These IDSA guidelines say “4-7 days,” but that implies rapid source control, no ongoing leak, everything going smoothly.
(And these smooth-sailing cases rarely trigger an ID consult.)
So what do you do in this particular situation? Please vote and comment — especially if you don’t like any of these answers!
January 2nd, 2014
A New Year’s Snowstorm ID Link-o-Rama
Some ID/HIV items jangling around in the inbox, just dying to get out, before they are covered in snow:
- Interesting, balanced piece in the New York Times about the slow uptake for PrEP, in particular among gay men. This caught my eye: “Certainly, fewer people have tried PrEP than many experts had anticipated.” I wonder who those experts were? Seems this always was going to be a relatively niche intervention.
- Fascinating editorial in the latest New England Journal of Medicine about preserving antibiotics, which includes this amazing statistic: Almost 80% of antibiotic use in the United States is for livestock. And here’s a great slide for your next talk on antibiotic resistance. Don’t those cows worry about upsetting their microbiome?
- Speaking of antibiotic resistance, I neglected to highlight this extraordinary CDC report on Antibiotic Resistant Threats when it first came out this year. The top three, with threat levels of “Urgent,” are C. difficile, Carbapenem-resistant Enterobacteriaceae (look at this chilling map), and Drug-resistant Neisseria gonorrhoeae. Sounds about right — but I’d have substituted MRSA for the last one — way greater clinical impact. MRSA’s threat level, by the way, is listed as “Serious.”
- Is some chronic low back pain caused by bacterial infection? According to this paper, and this randomized trial of amox-clav, the answer is clearly yes! An editorial rightly describes the implications of these studies for spine surgeons and pain specialists — never mind patients — as “momentous.” Yes, these are the winners of The Most Surprising Studies in ID, 2013. Confirmation of these findings by other investigators eagerly awaited. (What an understatement.)
- These three deaths from Lyme carditis are most worrisome — the patients were really young (26–38 years old), and though two of three had some pre-existing cardiac disease, they were overall pretty healthy. Fortunately, a review of 20,000 pathology specimens at a tissue bank did not find any additional cases, suggesting that Lyme carditis as a cause of death is rare indeed. Still, wouldn’t it be great if the Lyme vaccine for humans were available again?
- As more HIV drugs become generic, this should mean cost-savings, right? Not always, according to this remarkable (and disheartening) report. Lesson: If you don’t like the price of a generic drug, it pays to shop around for the best price. And if you live near a Costco Pharmacy, give them a try, even if you’re not a member — their pharmacies are available to all, with consistently low prices.
- SPOILER ALERT — if you haven’t seen the movie Philomena, just skip to the trailer below and read no further. But if you’re on the fence, you must see it, since it could have been the best film of 2013 — entertaining, well-acted, funny, heartbreaking. Just great. I cite it here on this site because one major plot turn occurs when the main character’s long-lost son is found to have died of AIDS — and though she is naturally very sad, her response was completely non-judgmental in a very non-Hollywood way. I was expecting the typical moral outrage, and was pleasantly surprised that it never came.
Stay warm, everyone, and Happy New Year!
December 24th, 2013
Brush with Greatness: John G. Bartlett
At the IDSA meeting in 2012, John Bartlett gave a lecture called, “Infectious Diseases Update for the HIV Provider” — what a great title — which was, as usual, information-packed, practical, well-referenced, and just plain fun. It also occurred to me at the time that there is probably no other person on the planet who could give this lecture, and made me vow to write something about what a treat it is chatting with John at ID meetings or other events.
For those of you who don’t keep up with the celebrities in Infectious Diseases, John was Chief of the Division of Infectious Diseases at Johns Hopkins for 26 years, stepping down in 2006. He was also the Co-Chair and one of the founding members of the Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents, a position that we’ve just learned he is leaving this year.
But John is much, much more than these titles. John is the true Renaissance Man of Infectious Diseases, the person in our field who somehow seems to know something — and usually a lot of something — about everything.
You want some examples? How many ID doctors are true experts in all of the following distinct topics?
- HIV
- Clostridium difficile
- Respiratory tract infections
- Antimicrobial resistance
- Anaerobic pulmonary infections
I’m fairly certain the answer is “Just one — John Bartlett”, and I’m no doubt doing him a disservice by leaving off several other areas of expertise that should be added to the list. Most of us ID doctors would make a career out of one of these topics.
