An ongoing dialogue on HIV/AIDS, infectious diseases,
August 22nd, 2008
We have met the enemy … and it is MRSA
In Jerry Groopman’s recent New Yorker piece on antibiotic-resistant bacteria, he quotes Dr. Louis Rice from the Cleveland VA, who uses the term “ESKAPE” bacteria: an acronym for Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumanni, Pseudomonas aeruginosa, and Enterobacter.
Nothing against the mostly gram-negative nasties in this list (and the focus of the New Yorker article), but in my opinion there is one bacterial King of Pain, and it is MRSA — methcillin-resistant Staph aureus. Already a hospital-based problem when I began medical school in the 1980s, MRSA is now absolutely everywhere, and I’ll go out on a limb and state that it is the most common and worrisome source of serious infectious suffering we have out there right now.
In this past week alone, I have seen or heard about the following patients (some details slightly changed due to HIPAA, and even more importantly, this list isn’t even all-inclusive):
August 8th, 2008
More from Mexico City
A bit more travelogue from the XVII International AIDS Conference:
- It’s impossible to see everything you want at such a large, sprawling conference, sometimes because of conflicting meetings, sometimes because the room is full, sometimes because of a feeling analagous to being in a giant museum for too many hours — fatigue just takes over. But I’m sure glad I didn’t miss Myron (Mike) Cohen’s plenary session Tuesday AM on HIV Prevention. It’s easy to get cynical about HIV prevention efforts given the number of recent failures in the field (vaccines, acyclovir, microbicides …), but as Cohen pointed out, some things out there are working, and he outlined a very reasonable (and optimistic) strategy for how this epidemic could be controlled. Plus he did it in his typically energetic and entertaining fashion, all the while maintaining absolute academic rigor. Don’t miss his name-brand idea for a combination product containing tenofovir, emtricitabine, and maraviroc — brilliant. Some web casts are worth watching, and this is one of them.
- Missing from this International AIDS Conference were the phonebook-thick abstract listings. Instead, we received the abstracts on CDs, a move that definitely saved lots of trees, sore backs and shoulders, but made it very hard (ok, impossible) to flip through the abstracts. I´m sure this is a direction that more meetings will take, but will definitely take some getting used to. USB drives will be coming soon, as CDs as a storage medium are definitely on the way out.
- Speaking of USB drives, the speaker-ready room was shut down on Wednesday for a while due to — I´m not making this up — a computer virus acquired from some rogue USB drive. Many jokes followed about computer condoms, vaccines, and microbicides, but I´ll leave it right there!
- I’ve already written about food here in Mexico City, but only from the Infectious Diseases perspective. Now I’ll be my mother’s son (she’s a food writer), and say the restaurants have been terrific, the food fresh, interesting-tasting, and reasonably priced, and the service attentive and professional. But — there was one glaring exception, and unfortunately it was the food at the convention center, which consisted mostly of wilted salads, sandwiches with scary soft meat-like products (colored a disturbing faded gray), and (I think, don’t hold me to this) tuna salad. As lines for food during lunchtime were 15-30 minutes long, it became quite easy to skip the mid-day meal or subsist on potato chips, water, and coffee, probably not the healthiest diet on the planet. I got back to my hotel room absolutely famished every day.
- All of these conferences have a theme — this one is “Universal Action Now” (italics theirs). Pretty good. I suppose one could fashion a challenging trivia quiz, asking people to match the theme with the city and date: “Time to Deliver” (Toronto, 2006), “Access for All” (Bangkok 2004), “Knowledge and Commitment for Action” (Barcelona 2002), “Break the Silence” (Durban 2000), “Bridging the Gap” (Geneva 1998) … Good sentiments all, but Durban wins by a mile. Of course if they had the conference in Boston, the theme would be, “Let’s go Red Sox.”
(I guess I’m getting a bit homesick.)
