{"id":7976,"date":"2015-12-26T15:48:46","date_gmt":"2015-12-26T20:48:46","guid":{"rendered":"http:\/\/blogs.nejm.org\/hiv-id-observations\/?p=7976"},"modified":"2015-12-26T15:48:46","modified_gmt":"2015-12-26T20:48:46","slug":"a-few-things-we-were-talking-about-on-rounds","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/a-few-things-we-were-talking-about-on-rounds\/2015\/12\/26\/","title":{"rendered":"A Few Things We Were Talking About On Rounds &#8230;"},"content":{"rendered":"<p><a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/12\/stamper-thing.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-7979\" src=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/12\/stamper-thing.jpg\" alt=\"stamper thing\" width=\"268\" height=\"195\" srcset=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/12\/stamper-thing.jpg 654w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/12\/stamper-thing-300x218.jpg 300w\" sizes=\"auto, (max-width: 268px) 100vw, 268px\" \/><\/a>Remember when people passed out papers of interesting clinical studies and relevant reviews? And how some doctors even had a special stamp they put in the upper right hand corner?<\/p>\n<p>OK, full confession &#8212;\u00a0I did that. <em>A lot.<\/em> See evidence to the right. Haven&#8217;t used the thing in well over a decade, surprised I still have it. Amazingly,\u00a0it\u00a0still works, though the print is getting somewhat faint.<\/p>\n<p>But <em>why<\/em> did I do that? Some indirect way of getting credit for the literature search-library run-photocopying? A way of preventing reprint theft? (Never much of a crime.) Just too lazy to write out my (very short) name? I do have terrible handwriting.<\/p>\n<p>Kind of ridiculous, when you think about it for a moment.<\/p>\n<p>I thought of this bygone practice since I just finished some time\u00a0on service, and mentioned various studies while on rounds. Passed out zero papers, for the record.<\/p>\n<p>But to prove\u00a0to the excellent fellow with whom I was working that\u00a0the studies weren&#8217;t just made up, here are a few that came up:<\/p>\n<ul>\n<li><strong>Dalbavancin<\/strong> is the long-acting\u00a0lipoglycopeptide that is FDA-approved for skin infections\u00a0, the two\u00a0doses separated by a week; oritavancin is approved for just single-dose therapy.\u00a0But <strong><a href=\"http:\/\/cid.oxfordjournals.org\/content\/early\/2015\/12\/20\/cid.civ982.long\" target=\"_blank\">this study<\/a><\/strong>\u00a0of skin and soft tissue infections suggests that dalbavancin given as just one dose is just as effective as the two dose regimen. It also doesn&#8217;t require the lengthy infusion time of oritavancin &#8212; only 30 minutes for dalbavancin, 3 hours for oritavancin.<\/li>\n<li><strong>Toxoplasmosis<\/strong> <strong>treatment<\/strong> is much in the news these days, thanks to the 5000% pyrimethamine price hike &#8212; and the always entertaining and recently arrested former CEO of the company that owns the rights to the drug. The price increase has forced many of us to adopt what most\u00a0other countries (and the transplant docs) have done for years, which is to use trimethoprim-sulfamethoxazole for toxo &#8212; an antibiotic that is cheap, readily available, and can be given either IV or PO. But what&#8217;s the dose? <strong><a href=\"http:\/\/aac.asm.org\/content\/42\/6\/1346.long\" target=\"_blank\">This small randomized clinical trial<\/a><\/strong>\u00a0used 5 mg\/kg of the TMP component q12h, and found it was better tolerated and just as effective as pyrimethamine and sulfadiazine; this dose is also listed in the <strong><a href=\"https:\/\/aidsinfo.nih.gov\/guidelines\/html\/4\/adult-and-adolescent-oi-prevention-and-treatment-guidelines\/322\/toxo\" target=\"_blank\">OI Guidelines<\/a>, <\/strong>and it comes out to\u00a02-3 DS tablets twice daily. Some recommend twice this dose based on other studies. Regardless, take that, Mr. Shkreli!<\/li>\n<li><strong>Leuconostoc<\/strong> is not only one of the few gram positive cocci intrinsically resistant to vancomycin, it&#8217;s also\u00a0not reliably\u00a0sensitive to linezolid. And boy does it sound weird\u00a0&#8212; a bacterium named by Russians? Who named it while working in Vladivostok? Treatment of choice is penicillin, but susceptibility testing is critical since resistance can occur. Macrolides, tetracyclines, carbapenems are also usually active. Here&#8217;s a <strong><a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC3892628\/\">recent case report<\/a><\/strong>\u00a0of successful treatment with tigecycline.<\/li>\n<li><strong><em><a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/12\/ntm-proportion-real-disease.