{"id":8797,"date":"2018-07-15T13:00:16","date_gmt":"2018-07-15T17:00:16","guid":{"rendered":"https:\/\/blogs.nejm.org\/hiv-id-observations\/?p=8797"},"modified":"2018-07-17T16:06:08","modified_gmt":"2018-07-17T20:06:08","slug":"service-digest-july-2018-special-section-just-staph-aureus","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/service-digest-july-2018-special-section-just-staph-aureus\/2018\/07\/15\/","title":{"rendered":"On-Service Digest, July 2018 \u2014 with Special Section Just for <i>Staph aureus<\/i>"},"content":{"rendered":"<div id=\"attachment_8811\" style=\"width: 306px\" class=\"wp-caption alignright\"><a href=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2018\/07\/interns.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-8811\" class=\" wp-image-8811\" src=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2018\/07\/interns.jpg\" alt=\"\" width=\"296\" height=\"197\" srcset=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2018\/07\/interns.jpg 450w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2018\/07\/interns-300x200.jpg 300w\" sizes=\"auto, (max-width: 296px) 100vw, 296px\" \/><\/a><p id=\"caption-attachment-8811\" class=\"wp-caption-text\">&#8220;Hey, medicine is fun!&#8221; she said, high-fiving enthusiastically with one of her co-interns.<\/p><\/div>\n<p>I&#8217;m currently on-service for the inpatient ID consult team, and this is July.<\/p>\n<p><em>At a teaching hospital.\u00a0<\/em><\/p>\n<p>Here&#8217;s where some would <a href=\"https:\/\/youtu.be\/ho9rZjlsyYY\" target=\"_blank\" rel=\"noopener\">play scary music<\/a>.\u00a0After all, the interns and fellows have just started!\u00a0<em>YIKES!<\/em><\/p>\n<p>But no scary music for me <span style=\"font-weight: 400\">\u2014<\/span> I <em>love<\/em> working with the July newbies.<\/p>\n<p>Because whatever they lack in experience or efficiency, they more than make up for it with enthusiasm and motivation. They&#8217;re on that steep upward slope in the learning curve, and it&#8217;s fun to experience this firsthand.<\/p>\n<p>Plus, there&#8217;s plenty of extra help around, and this year we hit the jackpot. In addition to an excellent first-year ID fellow, our team also has a resident with a distinguished\u00a0<a href=\"https:\/\/www.amazon.com\/Woman-Worm-Her-Head-Infectious-ebook\/dp\/B00C2RXWT0\/ref=sr_1_1?ie=UTF8&amp;qid=1530997500&amp;sr=8-1&amp;keywords=Pamela+Nagami+M.D.\" target=\"_blank\" rel=\"noopener\">ID pedigree<\/a>\u00a0and a medical student who has done ID research. If that weren&#8217;t enough, we also have a terrific ID PharmD who has his own keen residents.<\/p>\n<p>Yes, we almost have enough people on rounds to field a decent softball team. We make quite the sight entering and leaving the elevator.<\/p>\n<p>So what have we learned so far? Here are few items, ranging from obvious to obscure, inspired by a similar roundup\u00a0<a href=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/service-digest-december-2017-plus-holiday-song\/2017\/12\/24\/\" target=\"_blank\" rel=\"noopener\">last December<\/a>.<\/p>\n<ul>\n<li><a href=\"https:\/\/jumpshare.com\/v\/F4SHY4XQZ4lZQSJeAnhA\" target=\"_blank\" rel=\"noopener\"><strong>Here&#8217;s a terrific review for all clinicians of contemporary hepatitis C treatment.