January 6th, 2020

The Decade’s Top 10 Biggest Changes to ID Clinical Practice

Here’s a question for you ID and HIV and other clinicians out there as you start 2020 — what are the 10 biggest changes to ID/HIV clinical practice over the past 10 years?

Not necessarily what are the biggest stories or biggest advances (though they certainly are eligible) — but more specifically, when you are seeing patients, what are we doing or seeing or thinking now, in early 2020, that we never could have done in 2010?

You’ll see by reading this list that 10 years is plenty of time for progress — hooray for that. So with the up-front apology that my list inevitably reflects where I practice (USA, New England) and what I focus on academically (HIV), off we go with 10 big changes, one for each year — there obviously could be many more!

#10.
Then (2010): “Vancosyn” or “Vitamin L” (levofloxacin) for everyone? No problem …
Today (2020):  Certain antibiotics, once considered quite safe, now have well-recognized severe side effects.

On the inpatient side, there’s now broad agreement that giving vancomycin and piperacillin-tazobactam together increases the risk of nephrotoxicity. This awareness has led to dramatic reductions in the use of “Vancosyn,” which was all but ubiquitous on medical and surgical services a decade ago. And the toxicities of fluoroquinolones deserve their own brilliant graphic:

#9.
Then (2010):  Order an HIV test? What a pain.
Today (2020):  Written consent for HIV testing no longer required.
In 2010, labs required that formal written consent, signed by the patient, be on file before running an HIV test. This was an actual law in most states! While one might argue that such a policy made sense in the mid-1980s due to fears of discrimination and lack of effective HIV treatments, it was absolutely bonkers (that’s the medical term) in 2010, so many years after we had lifesaving HIV therapy, and were still facing a large proportion of those with HIV undiagnosed. And yes, Massachusetts was the last state to drop this outdated law — not proud about that fact! Fortunately today, a clinician who wants to order an HIV test now just needs to document that the patient verbally agreed to testing — easy peasy. Was that so hard?

#8.
Then (2010):  MRSA is taking over!
Today (2020):  MRSA is way less common.

If you’d asked me in 2010 to estimate what proportion of our hospital’s Staph aureus isolates would be MRSA in a decade, I’d probably have guessed 75%, or if I was feeling glum that day, 90% — the trend in the early 2000s was just up and up and up for this pesky and difficult-to-treat pathogen, and it was by far the most common microbiologically confirmed cause of skin infections. However, for reasons no one can quite understand, MRSA rates are down everywhere — both in inpatients and outpatients. (Our hospital’s antibiogram now lists MRSA as 27% of Staph aureus isolates.) Not only that, penicillin sensitivity locally among staph is making a comeback, too. No one predicted that.

#7.
Then (2010):  Otitis media — antibiotics needed now!
Today (2020):  Observation, rather than immediate antibiotics, is now an accepted strategy for certain cases of childhood otitis media.

I put this one in for the pediatricians, especially one particular pediatrician! Although treatment guidelines endorsed observation for otitis media in 2013, apparently only in the past few years have parents grown comfortable with this approach.

#6.
Then (2010):  CD4 700? You don’t need to start treatment, let’s monitor blood tests, see what happens.
Today (2020):  The “When to Start” debate in HIV therapy ended — everyone should be treated.

In 2010, we might have monitored someone with high CD4 cell counts for a while, allowing them to be viremic for months or even years if they remained asymptomatic. We would never do that today because the START study randomized people with HIV who had no symptoms and high CD4 cell counts to immediate versus deferred therapy, showing a clear clinical benefit for early treatment. Plus, there’s the #2 Big Change listed below as an additional factor favoring treatment.

#5.
Then (2010):  Recurrent C. diff? Let’s try another round of vancomycin, maybe with a long taper.
Today (2020):  Fecal transplants for relapsing C. difficile colitis are now standard of care.

After a period of initial (and quite understandable) disgust and reluctance from patients and clinicians alike, clinical data on the efficacy of fecal transplants for relapsing C. difficile colitis are now strong enough to give it a place in the most recent treatment guidelines. These clinical trials data have has been strengthened by largely favorable anecdotal experience. While not a panacea — some patients don’t respond, and there are ongoing safety and regulatory issues — the fact that fecal transplant has such a major role in treatment of any condition would have been unfathomable in 2010.

