HIV and ID Observations

Ellis Island, Contagious Disease Hospital Isolation Ward I; Library of Congress

For those of us who don’t do inpatient medicine all the time, the “blocks” doing inpatient Infectious Diseases consults are a stark reminder of just how complex and challenging the case material can be.

Think about it — if a hospitalized patient has a straightforward ID problem, we are not getting involved. No one consults ID for cellulitis that rapidly improves, for community-acquired pneumonia responsive to antibiotics, or for the post-op infectious complication easily amenable to incision and drainage.

I’ve said it before — you know that randomized study of short-course antibiotic therapy for abdominal fluid collections? The one where the entry criteria included “adequate source control”?

We’re never consulted on those cases. Just these.

That’s why it was no surprise to read this recent paper, which showed that among 2.5 million patients in Canada, those seen by ID ranked second in complexity among all the sub-specialists. We trailed only nephrology — who, by taking care of all those people on dialysis, certainly have their hefty share of complex patients.

In order to provide some structure to this on-service experience, I try to find at least one item daily to for us to learn.

My “criteria” for inclusion:

1. Has to be related to a case.
2. Has to have a reference.
3. Has to be interesting.
4. Has to have no patient confidentiality issues.

Unlike previous rotations, this time I did it on the fly (so to speak) using Twitter. While some stay away from Twitter since it is (to certain individuals) an irresistible way to say something stupid, medical Twitter can also elicit fascinating responses and dialogue from an incredibly diverse group of clinicians. Thank you for that!

So here are the daily ID Learning Units from two weeks on service — a truly enjoyable time spent with an outstanding first-year fellow and a great second-year medical resident, someone I’m hoping will one day go into ID!

Day #1 On-Service ID Learning Unit: The only approved HIV regimen with no renal metabolism is DTG + RPV — hence no dose adjustment required in ESRD. For pts with viral suppression only. Pivotal study here: https://t.co/VRXb6puD6F

— Paul Sax (@PaulSaxMD) November 27, 2018

Day #2 On-Service ID Learning Unit: In vertebral osteomyelitis, ESR > 55 and CRP > 2.75 at week 4 of antibiotics associated with higher risk of treatment failure. Small study but consistent with clinical experience. https://t.co/HGEdqVAh5O

— Paul Sax (@PaulSaxMD) November 28, 2018

Day #3 On-Service ID Learning Unit: Dental work may contribute to the development of streptococcal PV endocarditis; most cases still NOT related. But how to manage future dental work in patients who appear to have "failed" prophylaxis? https://t.co/CYumfjUJ7q

— Paul Sax (@PaulSaxMD) November 29, 2018

Day #4 On-Service ID Learning Unit: Who to screen for latent TB?
1) High likelihood of infection (e.g., from highly endemic region) OR
2) High likelihood of of progression to TB disease if infected (e.g., anti-TNF Rx)
Also, IGRA preferred over TST. https://t.co/0FIfbR2pic

— Paul Sax (@PaulSaxMD) November 30, 2018

Day #5 On-Service ID Learning Unit: The always-confusing EBV serologies–which are unfortunately called "antigens" (i.e., antigen antibodies). https://t.co/GKwhnGQjhR pic.twitter.com/uIvhyWgtXk

— Paul Sax (@PaulSaxMD) December 1, 2018

Day #6 On-Service ID Learning Unit: Linezolid vs vancomycin in MRSA pneumonia. Controversial clinical trial at the time–but critiques notwithstanding, linezolid at least as good as (and possibly better than) vanco for Staph aureus pneumonia.https://t.co/Lpr2Dzw950

— Paul Sax (@PaulSaxMD) December 2, 2018

Day #7 On-Service ID Learning Unit: The oral antibiotic options for penicillin susceptible streptococci in the POET trial of partial oral therapy for endocarditis. Not easy given pill burden, dosing frequency, drug interactions, etc. https://t.co/1LjCCwCARJ pic.twitter.com/qOFIis9SOo

— Paul Sax (@PaulSaxMD) December 3, 2018

Day #8 On-Service ID Learning Unit: Fever of Unknown Origin or Fever of Too Many Origins? Still the best depiction of the challenge of ICU ID consults. "Frequently, the treatment approach is like playing Whac-A-Mole." https://t.co/uaCw6IKIeo

— Paul Sax (@PaulSaxMD) December 4, 2018

Day #9 On-Service ID Learning Unit: Diabetes is a consistent risk factor for invasive gp B strep infection in adults. A representative recent study:https://t.co/YgLZblL7kW

— Paul Sax (@PaulSaxMD) December 5, 2018

Day #10 On-Service ID Learning Unit: C diff is a common cause of "unexplained" leukocytosis in hospitalized patient. Still a valid observation — but if you just ask about C diff symptoms, it doesn't remain unexplained for very long! https://t.co/34Wtji8n5h

— Paul Sax (@PaulSaxMD) December 6, 2018

Day #11 On-Service ID Learning Unit: Multiplex PCR for diagnosis of CNS infections may yield false + (as in this case report) and false – (esp HSV and cryptococcus) results. Tests increasingly used; larger validation studies warranted! (h/t @iddocjen) https://t.co/A9HWULtqMa

— Paul Sax (@PaulSaxMD) December 7, 2018

Day #12 On-Service ID Learning Unit: Can you stop PCP prophylaxis with viral suppression and CD4 < 200? In this cohort study, for pts with CD4 100-200 on ART, the incidence of PCP was zero after stopping prophylaxis. (Which is what I do.) https://t.co/Z1Tlgin92W

— Paul Sax (@PaulSaxMD) December 8, 2018

Day #13 On-Service ID Learning Unit: In several studies (including this recent one), RSV causes as much morbidity among adults as influenza — esp in those with concomitant cardiopulmonary dz or immunosuppression. A very underappreciated pathogen! https://t.co/M4r8BHHYv0

— Paul Sax (@PaulSaxMD) December 9, 2018

Day #14 (and final, for now) On-Service ID Learning Unit: Is that pesky low-level viremia (50-200) in our HIV patients adherent to ART of any clinical consequence? Depends! In this study, don't worry! [THREAD] https://t.co/aSNiEGWwp6 pic.twitter.com/OkIaclhW5J

— Paul Sax (@PaulSaxMD) December 10, 2018