August 4th, 2008
Mexico City: Drive on the right … most of the time
Some early and completely non-scientific observations from the XVII AIDS Conference, taking place now in Mexico City:
- Everyone said getting to and from the Banamex Convention Center would be difficult, and of course they were right. Mexico City is the largest city in the Western Hemisphere, has a road/traffic system that makes driving in Boston seem downright peaceful by comparison (that is hard to do), and of course none of the hotels are anywhere near the meeting. But it’s not as if we haven’t been through this before — namely, here in Bangkok and here in Rio, to cite some recent examples. So no big deal. But … I did experience something traffic-wise that was truly bizarre: On the drive in from the airport, the cab driver took a right turn onto a street and drove on the left for around a tenth of a mile, while the oncoming traffic was on the right — and it was actually planned that way, pefectly legal. To repeat (if that wasn’t clear): we were driving British style. According to the cab driver, it’s because left turns off some roads have become so congested that they simply moved that lane from the right to the left; after the busy intersection passed, we moved back to the right. I kid you not.
- What do Infectious Diseases specialists from the United States eat and drink when they’re in Mexico City? If my completely haphazard survey is any guide, we’re all over the map (ahem) when it comes to food safety while traveling. One colleague said she couldn’t live without salad, and the idea of visiting Mexico without a margarita (requires ice) was too depressing even to consider; another said he was sticking by the rules, eating only thoroughly cooked foods and drinking bottled beverages from “reputable sources,” whatever that means. (Maybe this.) One other said that the street food was one of the best reasons to visit Mexico to begin with. So far my approach has been pure pragmatism and selfishness: if there’s a tasty low E coli option available, great — but if not, and something looks too delicious to pass up, I’ll take my chances.
- The weather in Mexico City is wonderfully, delightfully cool in August. For some reason, I expected a summertime furnace, but it’s much cooler here than in Boston due to the altitude. Was I the only one in the world who didn’t know that?
Back with more later, maybe with some “real” content.
July 25th, 2008
Word salad: Jalapenos, abacavir, doripenem, and PAVE
Some miscellaneous recent items from the ID/HIV world jumbling around this Friday:
- Tomatoes are off the hook — it’s the jalapenos that likely caused the recent salmonella outbreak. Since this is the only time of year that tomatoes are even edible in this part of the world, I for one am quite relieved. I am sure many are wondering how bacteria could survive on those very hot peppers.
- HLA-B*5701 testing is now “officially” recommended before abacavir use to reduce the risk of hypersensitivity — it’s now in the package insert. We started doing this test two years ago (at the strong encouragement of some British and Australian colleagues), and it makes all the difference in the world when prescribing this drug — the counseling to patients about the safety of abacavir drops from a 30-minute terrifying review of possible death to a 5-minute, “this could happen, but it won’t.” Two further thoughts: 1) It’s too bad we didn’t have this tool available sooner (likely lots of debate within the boardrooms of the manufacturer on the pros and cons from a sales perspective); and, 2) Let’s hope that other companies can learn from this lesson and, if such tests are potentially available to improve patient safety, they move ahead quickly to validate them.
- Oh, and the other abacavir label change is related to the DAD data and the possible association between abacavir use and cardiac disease. Not much has changed since I last covered this issue, but one wonders what we’ll hear soon, either confirming or refuting this association. (Or likely, both confirming and refuting it.)
- In other FDA news, an advisory panel was split on whether to recommend approval of doripenem for treatment of nosocomial and ventilator-associated pneumonia — but overall narrowly favored approval. (No action by the FDA yet.) Not going to get into details of this particular drug or indication — the FDA’s decision is unlikely to change clinical practice in the short run — but isn’t it peculiar that we have a gazillion (stealing a word from one of our ID Fellows who speaks California-ese) cephalosporins, but only 4 carbapenems? And no oral option? Hey, imipenem was approved by the FDA in the mid 1980s! I asked a medicinal chemist about this a few years ago, and apparently it’s not so easy to synthesize these drugs — but the rise in ESBL-producing gram negatives certainly could (and should) spur further drug development.
- Last, the NIH halted plans to conduct the PAVE 100 HIV vaccine trial. The reason, obviously, is that this adenovirus-based vaccine strategy is similar in many ways to the one tested in the STEP trial — which showed that the vaccine not only didn’t work in protecting from HIV infection or lowering HIV RNA levels, but led to an increase in the risk of HIV acquisition for those persons vaccinated who had pre-existing adenovirus immunity. The challenges of developing an effective AIDS vaccine are legion, but here’s a particular tough one: can you imagine trying to write the informed consent for the next major efficacy trial? Yikes.
July 19th, 2008
“Floxins” and the black-box warning: Anyone notice? Anyone care?