The other impressive thing about John is that he’s a true visionary. Says his long-time former colleague Joel Gallant:
John is a man of incredible vision. He always knows what the next big thing will be, and embraces it long before it becomes the next big thing. There are many examples: managed care, bioterrorism, medical education on the internet (before he knew how to turn on his own computer), pandemic flu, and of course HIV/AIDS. Back when most hospitals, university medical centers, and ID divisions were running away from the AIDS epidemic, John took it on, both as a scientific priority and a moral imperative. With the help of Frank Polk and the Hopkins president, he established an outpatient AIDS clinic and an inpatient AIDS ward—both of which were way ahead of their time.
This last part is well worth reading again, which is why I bolded it. To start an HIV program at Hopkins in the 1980s was a truly brave move; many hospital administrators (possibly at Hopkins and definitely elsewhere — ahem, looking at you one particular Harvard hospital) strongly opposed opening HIV clinics or inpatient services, as they feared the stigma such a clinical and research focus would bring to their institutions. John discusses these early days in more detail
Finally, is there a person better at combining both the practical and the scholarly aspects of Infectious Diseases than John G. Bartlett? And someone who does it with such excitement? Not a chance — think of his numerous guidebooks … his “Game Changers” or “Hot Topics in ID” lectures at IDSA … his end-of-the-year summaries (here’s a good one for 2013, didn’t know there was a Mimivirus!) … his “Awards”, such as this one for most important bacterium, of all things.
You can just sense how fascinating he finds each of these topics, and that enthusiasm inevitably makes us excited too — a key quality of a great teacher.
John will be missed on the Guidelines panel, but we will always know where to find him at our ID meetings — sitting toward the front at a major plenary session, taking careful notes in longhand on a large yellow pad.
Hey, he doesn’t want to miss anything!
(One in a very occasional series.)
December 8th, 2013
Simeprevir and (Especially) Sofosbuvir Are Great Leaps Forward — and They Will Cost Plenty
Hepatitis C has been potentially curable for decades, but it’s hardly been easy. “I feel like I’m slowly killing myself,” said one of my patients, memorably, during week 24 of a planned bazillion-week course of interferon-ribavirin. (Actually it was only 48 weeks, but seemed like a bazillion weeks.)
Then in 2011 came the addition of telaprevir or boceprevir to the interferon-ribavirin, which made a cure more likely, but the treatment even worse. Rashes. Need for fatty meals. Tons of pills. Taste disturbance. Anal discomfort. (“Like shitting glass,” another memorable quote.) Anemia. And for the providers, having to manage these side effects and the complex “response-guided therapy” algorithms was no picnic.
Now, with the approval of simeprevir in November and in particular sofosbuvir Friday, HCV cure just got a whole lot easier. Both are one pill a day. Both have far fewer side effects than any existing HCV drug. Sofosbuvir adds the benefit of having almost zero important drug-drug interactions. (Simeprevir has many.)
The main problem with these new treatments is, frankly, their cost. They are very expensive — 12 weeks of simeprevir will be $65,000, of sofosbuvir $80,000. These costs are offset somewhat by reduced need for monitoring with safer therapies, a shorter course of interferon and ribavirin (if you go that route), and presumably down the road, prevented cases of cirrhosis, hepatocellular carcinoma, and liver transplantation.
And of course, few individuals will actually pay full price out of pocket for these treatments, just like few actually pay for their MRIs or their angioplasties or their stay in the ICU. Treating HCV is not like cosmetic surgery; it’s potentially lifesaving. And as with other expensive but lifesaving treatments, we’re hoping there will be generous patient-assistance programs for those who can’t pay.
But for those without coverage, people in other countries, or those charged with managing pharmacy budgets, this cost is a major hurdle.
All of which leaves me thinking that as of December 8, 2013, these are the best options for genotype 1 HCV infection (cost estimates approximate):
- Simeprevir + sofosbuvir for 12 weeks. PROS: More than 90% cure rate in the COSMOS study. Two pills once daily (it’s amazing even to write that.) CONS: The COSMOS study was very small. Simeprevir can lead to photosensitivity and has many drug-drug interactions. The Q80K polymorphism may reduce response to simeprevir. This regimen is not “FDA approved.” Cost = $145,000.
- Sofosbuvir + ribavirin for 24 weeks. PROS: Cured 76% of HIV/HCV co-infected patients in the PHOTON-1 study. May well do better in HCV mono-infected. Regimen is “FDA approved” for interferon-ineligible patients, which could help get insurance coverage. CONS. Ribavirin, and all its side effects. 24 weeks seems long compared to 12 weeks. Response rate is lower than other options listed here, which would require re-treatment. Cost (not including ribavirin) = $160,000.