<\/strong><\/a><strong>\u00a0<\/strong>Sofosbuvir\/velpatasvir (SOF\/VEL) and glecaprevir\/pibrentasvir (GLE\/PIB) are the best options for initial therapy <span style=\"font-weight: 400\">\u2014<\/span> pangenotypic, highly effective (&gt;95% cures), well tolerated. Why choose anything else? Also, most patients need minimal monitoring <span style=\"font-weight: 400\">\u2014<\/span> test for cure 12 weeks after treatment stops and monitor for re-infection if at ongoing risk. Provided they don&#8217;t have advanced liver disease (and referral to a hepatologist), that&#8217;s pretty much it!<\/li>\n<li><a href=\"https:\/\/academic.oup.com\/cid\/article\/61\/suppl_6\/S612\/436893\"><b>Compared to other candida species, <\/b><b><i>Candida glabrata<\/i><\/b><b> has both more azole and echinocandin resistance.<\/b><\/a><span style=\"font-weight: 400\"> This is particularly the case in transplant and oncology centers that use extensive antifungal prophylaxis. In vitro, <\/span><i><span style=\"font-weight: 400\">Candida parapsilosis<\/span><\/i><span style=\"font-weight: 400\"> also shows reduced susceptibility to echinocandins, but\u00a0<\/span><strong><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed?term=24642553\">the clinical significance of this finding is uncertain<\/a>.<\/strong><\/li>\n<li><a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/9624473\"><b>TMP\/SMX is likely fine for treatment of HIV-related cerebral toxoplasmosis.<\/b><\/a><b> <\/b><span style=\"font-weight: 400\">Small caveat \u2014 there has never been a fully powered comparative trial versus pyrimethamine\/sulfadiazine. However, there is extensive international experience with TMP\/SMX, plus increasing clinical use in the U.S. since Shkreli\/Turing Pharmaceuticals raised the price of pyrimethamine from\u00a0$13.50 to $750 per dose.<\/span><\/li>\n<li><b>Asplenia or hyposplenism is an important risk factor for severe babesiosis. <\/b>Others risk factors include older age (&gt;50, ugh), receipt of cancer chemotherapy, advanced HIV disease, and treatment with TNF blockers or rituximab.\u00a0<strong><a href=\"https:\/\/academic.oup.com\/cid\/article\/46\/3\/370\/389854\">The last of these is a particularly bad player in persistent infection.<\/a><\/strong><\/li>\n<li><b>Among patients with HIV, those with poor adherence often have little or no resistance.<\/b><span style=\"font-weight: 400\"> They don\u2019t take enough of their medications to select for resistance. Further proof comes from several treatment-experienced trials of second-line therapy or beyond \u2014 <\/span><strong><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/26424460\">baseline lack of resistance is associated with <em>worse<\/em> outcomes<\/a><\/strong>.<span style=\"font-weight: 400\"> Poor adherence carrying through to the second-line therapy explains this apparent paradox.<\/span><\/li>\n<li><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC3491851\/\"><span style=\"font-weight: 400\"><strong>Doxycycline reduces the risk of <i>C. diff<\/i> in hospitalized patients.<\/strong><\/span><\/a><span style=\"font-weight: 400\"> This is one of many reasons it remains many ID doctor\u2019s <strong><a href=\"https:\/\/academic.oup.com\/ofid\/article\/4\/3\/ofx107\/4084650\" target=\"_blank\" rel=\"noopener\">favorite antibiotic<\/a><\/strong>.<\/span><\/li>\n<li><b><a href=\"https:\/\/www.viivhealthcare.com\/media\/press-releases\/2013\/september\/viiv-healthcare-presents-positive-data-from-phase-iiibiv-study-of-dolutegravir-vs-darunavir-in-treatment-na%C3%AFve-adults-with-hiv-1.aspx\">In treatment-naive patients, dolutegravir plus lamivudine is non-inferior to dolutegravir plus TDF\/FTC<\/a><a href=\"https:\/\/www.viivhealthcare.com\/media\/press-releases\/2013\/september\/viiv-healthcare-presents-positive-data-from-phase-iiibiv-study-of-dolutegravir-vs-darunavir-in-treatment-na%C3%AFve-adults-with-hiv-1.aspx\">.