#4.
Then (2010):  Worried about acquiring HIV? Make sure you and your partner use condoms.
Today (2020):  Pre-exposure prophylaxis (PrEP) for HIV is an established HIV prevention strategy.
As I’ve mentioned before (and will continue mentioning forever, since it’s in hindsight so bizarre), the first time I  heard of this concept was in the 2002 CROI in Seattle, when keynote speaker Bill Gates was asked about people without HIV taking ART to prevent infection. (Why someone was asking the CEO of Microsoft this question is still not clear to me!) His response concisely summarized HIV prevention in that time: “Wouldn’t a condom be easier?” Fast-forward to the IpReX study, the FDA approval of TDF/FTC for PrEP in 2012, several follow-up studies — and today PrEP is broadly endorsed in national guidelines for HIV prevention.

#3.
Then (2010):  We have to bring tuberculosis diagnosis and treatment into the 21st century!
Today (2020):  TB diagnosis and treatment are both much better.

On the diagnostics side, the The GeneXpert MTB/RIF system has been absolutely transformative, both in high prevalence countries (where it establishes the diagnosis much faster and more reliably than smear), and here as well, where we can rapidly rule out the diagnosis and stop respiratory precautions in low risk cases. Treatment of latent TB now has several  shorter options than the old standard of care 9 months of INH. And for multi-drug resistant disease, Dr. Catherine Berry’s comparison says it all!

XDR-TB treatment

2010
“Cat IV” low priority, minimal access
6-7 drugs, daily IM aminoglycoside
2 yrs treatment
Daily vomiting, hearing loss
10 to 20% cure

2020
3 to 5 drugs
All oral
6 to 18 months
PN, ON, myelosuppression
?up to 90% cure

2022
Watch this space

#2.
Then (2010):  The most important thing you can do to protect your partner from acquiring HIV is to always use condoms, even if you’re on treatment.
Today (2020):  “Undetectable = Untransmittable” is now a mainstream part of HIV medicine.

Though the prescient Swiss Statement appeared in 2008, it was not until release of the HPTN 052 data in 2011 that this “treatment as prevention” idea gained mainstream acceptance — only to be further supported by the PARTNER and PARTNER2 studies. The bottom line is that we now routinely tell people with HIV that they are not contagious to others if they’re on suppressive HIV therapy. Few (if any) non-Swiss people would have been so bold to say that in 2010.

#1:
Then (2010):  Treatment of hepatitis C will be injectable interferon and multiple tablets of ribavirin. Not only that, you’ll need to take it for 12 months, endure many side effects, some of them quite severe — oh, and it will have a 20–30% chance of the treatment working.  Sorry about that.
Today (2020):  Hepatitis C is cured with 8–12 weeks of well-tolerated, oral treatment in around 99% of people.
I still don’t think we quite appreciate just how miraculous an advance this is, so I’m making it an emphatic #1 biggest change in ID clinical practice. (And Monica Mahoney, PharmD agrees, so it must be right.) As one of my patients said, after having relapsed during interferon treatment twice previously, and finally being cured with sofosbuvir/velpatasvir:  “Curing things is good. You doctors should work on more of that.” Agree!

What would be your Top 10? And of course my order won’t be your order, but that’s what the comments section is for!

12 Responses to “The Decade’s Top 10 Biggest Changes to ID Clinical Practice”

  1. John Leung says:

    Not high on the list, but may I suggest the threat of activating or reactivating certain infections like TB, HBV, HCV, HZV etc. in the course of many biologic/targeted treatments for autoimmune disorders or B-cell and T-cell malignancies.

  2. Monica says:

    Another one, although I suspect this will be 2030, is txt of infections in PWID.

    2010: What? No way. Not wasting resources on them.

    2020: Well, maybe we were a little too harsh before. But … still not using a PICC!

