HIV and ID Observations

We are a Royalty Free Stock Image — proof that sometimes you get what you pay for.

With Valentine’s Day and early spring training baseball both on the horizon this week, it’s obviously time for an extra special ID Link-o-Rama.

On to the links, with a bonus non-ID section and a highly recommended video at the end:

• The ACIP issued its official recommendations for herpes zoster (shingles) immunization. Preferred: the new recombinant zoster vaccine, abbreviated RZV, for people 50 and older. They do not recommend it (yet) for immunocompromised individuals — stay tuned. Does the recommendation include our stable, on-therapy HIV patients, who in increasing numbers are over 50? I say “Yes.”
• The new zoster vaccine is very “reactogenic.” Pain and swelling at the injection site, malaise, generalized aches, symptoms sometimes bad enough to interfere with daily activities. The incidence of these side effects is much higher with RZV than with the live virus vaccine, presumably due to the adjuvant that makes it so immunogenic — and effective. Warn your patients! And as noted above, I strongly suggest all clinicians watch the video, which is embedded at the end of this post — it’s highly informative and useful.
• CDC has issued dietary advice for Valentine’s Day.  I’m a huge fan of the CDC, the people who work there, and the excellent work that they do. But boy, this link is no fun at all.
• Multiplex respiratory panels face off in a head-to-head study. Isn’t it extraordinary that we can make a definitive diagnosis of what causes respiratory infections with a single nasopharyngeal swab? Nineteen different pathogens in this particular panel. The key to getting these tests more broadly adopted is decreasing the cost of implementation. Nonetheless, this approach is (in my opinion) the future, especially from a hospital infection control standpoint — even though for most of these viruses, there is no available therapy.
• In this terrible flu season, should we be choosing one type of flu vaccine over another? In the absence of head-to-head trials, it’s difficult to make an official endorsement. But as this interesting piece notes, there are differences between the available vaccines, differences that may lead to different rates of protection. Credit to Helen Branswell, a local journalist who has done superb reporting on the flu this year.
• As the flu season progresses, a higher proportion of cases are due to influenza B. Our local surveillance data mirror this national trend. Good news for those of us who have been vaccinated, as the vaccine appears to be more protective against influenza B than H3N2. And if you haven’t had your vaccine yet, it’s not too late — and please, don’t listen to this advice!
• More testing for C. diff artificially increases the rate of diagnosis. Nucleic acid testing for C. diff identifies carriers as well as people with the disease — hence the more we test, the more non-disease cases we “diagnose.” This finding is important, as healthcare associated infections such as C. diff are a major hospital quality metric. (Note I avoided writing the full first name of C. diff, very much intentionally as a protest about the discouraging news in the next link.)
• Clostridium difficile is now Clostridioides difficile. So says the Clinical and Laboratory Standards Institute (CLSI) in an update issued last week. If that’s not bad enough, Enterobacter aerogenes and Propionibacterium acnes also have new names. Sigh. I remember when Stenotrophomonas maltophilia was Xanthomonas maltophilia, those were the days. And whatever happened to Xanthomonas, anyway? Loved that word.
• FDA approves bictegravir/FTC/TAF for initial and switch HIV therapy. Now come two inevitable questions:  1) When will my patient’s insurance/ADAP/etc. cover it? 2) Who came up with that brand name? Biktarvy, jeepers.
• Elsulfavirine, an investigational NNRTI, is also approved for HIV therapy. OK, OK, so it’s approved in Russia, not here. Here’s a clinical trial comparing it to efavirenz from last year’s CROI.
• Adjunctive rifampin does not improve outcomes in MSSA bacteremia. Important negative randomized clinical trial. Although better approaches to this life-threatening condition are needed, imagine if this became standard of care — the drug interaction challenges would be nightmarish.
• Rabies immunizations given in U.S. emergency rooms can be shockingly expensive. Since the ER is where most people go after possible rabies exposures, this cost is an important barrier to a lifesaving intervention. Another excellent example of how our byzantine and opaque healthcare “system” (I use the word loosely) can lead to outrageous charges — the patients are the ones who suffer.
• Streptococcus pneumoniae as the cause of community-acquired pneumonia continues to decline. It’s gone from over 90% in the pre-antibiotic era down to 10–15% today, a remarkable drop attributed mostly to immunization practices. Higher in Europe, where pneumococcal vaccine used less often. Great figure here.
• In a prospective study of community acquired pneumonia, clinical symptoms did not predict etiology or outcome. Seems that the “atypical” in “atypical pneumonia” applies only to the extra-pulmonary manifestations of Mycoplasma (e.g., rash, hemolysis, neurologic disease, et al.) — which are very rare.
• A brief course of empiric antibiotics in the ICU does not appear to cause harm. The study suggests this “just in case” administration of broad spectrum therapy is fine, provided treatment is stopped when cultures are negative, or narrowed once a pathogen emerges — a good role for antibiotic stewardship teams.
• Invasive dental procedures may be associated with a significantly increased risk of streptococcal prosthetic valve endocarditis. The statistical acrobatics done in this complex cohort study notwithstanding, the results suggest a fraction of endocarditis cases are attributable to invasive dental work. The study furthermore found no protection from prophylaxis. However, given the limitations of the observational design, this should not change our practice — prophylaxis for this high-risk group is still indicated.
• More evidence that cefazolin is safer than anti-staphylococcal penicillins. In this meta-analysis of 14 studies, the point estimates all favored cefazolin. It’s unlikely anyone would fund a randomized clinical trial, but that would be most welcome. For now, I am switching patients from oxacillin to cefazolin as soon as bacteremia clears.

Ok, non-ID section — a few medical, one not medical at all.

• Here is a brilliant summary of how doctors assume predictable roles when discussing “code status” with their patients. Several recognizable types here. We can all learn something about improving our approach with this difficult conversation.
• This American wanted narcotics after her surgery in Germany, but all she got was herbal tea. Congratulations to the author for adopting the perfect tone in this very funny commentary — one that says quite a bit about how we ended up in such a mess with opiates in this country.
• Medical students forced to use fax machines are perplexed by this ancient technology. That headline reads like an Onion piece, but it’s true! And when I first wrote about this anachronistic practice over 4 years ago, never did I think it would remain so firmly entrenched in how we communicate. Is there no end in sight?
• A person is ranking all 205 Beatles songs. This effort joins prior similar lists, like this one, of 213 songs — about which I have major disagreements on his rankings. This time the anonymous author is posting a new one almost every day, which adds to the fun. For Beatles fans, be warned — a huge time sink!

Pitchers and catchers, music to my ears!

And take it away, Dr. Fryhofer — nice job on this video!