{"id":5206,"date":"2014-05-28T16:20:47","date_gmt":"2014-05-28T20:20:47","guid":{"rendered":"http:\/\/blogs.nejm.org\/?p=5206"},"modified":"2015-05-18T11:04:57","modified_gmt":"2015-05-18T15:04:57","slug":"some-id-stuff-were-talking-about-on-rounds","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/some-id-stuff-were-talking-about-on-rounds\/2014\/05\/28\/","title":{"rendered":"Some ID Stuff We&#8217;re Talking About on Rounds"},"content":{"rendered":"<p><a href=\"http:\/\/blogs.nejm.org\/wp-content\/uploads\/2014\/05\/Leeching-large.jpeg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-5211 size-medium\" src=\"http:\/\/blogs.nejm.org\/wp-content\/uploads\/2014\/05\/Leeching-large-300x237.jpeg\" alt=\"Leeching-large\" width=\"300\" height=\"236\" srcset=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2014\/05\/Leeching-large-300x237.jpeg 300w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2014\/05\/Leeching-large.jpeg 729w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>Just finished two weeks on the inpatient general medical service &#8212; hence the radio silence &#8212; giving me a chance to work with residents, interns, and medical students. Here&#8217;s a smattering of the ID topics we discussed, along with a comment or two:<\/p>\n<ul>\n<li><strong>&#8220;Common&#8221; causes of gram negative soft tissue infection<\/strong>\u00a0(at least for board exam\u00a0purposes), and their associations: \u00a0<em>Pasturella multocida <\/em>(<strong><a href=\"http:\/\/www.jhandsurg.org\/article\/S0363-5023(13)01539-6\/abstract\" target=\"_blank\">cat bites<\/a><\/strong>)<em>,<\/em>\u00a0<em>Vibrio vulnificus<\/em> (salt water, especially in warmer climates), <em>Aeromonas hydrophila<\/em> (fresh water and <strong><a href=\"http:\/\/cid.oxfordjournals.org\/content\/35\/1\/e1.full\" target=\"_blank\">leeches<\/a><\/strong>). Yes, leeches, which <strong><a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/22407551\" target=\"_blank\">do have some legitimate medical indications<\/a><\/strong>. Our patient had <em>Enterobacter cloacae <\/em>(not leech-related), which led to a discussion about &#8230;<\/li>\n<li><strong><a href=\"http:\/\/www.sciencedirect.com\/science\/article\/pii\/S0924857912002580\" target=\"_blank\">&#8220;Inducible&#8221; AmpC beta lactamases<\/a><\/strong>, which get expressed after in vivo exposure to cephalosporins or expanded-spectrum penicillins. These are\u00a0<strong><a href=\"http:\/\/cmr.asm.org\/cgi\/pmidlookup?view=long&amp;pmid=19136439\" target=\"_blank\">really tricky<\/a><\/strong> since the\u00a0microbiology lab will report enterobacter spp.\u00a0as sensitive to these antibiotics unless another resistance mechanism is present. So should all patients with serious infections due to enterobacter receive a carbapenem? Probably a good idea.<\/li>\n<li><strong>Parasites are thought frequently to cause eosinophilia, but protozoan (single cell) parasites rarely do<\/strong> &#8212; except for the uncommon\u00a0bugs\u00a0<strong><em><a href=\"http:\/\/ispub.com\/IJAAI\/5\/2\/6530\">Isospora belli<\/a>,\u00a0<\/em><a href=\"http:\/\/www.cid.oxfordjournals.org\/cgi\/pmidlookup?view=long&amp;pmid=23759351\"><em>Dientamoeba fragilis<\/em>,<\/a><\/strong>\u00a0and <em><a href=\"http:\/\/cmr.asm.org\/content\/23\/1\/218.full\" target=\"_blank\"><strong>Cyclospora cayetanensis<\/strong>.<\/a>\u00a0<\/em>So if your patient has parasite-related eosinophilia, think worms &#8212; strongyloides, schistosomiasis, filariasis, etc.<\/li>\n<li><strong>Is obsessive tweaking of vancomycin levels\u00a0useful<\/strong> if you&#8217;re not treating confirmed\u00a0<em>Staph aureus<\/em>\u00a0and the patient&#8217;s renal function is normal? <strong><a href=\"http:\/\/onlinelibrary.wiley.com\/doi\/10.1592\/phco.29.11.1275\/abstract\" target=\"_blank\">Highly doubtful<\/a>.<\/strong> The drive to get vancomycin troughs between 15-20 is\u00a0the ID-fellow equivalent for repleting potassium &#8212; a constant annoyance, and not always necessary.<\/li>\n<li><strong>Watch out for ritonavir-related drug-interactions<\/strong> &#8212; in particular with <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/15755851\" target=\"_blank\"><strong>inhaled<\/strong> <\/a>or <a href=\"http:\/\/omicsonline.org\/clinical-course-and-management-of-iatrogenic-cushing-syndrome-jaa.1000086.php?aid=22049\" target=\"_blank\"><strong>injectable<\/strong> <\/a>corticosteroids. Some EHR interaction alerts should not be ignored!<\/li>\n<li><strong>Still confused about the diagnostic approach to C diff?<\/strong> Here&#8217;s a <strong><a href=\"http:\/\/ofid.oxfordjournals.org\/content\/1\/1\/ofu007.full\" target=\"_blank\">very nice summary<\/a><\/strong> of what most micro labs are doing.<\/li>\n<li><strong>Hemolytic anemia occurring weeks to months after surgery should prompt consideration of\u00a0<a style=\"color: #1155cc\" href=\"http:\/\/annals.org\/article.aspx?articleid=474991\" target=\"_blank\">transfusion-related babesiosis<\/a><\/strong><span style=\"color: #222222\"><strong>.