HIV and ID Observations

If you’re wondering what to do between the end of the presidential conventions, the baseball trade deadline tomorrow, and the start of the Summer Olympics, here are a few ID/HIV related items to contemplate:

• Non-travel related Zika arrives in Florida. Start getting used to seeing more of that obscure word “autochthonous”.  The uncertainty was not whether Zika cases would occur here — that was inevitable — but when they would happen. Most experts still don’t think we’ll have a Brazil-sized outbreak; nonetheless, other southern states will have cases, and until we have better and more widely available tests, there will be tremendous anxiety in all affected regions. Meanwhile, we ID doctors continue to wonder why it’s so hard to get consensus on emergency funding for ID outbreaks. 
• Your nose may harbor antibiotic-producing bacteria.  Tons of media attention for this story! Maybe because that old favorite of ID rounds, Staph lugdunensis, is kindly providing the anti-MRSA agent, something the authors call “lugdunin”. (Not to be confused, of course, with laudanum.) This is yet another example of “colonization resistance”, a term of increasing relevance all the time.
• Training ID fellows to do penicillin allergy skin testing in hospitalized patients improved antibiotic use. It’s always such a relief to remove penicillin allergy from a patient’s problem list, especially since it’s a label usually based more on family lore than reality. (“My mother always told me I was allergic”, say even adults of advanced age.) This novel ID (not Allergy) -driven program yielded impressive implementation and outcomes data — more than half the patients who underwent skin testing then had optimization of their antibiotic regimens (narrower spectrum, more cost-effective).
• Cefazolin is as good (if not better) than nafcillin for MSSA bacteremia. Yet another study supporting the benefits of cefazolin over nafcillin (or oxacillin). The data from this and prior papers make it abundantly clear that this easier, safer treatment (cefazolin) should be chosen in most cases once patients are stable. We really do need a randomized clinical trial comparing cefazolin vs nafcillin/oxacillin for up-front therapy — who’s going to pay for it?
• FDA labels on fluoroquinolones updated to include “disabling and potentially permanent side effects of the tendons, muscles, joints, nerves, and central nervous system.” It is truly remarkable how far these drugs have fallen from their perch just a few years ago as the “Cadillac of Antibiotics” (am quoting a patient of mine commenting on ciprofloxacin — I guess even the car reference is a bit stale). It is critical to have more data on the frequency and risk factors for these rare but serious quinolone side effects, as this class of drugs is still quite useful.
• Treatment of acute HIV lowers the HIV “reservoir setpoint”, at least as measured by cell associated HIV DNA. These are the strongest data to date on this potential benefit of very early HIV treatment. I write “potential” benefit since such early treated patients are those most likely to be amenable to HIV cure strategies.
• A “microbiome” treatment for C diff failed to prevent recurrences better than placebo. Called SER-109, it is a “rationally designed ecology of bacterial spores enriched from stool donations obtained from healthy, screened donors.” It just could be that the natural stuff (ok, poop) has some unquantifiable healthy factors that just can’t be captured artificially. You know, kind of like real food vs extracted micronutrients given separately as pills, shots, whatever. Real food always wins.
• Elimination of routine contact precautions for MRSA and VRE did not increase the rate of these infections. It’s a retrospective study, and the hospitals also increased chlorhexidine bathing, but still –hospital-based clinicians are eagerly awaiting the moment when the futility of contact precautions is proven, and subsequently abandoned. Here’s hoping.
• This “patient simulation” expertly guides outpatient providers on how to avoid prescribing unnecessary antibiotics. Note that it tries to do so without making your patients mad at you, a tough challenge. One of our superb social workers is a huge fan of motivational interviewing — she most definitely would approve.
• Guidelines for treatment of coccidioidomycosis updated. If you live outside of a cocci-endemic area — which emphatically includes all of us who work in New England — good treatment guidelines and the email address of the lead author, John Galgiani, are essential items. Always makes sense to get help from those who see a lot of this sometimes serious fungal infection.
• Antibiotics for pneumonia can be stopped after 5 days, provided patients are stable and fever-free for 48 hours. Two reasons why short course therapy works: 1) The immune system is probably doing most of the work once patients start to improve; 2) Many cases of CAP aren’t caused by bacteria anyway!
• A bill added to the Massachusetts state budget would mandate insurance coverage for long-term antibiotic treatment of Lyme disease. As I’ve written before, the optimal therapy for patients with residual symptoms after Lyme treatment is anything but clear. Seems legislating coverage in an area of such clinical controversy is not the right move, and Gov. Charlie Baker fortunately agrees. 

Hey, World Hepatitis Day was this past week (specifically, July 28). Do these “Diseases Awareness Days” (I made that term up) actually do anything? I can understand the motivation, but the cynic in me says that they are just preaching to the already aware. Maybe somebody has done a study of their usefulness?

Oh, and the day after was National Lasagna Day.

(Photo source: Library of Congress)