Fluoroquinolones — the “floxins”, every medical house officer’s favorite antibiotic class — will carry a black-box warning about the risk of tendinitis and tendon rupture. We’ve known about this side effect for years, why now the change? In FDA speak:
FDA’s recent evaluation of the medical literature and the post-marketing adverse event reports submitted to the Adverse Events Reporting System (AERS) confirmed that serious reports of tendinitis and tendon rupture with the fluoroquinolones continue to be reported in similar or increased numbers.
In other words, the rate of this side effect hasn’t increased. Or it has.
Regardless, it’s a good idea to get this information out to practitioners. The use of these drugs is so pervasive I suspect some clinicians believe that patients suffer from levofloxacin deficiency. (Cure: give levofloxacin.) Since they’re used so commonly, even rare severe side effects are important.
And when Achilles tendon rupture occurs, it’s pretty devastating. Pain, then surgery, then immobility for months. I’ve seen 3 cases, one of which ironically occurred in a pediatrician — who I bet won’t prescribe a quinolone to kids even if the drugs ultimately get approved for pediatric use. One hopes that telling a patient to stop the drug and avoid exercise if pain or swelling occurs while on a quinolone might prevent the tendon from rupturing.
Will this change prescribing practices, either in the hospital or office setting? Doubtful — the side effect is pretty darn rare, and it seems to be a local ordinance in some hospitals that every patient must receive at least one dose of levofloxacin before discharge. Nonetheless, it’s a good reminder that even our best drugs have some warts.
July 10th, 2008
CROI 2009: Feb 8-11, Montreal
Last month I wrote about the annual mystery surrounding the date and location of the Conference on Retroviruses and Opportunistic Infections, or CROI.
Mystery solved: February 8-11, 2009, Montreal.
(Small suggestion to the conference organizers: perhaps start working on date/venue for 2010 now?)
July 6th, 2008
HIV Testing: The Bronx is Up …
So the New York City Public Health Department would like to have every adult living in the Bronx tested for HIV. The Times coverage of the effort cites the best reason for reason for such a move — the high death rates from the disease, and the cause:
Public health officials attribute this [the deaths] to people not getting tested until it is too late to treat the virus effectively, thus turning a disease that can now be managed with medication into a death sentence.
I confess whenever I see the word “Bronx” in the New York Times, my first association has absolutely nothing to do with HIV and frequently makes me unpopular here in Boston.
Baseball connections notwithstanding, this move in the Bronx makes abundant sense, and suggests that we in Massachusetts could learn a thing or two from our neighbors/rivals to the South beyond how to play winning baseball.
(Which the Red Sox have learned very well recently, thank you very much.)
One barrier to expanded testing is the requirement for written informed consent. Dr. Thomas Frieden, the New York Health Commissioner, said the New York HIV consent law is among the “toughest in the nation.” It’s arguably even tougher here in Massachusetts, where the requirement for written consent for HIV testing is embedded in the same law that protects HIV confidentiality — the famous Chapter 111, Section 70F law:
Massachusetts General Law Chapter 111, Section 70F provides that a physician, health care provider, or health care facility may not without first obtaining a person’s written informed consent: 1) Test a person for HIV; 2) reveal to third-parties that a person took an HIV test; or 3) disclose to third-parties the results of a person’s HIV test.
When I’ve suggested that these be separated — written consent for testing and disclosure of HIV-related test results are not the same thing, after all — legal experts roll their eyes, saying it just can’t be done (“there he goes again …thinking like a doctor”). Sorry, can’t help myself, but I don’t see why this law can’t be changed.
So my advice to Massachusetts: pay attention to what’s going on in the Bronx, and the rest of New York City; and even more importantly, see what’s recently happened in California, Illinois, and Maryland, all of which eliminated the requirement for written informed consent for HIV testing. The goal? Make it easier to find the undiagnosed so that they can receive life-saving treatment. In California, published data already show that this works.
And may the best team win.
Which is (remarkably as of July 6, 2008), The Tampa Bay Rays.
July 4th, 2008
Announcement: CROI 2009 Date Still Not Announced
As I wrote last month, the date and location of the Conference on Retroviruses and Opportunistic Infections (CROI) each year is an annual mystery of legendary proportions. As of July 4, 2009, the mystery continues.
Constructive criticism for the conference organizers: why not start working on the date/location for the 2010 meeting now?
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
Learn more about HIV and ID Observations.
