October 24th, 2015

Pumpkin-Flavored ID Link-o-Rama

autumn leavesAs the leaves change colors and fall from the trees, the days grow shorter and colder, and pumpkin-colored and flavored merchandise shows up everywhere, I ask you this important question:

What precisely are the infectious risks of bobbing for apples?

Off we go.

  • Receiving antibiotics in childhood is associated with weight gain. The important finding in this study is that the effect occurs throughout childhood, not just infancy. Could it be that the antibiotic-obesity association will have a greater effect in reducing outpatient use of antibiotics than the risk of resistance? Lots of press coverage.
  • At the other end of the age spectrum, here’s a thoughtful perspective on the widespread use of antibiotics at the end of life. I’ve covered this topic before — why are antibiotics so often given at the end of life when all other medical interventions are stopped? Paper cites one study suggesting “greater comfort, albeit shorter survival, among patients with advanced dementia and suspected pneumonia who were not treated with antimicrobials.” Sounds like withholding antibiotics could be the right move in palliative care.
  • HCV therapy with paritaprevir/ombitasvir/ritonavir may precipitate hepatic decompensation and liver failure. Not surprisingly, “most” of the cases (which have precipitated an FDA-mandated label change) have occurred in patients with advanced cirrhosis.
  • There are infectious risks associated with receiving injections of live cells, including Q fever from sheep cells and M abscessus from human fetal cells. Certainly infection is one good reason not to undergo these treatments; the second and even better one is that none of these therapies has any proven medical benefit. A bit more on this longstanding form of quadkery here.
  • The ocular syphilis cluster on the West Coast is a reminder that in the post-PrEP, post treatment-as-prevention world, condomless sex is inevitably increasing among MSM, along with rates of sexually transmitted infections. Note that this report repeats the recommendation that all patients with ocular syphilis should 1) undergo a CSF exam (which may be negative in ocular syphilis) and 2) be treated for neurosyphilis regardless of CSF results. Which prompts me to ask — then why do the CSF exam if treatment isn’t changed based on the results?
  • Transmitted NNRTI resistance does not appear to influence response to integrase-based ART. This nice analysis presented at IDWeek from a Stanford/Kaiser collaboration confirms previous reassuring findings from prospective clinical trials. And it means you probably don’t need to use a boosted PI in this situation.
  • Promising results from a small (n=20) single-arm pilot study of two-drug, dolutegravir + lamivudine ART in treatment-naive patients. Think GARDEL strategy, only with DTG and not LPV/r. 20/20 are virologically suppressed at week 24, and all but one were < 50 by week 8. Note that the inclusion criteria limited enrollment to patients with HIV RNA < 100,000 and CD4 > 200. A larger (but still not comparative) clinical trial of this strategy is opening soon.
  • In the vaccine world, is there anything more complicated than the recommendations for meningococcal immunization? Based on a meeting that took place this June, they’ve now changed again to include the serogroup B vaccine for late adolescents. When in doubt on vaccine-related issues, head over to the invaluable immunize.org site, in particular the “Ask the Experts” section.
  • No clinically significant drug-drug interactions between ECF-TAF or RF-TAF and sofosbuvir/ledipasvir. Even with the ledipasvir slightly boosting tenofovir exposure, levels remain 5X lower than when TDF is used. ECF-TAF (“Stribild 2.0”) approval expected next month, RF-TAF (“Complera 2.0”) next year.
  • Here’s a nifty case report: A 91-year-old man had 10 separate hospital visits for fevers, chills, and hypotension over a two year period, several times with positive blood cultures for Aeromonas hydrophila. The source? Contaminated well water. My favorite quote from the paper: “Culture results revealed significant overgrowth of A hydrophila from his master bathroom sink; he used this water supply to soak his dentures nightly.” Made me think of this household product — he’s old enough to have watched that ad.
  • On the topic of great cases, here’s a very nice inaugural piece on the In Practice blog by Harrison Reed, who reminds us that these rare and astounding cases — zebras — are vastly outnumbered by the more common cause of hoofbeats, horses.

Warning, adult content time. In her HBO special, Amy Schumer not surprisingly has a plenty of ID-related jokes — including this surprising one:

I was dating an Infectious Diseases doctor, cause two birds …

How convenient! And by the way, Amy — if you need a new writer, you know where to find me! Right here — and now on Twitter at @PaulSaxMD.

[youtube http://www.youtube.com/watch?v=5HlImrCEkWo&w=560&h=315]

6 Responses to “Pumpkin-Flavored ID Link-o-Rama”

  1. Could PREP and well-tolerated ART regimens be “component causes” of unprotected sex among MSM and increasing syphilis incidence? In epidemiology we talk about Rothman’s “Sufficient and component cause model.” Basically, it’s a model of causation to facilitate the conceptualization of epidemiologic problems. A cause is an event, condition, or characteristic that plays an essential role in producing an occurrence of the disease. The cause of any effect must consist of a constellation of components that act in concert. A sufficient cause is a set of minimal conditions and events that inevitably produce disease. A component cause is an individual event, condition, or characteristic required by a given sufficient cause. A necessary cause is a component cause present in every sufficient case. Could PREP/ ART be leading to risk compensation behavior?

  2. Loretta S says:

    This phrase from the article about the dangers of apple-bobbing and everything else associated with Halloween caught my attention: “Other eye injuries that eye doctors in A&E’s departments have to deal with on a busy Halloween night include… infections as a result of poor removal of children wearing make-up.” Hmm. Eye infections can be caused when we fail to remove children who are wearing make-up? And where are we removing them from? To?

  3. miriam says:

    Initial treatment isn’t changed by the LP results in ocular syphilis, but the LP identifies who qualifies for post-treatment CSF monitoring to assess for treatment failure…

    • Paul Sax says:

      Hi Miriam, you write:

      LP identifies who qualifies for post-treatment CSF monitoring to assess for treatment failure…

      But what is the evidence that this improves outcome? Almost everything in the syphilis world is based on strongly held “expert opinion” rather than evidence from controlled trials or even population-based comparative studies.


  4. Laura says:

    I was totally going to say what Miriam said about the LP! She trained me well 🙂
    Also, this is fun Halloween ID news: a scientific study explaining how Listeria can contaminate caramel apples even though it cannot grow in either caramel or apples. http://mbio.asm.org/content/6/5/e01232-15

    • Paul Sax says:

      Thanks for the link, Laura. And if you find that literature supporting the clinical benefit of monitoring CSF after treatment of neurosyphilis, send it my way!


HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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