{"id":11143,"date":"2024-06-20T15:12:16","date_gmt":"2024-06-20T19:12:16","guid":{"rendered":"https:\/\/blogs.nejm.org\/hiv-id-observations\/?p=11143"},"modified":"2024-06-20T16:37:44","modified_gmt":"2024-06-20T20:37:44","slug":"early-heatwave-id-link-o-rama","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/early-heatwave-id-link-o-rama\/2024\/06\/20\/","title":{"rendered":"Early Heatwave ID Link-o-Rama"},"content":{"rendered":"<p>We&#8217;ll get to the links in a moment, but first, a little poll. You might have heard that there&#8217;s a new Editor-in-Chief at NEJM Journal Watch, <a href=\"https:\/\/www.jwatch.org\/na57638\/2024\/06\/13\/message-raja-elie-abdulnour-md-nejm-journal-watch-editor?query=etoc_jwgenmed&amp;jwd=000000116284&amp;jspc=ID&amp;cid=DM2345638_Subscriber&amp;bid=-1938551645\" target=\"_blank\" rel=\"noopener\">Dr. Raja-Elie Abdulnour<\/a>. We met recently, and discussed this column or blog or newsletter or whatever you want to call it.<\/p>\n<p>A topic came up that we&#8217;ve been wondering about for a while &#8212; who are you, the readers of this thing? If you could take a moment to vote, I&#8217;d very much appreciate it.<\/p>\n<div id=\"polls-64\" class=\"wp-polls\">\n\t<form id=\"polls_form_64\" class=\"wp-polls-form\" action=\"\/index.php\" method=\"post\">\n\t\t<p style=\"display: none;\"><input type=\"hidden\" id=\"poll_64_nonce\" name=\"wp-polls-nonce\" value=\"e48b35a285\" \/><\/p>\n\t\t<p style=\"display: none;\"><input type=\"hidden\" name=\"poll_id\" value=\"64\" \/><\/p>\n\t\t<p style=\"text-align: center;\"><strong>I'm a reader, and this statement best describes me:<\/strong><\/p><div id=\"polls-64-ans\" class=\"wp-polls-ans\"><ul class=\"wp-polls-ul\">\n\t\t<li><input type=\"radio\" id=\"poll-answer-209\" name=\"poll_64\" value=\"209\" \/> <label for=\"poll-answer-209\">Person who focuses on ID or HIV (doctor, nurse, PharmD, other)<\/label><\/li>\n\t\t<li><input type=\"radio\" id=\"poll-answer-210\" name=\"poll_64\" value=\"210\" \/> <label for=\"poll-answer-210\">Not an ID person, but still in the medical world in some way<\/label><\/li>\n\t\t<li><input type=\"radio\" id=\"poll-answer-211\" name=\"poll_64\" value=\"211\" \/> <label for=\"poll-answer-211\">Neither of the above<\/label><\/li>\n\t\t<\/ul><p style=\"text-align: center;\"><input type=\"button\" name=\"vote\" value=\"   Vote   \" class=\"Buttons\" onclick=\"poll_vote(64);\" \/><\/p><p style=\"text-align: center;\"><a href=\"#ViewPollResults\" onclick=\"poll_result(64); return false;\" title=\"View Results Of This Poll\">View Results<\/a><\/p><\/div>\n\t<\/form>\n<\/div>\n\n<p>Feel free to elaborate further in the comments. I promise that no one will follow up asking you to explain how to <a href=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/how-to-figure-out-the-length-of-antibiotic-therapy\/2010\/10\/22\/\" target=\"_blank\" rel=\"noopener\">determine the length of antibiotic therapy<\/a>, why <a href=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/learning-the-names-of-hiv-drugs-is-horribly-difficult-heres-why\/2019\/11\/03\/\" target=\"_blank\" rel=\"noopener\">learning the names of HIV drugs is so difficult<\/a>, or the reason why medical students <a href=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/a-mysteriosis-about-listeroisis\/2011\/11\/05\/\" target=\"_blank\" rel=\"noopener\">know more about listeria than any other bacterial infection<\/a>.<\/p>\n<p>On to the links we go!<\/p>\n<p style=\"padding-left: 40px\"><a href=\"https:\/\/www.gilead.com\/news-and-press\/press-room\/press-releases\/2024\/6\/gileads-twiceyearly-lenacapavir-demonstrated-100-efficacy-and-superiority-to-daily-truvada-for-hiv-prevention\" target=\"_blank\" rel=\"noopener\"><strong>In a randomized clinical trial of pre-exposure prophylaxis for prevention of HIV in women, twice-yearly injectable lenacapavir was superior to the oral options TDF\/FTC (Truvada) or TAF\/FTC (Descovy).