<\/strong> Cases may be seen year-round (but most in the summer) and throughout the USA. Median age 65. \u00a0Median time to onset of symptoms around 50 days. And no, there is currently no routine screening of blood donors &#8212; but as soon as there is a reliable screening test, suspect there will be.<\/span><\/li>\n<li><strong>One important cause of potentially severe hepatitis is <a href=\"http:\/\/cid.oxfordjournals.org\/content\/24\/3\/334.long\" target=\"_blank\">herpes simplex virus<\/a><\/strong>, which can occur in both immunocompromised and immunocompetent hosts &#8212; in the latter, pregnant women seem particularly susceptible. Diagnostic test of choice is <strong><a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC3618973\/\" target=\"_blank\">blood PCR for HSV DNA<\/a><\/strong>.<\/li>\n<li><strong>The days of Western blot used to confirm HIV diagnosis are numbered<\/strong>, as we head towards <strong><a href=\"http:\/\/www.cdc.gov\/mmwr\/preview\/mmwrhtml\/mm6224a2.htm?s_cid=mm6224a2_e\" target=\"_blank\">this new algorithm.<\/a>\u00a0<\/strong>I note that one large commercial lab has already stopped sending the Western blot in favor of <strong><a href=\"http:\/\/www.questdiagnostics.com\/testcenter\/TestDetail.action?ntc=91431\" target=\"_blank\">the HIV-1\/2 differentiation\u00a0assay<\/a><\/strong> &#8212; progress!<\/li>\n<\/ul>\n<p><strong><em>Rapid fire round:<\/em><\/strong> If culture results say &#8220;suspected enteric gram negative rods,&#8221; it will not be pseudomonas; ditto GNR that grow in both aerobic <em>and<\/em> anaerobic blood culture bottles (true <em>most<\/em> of the time) &#8230; with disk diffusion susceptibility testing, large numbers indicate greater sensitivity (zone of inhibition), but with MICs, it&#8217;s a low number you want &#8230; a nice adaptation of the disk diffusion method is the <a href=\"http:\/\/blogs.nejm.org\/index.php\/id-learning-unit-the-etest\/2012\/06\/12\/\" target=\"_blank\">Etest<\/a> &#8230; sending sputum cultures gram stains and cultures on patients with pneumonia after they have been started on antibiotics is all but useless (does not apply to ICU intubated patients) &#8230; no one really knows the <a href=\"http:\/\/blogs.nejm.org\/index.php\/unanswerable-questions-in-infectious-diseases-persistent-mrsa-bacteremia\/2014\/01\/30\/\" target=\"_blank\">optimal management of persistent MRSA bacteremia<\/a> &#8230; hepatitis B serologies are an endless source of diagnostic confusion for legions of medical students (and some house staff), so here&#8217;s a <a href=\"http:\/\/vhba.org.au\/understanding-hepatitis-b-testing-0\" target=\"_blank\">nifty chart<\/a> &#8230; as we head into summer here in New England, the &#8220;doxy deficiency&#8221; work-up for febrile adults in the outpatient setting (without an obvious other source) consists of Lyme antibody, anaplasma (not ehrlichia) PCR, and babesia PCR &#8230; an organism that is resistant to ceftazidime but sensitive to cefoxitin or cefotetan will be an extended spectrum beta lactamase producer &#8230;<\/p>\n<p>Finally, an observation that several\u00a0commonly used drugs <a href=\"http:\/\/blogs.nejm.org\/index.php\/back-to-school-top-questions-from-id-in-primary-care\/2013\/10\/18\/\" target=\"_blank\">share the fate of trimethoprim-sulfamethoxazole<\/a>, meaning they may eternally be referred to on rounds by their brand names even though they are all off patent, some for many\u00a0years. The leaders are:<\/p>\n<ul>\n<li>Hydromorphone (Dilaudid)<\/li>\n<li><span style=\"font-size: 13px\">Levetiracetam (Keppra)<\/span><\/li>\n<li><span style=\"font-size: 13px\">Furosemide (Lasix)<\/span><\/li>\n<li>Piperacillin-tazobactam (Zosyn)<\/li>\n<\/ul>\n<p>Ready for 2&#8217;45&#8221; of fun? Off we go:<\/p>\n<p><center><iframe loading=\"lazy\" src=\"\/\/www.youtube.com\/embed\/cePKpt5nOJ0\" width=\"420\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/center><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Just finished two weeks on the inpatient general medical service &#8212; hence the radio silence &#8212; giving me a chance to work with residents, interns, and medical students. Here&#8217;s a smattering of the ID topics we discussed, along with a comment or two: &#8220;Common&#8221; causes of gram negative soft tissue infection\u00a0(at least for board exam\u00a0purposes), [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,4,5,6],"tags":[],"class_list":["post-5206","post","type-post","status-publish","format-standard","hentry","category-health-care","category-hiv","category-infectious-diseases","category-medical-education"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/5206","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=5206"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/5206\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=5206"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=5206"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=5206"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}