HIV and ID Observations

An ongoing dialogue on HIV/AIDS, infectious diseases,
all matters medical, and some not so medical.

January 6th, 2011

Thursday Thienamycins

0901008P BLUE JAYS 7 WH.SOX 3Plenty going on in the ID, HIV, and (for the middle of winter) baseball worlds:

  • Just out in CID, there’s a comprehensive review of Management of MRSA as part of the IDSA’s Practice Guidelines Series. Soft tissue infections, bacteremia, endocarditis, pneumonia, bone and joint infections, frequent relapses …  MRSA in all its painful glory. Some interesting tidbits:  1) no gentamicin recommended for MRSA native-valve endocarditis or bacteremia (a pet peeve of mine, hope that practice disappears); 2) ECHO recommended for all adult patients with bacteremia, with a preference for transesophageal ECHO; 3) no systemic antimicrobials recommended as part of “decolonization” strategies in cases of recurrent MRSA soft tissue infections; 4) no mention of household pets as a source of MRSA.
  • Speaking of MRSA, ceftaroline — approved late last year by the FDA — is now actually available for use (that is, obtainable by your hospital pharmacy).  This is the first beta lactam with anti-MRSA activity, and while it has been approved for community-acquired pneumonia and complicated skin and soft tissue infections, I strongly suspect it may eventually have another role — namely, management of MRSA bacteremia/endocarditis, especially refractory cases.  After all, our current therapy for that condition is pretty dismal.  Time (and I hope a prospective clinical trial, though nothing here) will tell whether ceftaroline in fact offers an advantage in this challenging situation.
  • Etravirine now comes in a 200 mg tablet, reducing the pill burden to 1 pill twice daily.  Although not approved for once-daily use, the pharmacokinetic profile supports giving the drug this way, so I wouldn’t be surprised to see a greater use of this NNRTI as a once-daily “key third drug” in patients without NRTI resistance.  (It’s an “unlabeled use”, but so be it.)  Turns out that although the new formulation is still uncoated, it may have reduced the quirky chalky texture of the 100 mg tablets, as tests conducted by the company show that it’s easier to swallow.  It still can be dispersed in water, if patients prefer to take it this way.
  • Rifaximin, the non-absorbable cousin of rifampin, reduces symptoms of irritable bowel syndrome (IBS).   Great news — until you read the fine print, which shows that the placebo group did nearly as well (around a 40% response rate for rifaximin, vs 30% for placebo).   Oddly, this rifaximin/IBS study comes on the heels of this well-publicized paper, which showed that placebos for IBS still worked even if patients knew they were taking them. I think we’re compelled to think again about how to leverage the extraordinary power of the mind to help control certain diseases.
  • As expected (and deserved), Robbie Alomar was elected to the National Baseball Hall of Fame, receiving 90% of the votes. Does his alleged HIV positive status “pose a problem” for the Hall of Fame?  I think not — so long as he does the right thing and tells the truth, whatever that may be. Again, as I’ve written before, the acceptance speech he gives in Cooperstown this summer could be the perfect opportunity.

Thienamycin’s real identity?  Read all about it.

Categories: Health Care


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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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