<\/strong> <\/a>None &#8212; that\u2019s right ZERO! &#8212; of the 2134 women who received lenacapavir contracted HIV, versus 16 of 1068 on TDF\/FTC, and 39 of 2136 on TAF\/FTC. Study was conducted in 25 sites in South Africa and in Uganda. Many more details on this important study undoubtedly to come at this summer&#8217;s AIDS 2024 conference in Munich, but based on these results alone, it&#8217;s a major advance in HIV prevention strategies.<\/p>\n<p style=\"padding-left: 40px\"><a href=\"https:\/\/jamanetwork.com\/journals\/jama\/fullarticle\/2819971\" target=\"_blank\" rel=\"noopener\"><strong>In antibiotic treatment of sepsis, continuous versus intermittent \u03b2-lactam antibiotic infusions did not significantly reduce 90-day mortality.<\/strong> <\/a>The study, cleverly called BLING III (&#8220;<strong>B<\/strong>eta-<strong>L<\/strong>actam <strong>I<\/strong>nfusion <strong>G<\/strong>roup&#8221;), promises to generate lots of controversy, as there was an observed benefit &#8212; just not enough to be statistically significant for the primary endpoint. Another way of looking at it is that there <em>could<\/em> be benefit for this critically ill population. Suspect many will continue to use continuous infusion therapy unless there&#8217;s shown to be some harm.<\/p>\n<p style=\"padding-left: 40px\"><a href=\"https:\/\/jamanetwork.com\/journals\/jamainternalmedicine\/article-abstract\/2818278\" target=\"_blank\" rel=\"noopener\"><strong>Compared to vancomycin plus cefepime, a cohort study showed an association between use of vancomycin and piperacillin-tazobactam and increased mortality.<\/strong><\/a> The study design took advantage of a &#8220;natural experiment,&#8221; one driven by a shortage of the pip-tazo. The leading hypothesis for the results is that the extra anaerobic coverage of pip-tazo is harmful. Alternatively, perhaps this is just an association due to the different time periods, with actual no causation &#8212; remember, the randomized <a href=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/a-brilliant-strategy-for-conducting-clinical-trials-the-acorn-study\/2023\/10\/17\/\" target=\"_blank\" rel=\"noopener\">ACORN trial<\/a> showed no difference in major clinical outcomes between pip-tazo and cefepime as empiric therapy.<\/p>\n<p style=\"padding-left: 40px\"><a href=\"https:\/\/doi.org\/10.1093\/cid\/ciae261\" target=\"_blank\" rel=\"noopener\"><strong>In a prospective analysis of a large patient population switching to tenofovir\/lamivudine\/dolutegravir (TLD), virologic failure with resistance occurred, but was rare.<\/strong> <\/a>Switching to this regimen while viremic was a risk factor. With over 20 million people on this treatment globally, ongoing monitoring for emergent integrase inhibitor resistance will be critical &#8212; as will transmitted resistance, as the default first-line and second-line therapy in most of the world is now TLD.<\/p>\n<p style=\"padding-left: 40px\"><em>Brief aside &#8212; I learned recently from my brilliant colleague Dr. Emily Hyle that a month of TLD now costs around $3 in Africa, while a resistance genotype is still $300! In an era where another molecular test, the GeneXpert for TB, is widely available in this region, this high price of HIV resistance testing is an absurdity that must end soon.<\/em><\/p>\n<p style=\"padding-left: 40px\"><a href=\"https:\/\/doi.org\/10.1016\/S2352-3018(24)00061-4\" target=\"_blank\" rel=\"noopener\"><strong>Is there a role for two-drug HIV therapy in Africa?