    2030: Dude. We were ever dumb. Standard of care for PWID and nPWID is the same. ‍♀️

  3. Monica says:

    (That weird pink symbol was supposed to be “person smacking forehead” emoji, female version. Maybe in 2030 responses will include emojis too)

  4. Loretta S says:

    I don’t practice ID (darn!), but in primary care, your #10 is our #1. And I would say your #1 is our #2. Absolutely, the shift away from fluoroquinolones as Abx of choice has been the biggest day-to-day practice change. I cringe when I think of how often I prescribed ciprofloxacin for a garden-variety UTI. It worked great, and it worked fast! Happy patient! Next! And levofloxacin for a sinus infection? No problem! Here ya go. Now I think of FQs as almost radioactive, and reserve them for certain situations. When I teach about FQs, my students wonder why anyone uses them, due to the number of potential adverse reactions and BBWs we discuss. That said, I would not hesitate to use an FQ in the appropriate circumstance — still highly effective. It’s just those dang adverse reactions.

    Regarding your #1, yeah. Absolute game-changer. I had patients who were being monitored for years because they had chronic Hep C and had either tried interferon and it did not cure them, or (more likely) they could not tolerate the adverse effects. I am still gobsmacked that the HCV drugs, taken once a day for 8-12 weeks, can cure Hep C.

    We still see a fair amount of MRSA in primary care. Where do patients tend to get it? Gym equipment is high on my list of fomites MRSA can hang out on. And tattoos…. Patients who are skin colonized w/MRSA can get some nasty MRSA infections after a tattoo session, even at a reputable studio that takes recommended precautions. And they usually don’t want to give up getting tattoos.

    • Paul Sax says:

      Yes, definitely still seeing MRSA — as noted, around a quarter of our Staph isolates. But so much less than 2010, when it was at least half! I thought it was going to take over.

      -Paul

  5. Jon Blum says:

    I wouldn’t argue with your list at all. So maybe I will suggest runners-up:
    1. The rise in resistant GNR. It’s not that long ago that resistance to third-generation cephalosporins and even quinolones was rare, and mostly seen in ICU superbugs. Now everybody walks in off the street with those. We have met the enemy, and they are us.
    2. The rise of EHRs. This has changed the way we practice in good ways and bad. I don’t want to reiterate the debate, but it’s been a very big impact.

  6. Alan A. Pollock, M.D. says:

    While undetectable = untransmittable is reassuring, it misses the point about other STD’s that would have been prevented by use of a condom. As obvious examples, the incidence of syphilis in NYC had markedly increased when PREP became common (this shouldn’t be a surprise), HPV-associated anal cancers, GC infections with rising MIC’s to standard drugs (and few alternative treatments), and the omnipresent HSV would all be preventable by condom use. Some old-fashioned recommendations are still appropriate.

  7. Antoine says:

    A decade or two from now, if we go back and look at the last 20 or 30 years of ID and the biggest changes, FMT might jump to #1 on top of your list. In the age of deep sequencing and AI, viral drug discovery (such as the HCV miracle you speak of) may become more trivial and it would not be unforeseen that we are ushered in a new age where disease is manipulated through genome – both yours and the collective genome of whatever lives in your gut, on your skin, in your mouth and so on.

  8. Antoine says:

    Loretta, your comment makes me think: when you prescribed FQs as garden variety, how many, if ever, have you ever actually witnessed of these terrible side effects? While I’m all for stewardship and safer drugs, I must say the amount and content of black box warnings are a very american thing driven by a culture of too extreme risk aversion and defensive medicine. Fluoroquinolones are immensely useful antibiotics, even in 2020.

  9. Aurora Orzechowski MD FACP says:

    Paul,
    I am concern about criminalization in our HIV patients, also in Mexico you can go to jail if you prove that your sexual partner is infected although his/her viral load its undectable, if he isnt undetectable its a crime( lawyers call it homocide…!)

  10. Anthony Weaver says:

    General internist. Is there room on your list for HPV vaccine and testing?

  11. Jaan Naktin says:

    I am not sure I agree with number 5. C diff testing and testing algorithms especially in the inpatient setting have made colonization much more common than active toxin producing disease. At my institution the new testing algorithms, which are consistent with what is happening nationwide, rates of c diff both inpatient and outpatient have dropped substantially.

    Recurrent disease or disease that fails to respond accordingly has also dropped since less “real” diagnoses are made.

    The promise of oral fecal transplant has not materialized due to prohibitive cost and lack of insurance coverage. Colonoscopic transplants are still available, but I cannot remember the last time I referred someone to GI.

    Also, the move to preferential treatment with vancomycin rather than metronidazole as a first line agent in the last 10 years has in my opinion led to less recurrences.

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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