An ongoing dialogue on HIV/AIDS, infectious diseases,
December 19th, 2008
Infectious Disease in the ICU: Help Please? Part I
I am currently attending on the inpatient service, which means I spend a good chunk of my day seeing new ID consults and rounding on follow-ups. As I’m sure is true in most hospitals, many of these consults are from the intensive care units (ICUs).
After 18 years in this ID business, I confess I still find myself quite challenged by ICU Infectious Diseases. It’s not due to the complexity of the cases, in fact just the opposite — paradoxically, there’s a sameness to the cases that is worlds away from the wonderful variety of ID/HIV elsewhere: the outpatient with fever of unknown origin, or the inpatients with endocarditis, meningitis, orthopedic infection, HIV-related complication, or tropical fever (the stuff that makes up much of the rest of the consult volume). One intensivist says that once patients get past the first few days after admission, most of the medical issues they face are similar.
From the ID perspective, this means “rounding up the usual suspects,” including searching for line infections, UTIs, C diff, sinusitis, pancreatitis, surgical site infections, acalculous cholecycstitis, drug fever, infected pressure ulcers and — especially — nosocomial pneumonia.
There’s a sameness to these investigations that makes individualizing care difficult, and often forces us to focus on the (abundant) microbiologic data as distinguishing characterisitics. Just how resistant are the bacteria isolated from this patient’s respiratory sample? How many different possible pathogens can be cultured from a surgical drain? What is the significance of candida isolated from several non-sterile sites? How about those few colonies of coagulase negative staph on a removed line tip?
So where to go for help? For a comprehensive “how to” for this patient population, check out the recent IDSA/American College of Critical Care Guidelines. It’s an impressive document.
And give yourself plenty of time — it’s 20 pages long, and has over 200 references.
(In Part II, the issue of empiric antibiotics in the ICU.)
December 5th, 2008
New Case Definition for HIV Infection? Yawn …
The CDC has revised its case definition for HIV infection and AIDS, so that now laboratory evidence — a positive antibody test, or detectable HIV RNA or DNA – is required for the diagnosis.
It’s not intended to guide clinical practice, but still — what took them so long? A clinical diagnosis of AIDS was only necessary before HIV had been discovered. I cannot imagine someone reporting a case of AIDS or HIV infection without a positive blood test, especially since there have been several well-publicized cases of erroneous HIV diagnoses when laboratory confirmation was unavailable, or not performed.
So good move here, glad the epidemiologists have caught up. And nostalgists may enjoy reading prior versions of various AIDS case definitions here.
December 4th, 2008
More Support for HIV Screening
On Monday December 1 — World AIDS Day, if you’re keeping track — the American College of Physicians released a position paper supporting routine HIV screening for adolescents and adults in the United States.
(If you don’t want to read the whole thing, we’ll have a perfectly-executed summary by the inimitable Abbie Zuger on our AIDS Clinical Care site any day now; it’s been written, but somehow getting material up there is harder than it is here. Go figure. UPDATE: Now you can read it here.)
In essence, these ACP Guidelines are highly concordant with those issued in 2006 by the CDC: One-time testing for adults in health-care settings. Frequency of repeat testing to be determined by risk assessment.
This leaves the US Preventive Services Task Force as a mild voice of dissension about the issue of HIV screening, as it neither endorses nor discourages routine screening. The USPSTF does recommend screening “at-risk” populations, a useful strategy but one that still leaves a substantial proportion of HIV diagnoses undetected.
Meanwhile, the number of states still requiring written informed consent for HIV testing continues to fall …
November 25th, 2008
Coming Soon: A Great Advance in TB Diagnostics
An all-too-frequent problem in the ID clinical world is the case where tuberculosis is possibly the diagnosis, but confirming it is difficult, or impossible.
Now, in a scientific breakthrough of such magnitude that it warranted front page coverage in our local newspaper, I am pleased to report that we may have a solution: giant rats.
Yes, giant rats. In a pilot program in Daar es Salaam, rats evaluate saliva samples at a rate of 40 every 10 minutes, signaling with “unmistakable paw motions” when they detect a sputum infected with TB.
And here’s a bonus — they can also sniff out land mines, in case you happen to need that service too.
No doubt these critters will be showing up in our microbiology labs any day now. I can’t wait to read the OSHA regulations for their protection.
November 17th, 2008
Promising C diff Rx, and Google as Surveillance Tool
A few items from recent ID/HIV news:
- Bad enough when it happens once, relapsing C diff is one of the modern plagues for which our bag of tricks sometimes comes up woefully short. (Anything that tests stool transplants as a therapy is pretty desperate.) Here was some bright news on the treatment front, however: an experimental drug named OPT-80 was just as effective as vancomycin, but with a lower rate of relapse (13% vs 24%). What kind of drug is OPT-80? Why, it’s a “macrocycle” (first I’ve heard of them, I confess), and has shown focused activity against gram positive anaerobes only — including C diff. Sounds ideal for this indication.
- Google has quietly convinced us it can do just about anything, so why not influenza surveillance? By the way, note how they switched from “google.com” to “google.org” for their philanthropic activities. Does that not-for-profit designation mean they are the future Gates Foundation, ready to offer vast sums to solve global health problems? Or is it just a subtle PR move? Likely some combination, but I like the idea of their putting their technology skills to the public good.
- I guess Tony Fauci and Robert Gallo were none too impressed with that “cured” case of HIV recently in the news. Oh well, I guess it takes a lot to impress you when you’ve been at this HIV/AIDS game from the start. Still …
November 10th, 2008
Yes, Just a Case Report, but Incredibly Cool
At this year’s Retrovirus Conference (was it really this year’s conference, seems like much longer ago than that), there was a poster presentation summarizing a very unusual case. A man with HIV, stable on antiretroviral therapy, developed acute leukemia. He underwent an allogeneic bone marrow transplant — here’s the kicker — from a donor who was homozygous for the CCR5 delta 32 mutation. In other words, the donor’s CD4 cells were all but resistant to infection with CCR5-tropic virus.
All antiretrovirals were stopped at the time of transplant, and — amazingly — no rebound in HIV viremia occurred for a year. No virus found in plasma or PBMCs; no HIV found in bone marrow or in rectal biopsies. He remained HIV seropositive, but the virus was nowhere to be found.
When I presented this single case in summaries of the highlights of this year’s CROI, inevitably the response was astonishment, even though it was just one case. But then the case disappeared from view, and I don’t believe it has been published yet in a peer-reviewed journal.
Now the story has been updated in the Wall Street Journal — the patient is now off antivirals for over 600 days, still no virus rebound. Today it’s the most e-mailed piece in the Journal.
Just a hunch, but I think this is the closest thing we’ve come to a cure for HIV infection. Granted, it’s not practical to offer bone marrow transplants to the 33 million or so people infected with HIV in the world, never mind the difficulty of finding donors who are appropriate matches and have the delta 32 mutation (the mutation occurs in only approximately 5% of individuals, and is even rarer in persons of African and Asian descent).
Regardless, if ever there were a plausible target for gene therapy, the CCR5 delta 32 mutation seems like a great place to start.