<\/strong><\/a> From a medical perspective, the answer to this question is of course there is &#8212; there&#8217;s a role for such treatment now in the developed world, with dolutegravir\/lamivudine and long-acting injectable cabotegravir and rilpivirine being the most important options. But availability of lab testing is a major barrier, with limited access to renal monitoring, assessment of hepatitis B status, and the already called-out HIV resistance testing. Not so bold prediction: In the not-so-distant future, we will be hearing a lot about\u00a0 tenofovir DF complications (renal, bone disease) in older PWH globally, especially those with comorbidities.<\/p>\n<p style=\"padding-left: 40px\"><strong><a href=\"https:\/\/www.accessdata.fda.gov\/drugsatfda_docs\/label\/2024\/216483s000lbl.pdf\" target=\"_blank\" rel=\"noopener\">Pivmecillinam is now FDA-approved for treatment of uncomplicated UTIs in the United States.<\/a><\/strong> In case you&#8217;re surprised at the development of this &#8220;new&#8221; antibiotic for this indication (raises hand!), there&#8217;s a reason I put <em>new<\/em> in quotes &#8212; it&#8217;s been available in other countries for decades. Despite broad use in some European countries, <a href=\"https:\/\/doi.org\/10.1093\/ofid\/ofae296\" target=\"_blank\" rel=\"noopener\"><strong>this review found resistance to be uncommon<\/strong><\/a>. I&#8217;ve been told by one of our ID pharmacists that it won&#8217;t be available in our pharmacies here in the USA until 2025.<\/p>\n<div id=\"attachment_11148\" style=\"width: 204px\" class=\"wp-caption alignright\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11148\" class=\" wp-image-11148\" src=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2024\/06\/insider-monkey-png.png\" alt=\"\" width=\"194\" height=\"194\" srcset=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2024\/06\/insider-monkey-png.png 512w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2024\/06\/insider-monkey-png-300x300.png 300w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2024\/06\/insider-monkey-png-150x150.png 150w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2024\/06\/insider-monkey-png-144x144.png 144w\" sizes=\"auto, (max-width: 194px) 100vw, 194px\" \/><p id=\"caption-attachment-11148\" class=\"wp-caption-text\">An insider monkey.<\/p><\/div>\n<p style=\"padding-left: 40px\"><a href=\"https:\/\/www.insidermonkey.com\/blog\/20-cities-with-the-highest-hiv-aids-rates-in-the-us-1310216\/?singlepage=1\" target=\"_blank\" rel=\"noopener\"><strong>The metropolitan area in the United States with the highest HIV rate is in southern Florida, the Miami-Fort Lauderdale area.<\/strong> <\/a>Caveat &#8212; this list is from a link found on Yahoo Finance called <a href=\"https:\/\/www.insidermonkey.com\/\" target=\"_blank\" rel=\"noopener\">Insider Monkey<\/a>, and though they used CDC data, I didn&#8217;t check their methodology. But the results show no major surprises &#8212; most of the top cities are either in the South, or the big metropolitan areas in the Northeast (south of New England) and California.<\/p>\n<p style=\"padding-left: 40px\"><a href=\"https:\/\/doi.org\/10.1093\/cid\/ciae253\" target=\"_blank\" rel=\"noopener\"><strong>Patients who had de-escalation of broad-spectrum beta-lactam therapy experienced a reduced risk for emergent gram-negative infections compared to those who did not.<\/strong><\/a> While the results could be confounded by baseline differences in patient characteristics, this result makes abundant sense. In other words, let&#8217;s change that meropenem to ceftriaxone when we can!<\/p>\n<p style=\"padding-left: 40px\"><a href=\"https:\/\/doi.org\/10.1093\/cid\/ciae320\" target=\"_blank\" rel=\"noopener\"><strong>In a prospective study of healthcare workers who did not respond to hepatitis B vaccination, two doses of the adjuvanted hepatitis B vaccine elicited serologic responses in 91%.