- Sofosbuvir + interferon + ribavirin for 12 weeks: PROS: 90% cure rate in the NEUTRINO study. Only 12 weeks of interferon and ribavirin. Cost = $90,000. CONS: Interferon. Ribavirin. Enough said.
All are a lot better than what we had just last week. All of them contain sofosbuvir. And all are expensive.
November 30th, 2013
Five ID/HIV Things to Be Grateful for This Holiday Season
I was speaking with a British colleague the other day, and she was remarking how jealous she was that we get a Thanksgiving holiday each year. Starting with a long whine (or moan, as they would say) about the pressures, commercialization, cost, and religious aspects of Christmas, she then went on about how perfect Thanksgiving seems from her outsider perspective.
“What’s not to like? A big pot-luck dinner. Family and friends get together. No presents. A four-day weekend. And the sentiment of gratitude is so lovely.”
(That’s another one of their words — “lovely.”)
Can’t say I disagree, so in that spirit, here’s a quick list of five things from our little ID/HIV worlds to be grateful for, in no particular order:
- Vaccines. Did you see this paper in the New England Journal of Medicine? By conservative estimates, 75 million to 106 million cases of polio, measles, rubella, mumps, hepatitis A, diphtheria, and pertussis prevented by the vaccines in the United States alone. Add to this hepatitis B, H. flu, rotavirus, varicella, etc., along with the global effect of preventing all these infections, and the impact of vaccines on public and personal health cannot be overstated.
- Antiretroviral therapy. For those of us who have been doing this HIV treatment thing for a while, the movie “Dallas Buyers Club” quickly takes us back to a time that is almost unimaginable today — before effective antiretroviral therapy, before opportunistic infection prophylaxis, to a time when the clinical and research medical establishment was often at odds with the very people we were supposed to help, the people with AIDS. Sure, some of the medical details in the film are screwy — ddC a better treatment than AZT? — but it’s highly recommended nonetheless, with an unbelievably great performance by Matthew McConaughey, as you can see in the trailer below. Good to be reminded, every so often, just how transformed HIV disease is by current therapy.
- Doxycycline. How much do we ID doctors love you? Let me count the ways: Lyme disease, MRSA, anaplasmosis, ehrlichiosis, community-acquired pneumonia, urethritis, syphilis, Rocky Mountain Spotted Fever, malaria prevention, anthrax prophylaxis, pelvic inflammatory disease, brucellosis, wolbachia (that last one a trivia question for ID fellows)… And not only that, the drug is relatively safe (just don’t take it before lying down) and inexpensive (this year a bit less so, unfortunately). To continue the British theme, if you want to know every ID doctor’s “Desert Island Drug”, this is it — just be sure to bring the sunscreen. “Doxy,” thank you for being you — we are very, very grateful.
- AIDS Drug Assistance Programs (ADAPs). Here’s a challenging problem for the healthcare “system” (ha): A disease that is fatal, transmissible, stigmatized, and disproportionately targets the poor. Oh, and treatment is extremely effective, but also quite expensive. Problem? What problem? For HIV, we have a national program, administered by the states, that virtually guarantees everyone (with few exceptions) lifesaving antiretroviral therapy, regardless of their ability to pay — yes, ADAPs are truly miraculous. Sure, we worry about waiting lists and strained budgets (especially in the Southeast), but the number of people denied HIV therapy in the United States today remains small indeed. Who knows what form ADAPs will be in over the next few years with institution of the Affordable Care Act, but let’s hope this remarkable state of affairs is preserved.
- Microbiome and Resistance Awareness. Every healthcare provider has vast experience with the “green phlegm” patient encounter. It goes something like this: Patient is suffering from a prolonged cough, or runny nose, or some other respiratory symptom, and he/she keeps telling you that they have “green phlegm.” This term, you see, has long been a code for, “I need an antibiotic.” Never mind that the color of these secretions says little about whether the infection is bacterial or viral, somehow the public perception was that the only way to return to health, to eliminate the nasty green goo, was to start an antibiotic. Yet over the past few years, a Gladwellian Tipping Point has been passed: We still have the green phlegm conversations — isn’t being a doctor/nurse wonderful? — but for various reasons there are now lots of people out there who would prefer not to take an antibiotic if at all possible. Microbiome (all those good bacteria) awareness? Fear of antibiotic resistance? A friend/family member with C diff? Probably all of the above, and it couldn’t be more sensible, since of course all antibiotics can be harmful (even doxycycline).
What are you grateful for these days?
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
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