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignright size-medium wp-image-7977\" src=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/12\/ntm-proportion-real-disease-300x150.jpg\" alt=\"ntm proportion real disease\" width=\"300\" height=\"150\" srcset=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/12\/ntm-proportion-real-disease-300x150.jpg 300w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/12\/ntm-proportion-real-disease-1024x513.jpg 1024w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/12\/ntm-proportion-real-disease-900x451.jpg 900w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/12\/ntm-proportion-real-disease.jpg 1800w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a>Mycobacterium gordonae<\/em><\/strong>\u00a0is a slow-growing non-tuberculous mycobacteria that can sometimes cause clinically important infection, but is <strong><a href=\"http:\/\/thorax.bmj.com\/content\/64\/6\/502.long\" target=\"_blank\">much more likely to be a colonizer or contaminant<\/a>\u00a0&#8212;\u00a0<\/strong>figure to the right is proportion of pulmonary isolates that caused real disease among NTMs in the Netherlands. <em>M gordonae<\/em>\u00a0is\u00a0<strong><a href=\"http:\/\/cid.oxfordjournals.org\/content\/31\/2\/472.long\" target=\"_blank\">commonly found in tap water,<\/a><\/strong>\u00a0and also is infamous for causing pseudo-outbreaks through its propensity to\u00a0colonize bronchoscopes, ice machines, cleaning devices, etc.<\/li>\n<li><strong>Penicillin-sensitive <em>Staph aureus<\/em><\/strong> is on the rise!\u00a0Here are the percentage of MSSA that are also penicillin-sensitive\u00a0according to <strong><a href=\"http:\/\/www.who.int\/drugresistance\/whonetsoftware\/en\/\" target=\"_blank\">WHONET<\/a>\u00a0<\/strong>(H\/T to Michael Calderwood):<br \/>\n<a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/12\/mssa-that-are-pcn-susceptible.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-full wp-image-7978\" src=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2015\/12\/mssa-that-are-pcn-susceptible.jpg\" alt=\"mssa that are pcn susceptible\" width=\"270\" height=\"207\" \/><\/a>Our hospital has similar rates. No one (I don&#8217;t think) has any idea <em>why<\/em> this is happening &#8212; theories welcome. And we continue to be surprised by\u00a0<strong><a href=\"http:\/\/circ.ahajournals.org\/content\/132\/15\/1435.full\" target=\"_blank\">the latest endocarditis<\/a><a href=\"http:\/\/circ.ahajournals.org\/content\/132\/15\/1435.full\" target=\"_blank\"> guidelines<\/a><\/strong>,<strong>\u00a0<\/strong>which\u00a0recommend nafcillin or oxacillin for <em>all<\/em> MSSA regardless of penicillin sensitivity &#8212; though many experts (including those who taught me) will choose penicillin if susceptibility is confirmed, since it is more active in vitro, and there is <strong><a href=\"http:\/\/jac.oxfordjournals.org\/content\/68\/8\/1894.long\" target=\"_blank\">this suggestive study.<\/a><\/strong> The key is that the micro lab just needs to do the extra step of confirming absence of inducible beta lactamase &#8212; not difficult, and potentially clinically relevant.<\/li>\n<li><strong>Nitrofurantoin<\/strong>\u00a0should not be prescribed to\u00a0patients with creatinine clearance &lt; 40 due to lower efficacy and increased toxicity &#8212; accumulation of toxic nitrofurantoin-derived metabolites can occur. That means it&#8217;s not an option for the 90-year-old woman admitted with a UTI and a creatinine of 1.6 (which for the record calculates to an estimated creatinine clearance of around 20). Great recent\u00a0<strong><a href=\"http:\/\/jac.oxfordjournals.org\/content\/70\/9\/2456.long\" target=\"_blank\">review of nitrofurantoin\u00a0here<\/a>,\u00a0<\/strong>which is particularly helpful since\u00a0use of this drug\u00a0has increased enormously since the change in the UTI guidelines and the rise in fluoroquinolone and TMP-SMX gram negative resistance.<\/li>\n<\/ul>\n<p>Hey, hope the holidays brought you got some wonderful presents &#8212; something better than these items in the video below, which could be less useful than my\u00a0stamp thing (which at least takes up almost no space in the back of my desk):<\/p>\n<p>[youtube http:\/\/www.youtube.com\/watch?v=FgFeVlw2Ywg]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Remember when people passed out papers of interesting clinical studies and relevant reviews? And how some doctors even had a special stamp they put in the upper right hand corner? OK, full confession &#8212;\u00a0I did that. A lot. See evidence to the right. Haven&#8217;t used the thing in well over a decade, surprised I still [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,5,6],"tags":[],"class_list":["post-7976","post","type-post","status-publish","format-standard","hentry","category-health-care","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\/7976","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=7976"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/7976\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=7976"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=7976"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=7976"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}