<\/strong><\/a> Participants had to have non-response to <em>five doses<\/em> of the standard vaccine, hence these are impressive results. Though not a comparative clinical trial, how long before this vaccine\u00a0 is the default recommended strategy for this population at high-risk for occupational exposure?<\/p>\n<p style=\"padding-left: 40px\"><strong><a href=\"https:\/\/doi.org\/10.1093\/ofid\/ofae343\" target=\"_blank\" rel=\"noopener\">A detailed virologic study of 563 HIV isolates from blood donors from 2015&#8211;2020 found PI, NRTI, and NNRTI resistance mutations in 5.0%, 4.6% and 13.9% of sequenced samples.<\/a><\/strong> The overwhelming majority (96%) were subtype B. Resistance declined over time. Two samples (0.4%) had the M184V mutation, including one that also had K65R &#8212; perhaps in a person who had taken PrEP? Unfortunately, no sequencing of integrase inhibitor mutations was performed.<\/p>\n<p style=\"padding-left: 40px\"><a href=\"https:\/\/doi.org\/10.1093\/ofid\/ofae342\" target=\"_blank\" rel=\"noopener\"><strong>Here are some ID-related &#8220;therapeutic myths&#8221; in solid-organ transplantation.<\/strong><\/a> Highlights include treatment of all asymptomatic bacteriuria after kidney transplant (don&#8217;t), giving antibiotic prophylaxis for dental work (don&#8217;t again), and the lack of evidence for vaccinations inducing rejection. Good <strong><a href=\"https:\/\/academic.oup.com\/view-large\/figure\/467323618\/ofae342_ga1.jpg?itm_medium=graphical+abstract+image&amp;itm_content=open+image&amp;itm_source=http:\/\/academic.oup.com\/ofid\/advance-article\/doi\/10.1093\/ofid\/ofae342\/7693891&amp;itm_campaign=graphical+abstract\" target=\"_blank\" rel=\"noopener\">graphic summary<\/a><\/strong>.<\/p>\n<p style=\"padding-left: 40px\"><a href=\"https:\/\/www.fda.gov\/vaccines-blood-biologics\/updated-covid-19-vaccines-use-united-states-beginning-fall-2024\" target=\"_blank\" rel=\"noopener\"><strong>The FDA advised companies to update the COVID vaccines to target the KP.2 strain.<\/strong><\/a> This is a descendent of the JN.1 variant that circulated widely this past winter. COVID cases will inevitably increase this respiratory virus season (mid-late November is when it typically kicks into high gear), so having an updated vaccine for people at high risk for complications is a good idea. The question remains whether <em>all<\/em> previously immunized and infected people need annual boosters &#8212; hope one day we get a good trial to answer that question.<\/p>\n<p style=\"padding-left: 40px\"><a href=\"https:\/\/www.fda.gov\/vaccines-blood-biologics\/capvaxive\" target=\"_blank\" rel=\"noopener\"><strong>Believe it or not, there&#8217;s another pneumococcal vaccine coming.<\/strong><\/a> This version covers 21 serotypes, just 1 more numerically than the PCV-20. However, the serotypes are different, including 8 not covered by other currently available pneumococcal vaccines. The manufacturer has data that these serotypes more closely match the disease-causing strains in adults. On June 27, the CDC\u2019s Advisory Committee on Immunization Practices will meet to review how it should fit in with currently available options.<\/p>\n<p style=\"padding-left: 40px\"><a href=\"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2820022\" target=\"_blank\" rel=\"noopener\"><strong><em>Staph aureus<\/em> susceptibilities over a 10-year period showed a rising rate of resistance to tetracyclines and trimethoprim sulfamethoxazole, especially in MRSA strains.<\/strong><\/a> The study included 382 149 isolates from 2010&#8211;2019, stratified by MRSA versus non-MRSA. Among MRSA strains, tetracycline resistance increased from 3.6% in 2010 to 12.8% in 2019; for TMP-SMX, it increased from 2.6% to 9.2%. The good news? The proportion overall that were MRSA declined from 53.6% in 2010 to 38.8%, a favorable (and mysterious) trend seen previously in other studies that no one has been able to explain.