Dolutegravir monotherapy lands with a thud. In the linked study, nearly 10% failed by week 48 (some of whom developed resistance), prompting cessation of the study. A second study done in patients treated during early infection suggests the monotherapy strategy may work in patients with a low viral reservoir, but 1) we don’t measure reservoir in clinical practice, and 2) what’s the point?
Fusobacterium necrophorum is often implicated in recurrent peritonsillar abscess. This anaerobic gram-negative infection is more famously known for causing septic jugular vein thrombosis (Lemierre’s syndrome), but it clearly has a role in other suppurative complications. Question: Would a throat swab diagnostic test for F. necrophorum help identify the non-strep pharyngitis cases that would benefit from antibiotics?
Here’s a simple framework to guide antibiotic prescribing: 1) Is infection one that needs an antibiotic? 2) Have cultures or other studies been sent? 3) What empiric treatment should be started? 4) How should results alter therapy? 5) What duration is required? ID clinicians have internalized these thoughts, but no harm making them explicit.
A woman acquired HIV that was highly resistant to all available integrase inhibitors. Transmission of integrase inhibitor resistant virus is very rare; these viruses have typically still retained susceptibility to dolutegravir and bictegravir. Not this one — the baseline isolate had three major integrase mutations, E138A, G140S, and Q148H. The critical information from the case report was the identification of the source patient, for whom the authors obtained detailed resistance information.
For ID specialists, management of Staph aureus bacteremia is all over the map. Treatment of choice, management of persistent bacteremia, duration of therapy — plenty of variation! Example: For MSSA endocarditis, 32% chose cefazolin, 29% favored nafcillin, while 32% considered the two the same. Practice variation can represent differences in quality, but here I think they reflect lack of a clear, evidenced-based choice.