<\/p>\n<p style=\"padding-left: 40px\"><a href=\"https:\/\/doi.org\/10.1093\/cid\/ciae325\" target=\"_blank\" rel=\"noopener\"><strong>A review of over 60,000 inpatient ID consults at an academic medical center from 2014&#8211;2023 found a high proportion were done on patients with terminal or incurable illness, with a 7.5% mortality during the admission.<\/strong><\/a> There were two striking findings in this study. First, the obvious one, which is that people who need ID consults are really sick. Second, the volume of ID consults has <em>nearly doubled over the past decade &#8212; <\/em>from 5.0\/100 to 9.9\/100 patients. If you think you&#8217;ve been increasingly busy on your inpatient consult service, this is no illusion.<\/p>\n<p style=\"padding-left: 40px\"><strong><a href=\"https:\/\/jamanetwork.com\/journals\/jama\/article-abstract\/2820168\" target=\"_blank\" rel=\"noopener\">In a randomized clinical trial, povidone iodine in alcohol was noninferior to chlorhexidine gluconate in alcohol to prevent infection after cardiac or abdominal surgery.<\/a> <\/strong>The importance of the study is the much-lower cost of the povidine iodine, and chlorhexidine is therefore much less widely available globally. Hey, I believe this is the first time I&#8217;ve covered a topical antimicrobial study in a Link-o-Rama!<\/p>\n<p>Before we wrap up, first, don&#8217;t forget to take the poll (see above); and second, a little childhood history for those of a certain age (mine, or a bit older).<\/p>\n<p>In the 1960s, I learned there was an important debate about the best baseball player in the world, Willie Mays or Mickey Mantle. Increasingly obsessed with this sport to the point that I bored my parents senseless with my endless ruminations on this and other baseball-related topics, I intensively studied biographies and statistics of these two players, wanting ever so much for Mickey Mantle to be the winner with a passion that makes absolutely no sense today.<\/p>\n<p>Turns out, no matter how I twisted the data &#8212; focusing only on their best years, or most heroic moments, or their potential without injuries &#8212; the answer came back the same again and again.<\/p>\n<p>Willie was better. Possibly <a href=\"https:\/\/www.nytimes.com\/athletic\/1740980\/2020\/04\/13\/the-baseball-100-no-1-willie-mays\/\" target=\"_blank\" rel=\"noopener\">best ever<\/a>. Rest in peace, Say Hey Kid!<\/p>\n<p><iframe loading=\"lazy\" title=\"Say Hey! Willie Mays\" width=\"500\" height=\"375\" src=\"https:\/\/www.youtube.com\/embed\/5abB64ISJo8?feature=oembed\" frameborder=\"0\" allow=\"accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share\" referrerpolicy=\"strict-origin-when-cross-origin\" allowfullscreen><\/iframe><\/p>\n","protected":false},"excerpt":{"rendered":"<p>We&#8217;ll get to the links in a moment, but first, a little poll. You might have heard that there&#8217;s a new Editor-in-Chief at NEJM Journal Watch, Dr. Raja-Elie Abdulnour. We met recently, and discussed this column or blog or newsletter or whatever you want to call it. A topic came up that we&#8217;ve been wondering [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,4,5],"tags":[],"class_list":["post-11143","post","type-post","status-publish","format-standard","hentry","category-health-care","category-hiv","category-infectious-diseases"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/11143","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=11143"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/11143\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=11143"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=11143"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=11143"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}