<\/a><\/b><span style=\"font-weight: 400\"> Full results to be presented soon. This should mean that prices for HIV drugs come down \u2014 but it won&#8217;t be so simple, as explained in <\/span><strong><a href=\"https:\/\/www.nejm.org\/doi\/full\/10.1056\/NEJMp1710914\">this excellent perspective from the <i>NEJM<\/i><\/a><\/strong>.<\/li>\n<li><strong>Carbamazepine and phenobarbital induce the metabolism of dolutegravir.<\/strong> For phenobarbital, the effect is likely to be substantial enough to make<strong> <a href=\"https:\/\/www.hiv-druginteractions.org\/interactions\/81698\" target=\"_blank\" rel=\"noopener\">co-administration with dolutegravir contraindicated<\/a><\/strong>.<\/li>\n<li><strong><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/29318906\" target=\"_blank\" rel=\"noopener\">Cefiderocol is an investigational cephalosporin with activity versus highly resistant gram negative infections.<\/a>\u00a0<\/strong>This includes many carbapenem-resistant isolates.\u00a0It is a novel &#8220;siderophore cephalosporin,&#8221; meaning it&#8217;s transported through the outer membrane of bacteria through iron transporters (at least, I think that&#8217;s what it means).<\/li>\n<li><a href=\"https:\/\/academic.oup.com\/ofid\/article\/5\/6\/ofy030\/5034833\"><strong>Obesity and diabetes are risk factors for invasive group B strep infections.<\/strong><\/a> This is now a more common pathogen in older adults than it is in newborns, a fact that surprises many medical students.<\/li>\n<li><strong><a href=\"http:\/\/www.croiconference.org\/sessions\/randomized-controlled-trial-prednisone-prevention-paradoxical-tb-iris\" target=\"_blank\" rel=\"noopener\">Prednisone reduces the risk of immune reconstitution inflammatory syndrome (IRIS) in patients with HIV-related TB.<\/a>\u00a0<\/strong>IRIS was diagnosed in 47% of those in the placebo arm, versus 33% in prednisone arm. There was no difference in mortality.<\/li>\n<li><span style=\"font-weight: 400\"><strong><em>Corynebacterium striatum<\/em>, commonly found as part of normal skin flora,\u00a0can cause clinically significant infections. <\/strong>Vancomycin is the preferred initial therapy, as\u00a0<strong><a href=\"https:\/\/www.nature.com\/articles\/s41598-017-10081-y\" target=\"_blank\" rel=\"noopener\">the organism is increasingly resistant to beta-lactams and quinolones<\/a><\/strong>.\u00a0Other options include linezolid and daptomycin, based on susceptibility testing. Device, hardware and line-related infections are most commonly reported, along with respiratory tract infections in immunocompromised hosts and patients with COPD.<\/span><\/li>\n<\/ul>\n<p>Special\u00a0<em>Staph aureus<\/em> section &#8212; hey, this is inpatient ID, remember?<\/p>\n<ul>\n<li style=\"font-weight: 400\"><a href=\"http:\/\/aac.asm.org\/content\/60\/5\/3090.long\"><b>Oxacillin is marginally better tolerated than nafcillin.<\/b><\/a> <span style=\"font-weight: 400\">Nafcillin has more renal-related adverse effects. However, <\/span><strong><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/29600576\">cefazolin is better tolerated than both of them<\/a><\/strong><span style=\"font-weight: 400\"> \u2014 but <\/span><strong><a href=\"https:\/\/academic.oup.com\/ofid\/article\/5\/6\/ofy123\/5003417\">is it as active<\/a><\/strong>? Let the debate rage on.<\/li>\n<li style=\"font-weight: 400\"><a href=\"https:\/\/academic.oup.com\/jac\/article\/68\/8\/1894\/867974\"><b>Penicillin-susceptible <\/b><b><i>Staph aureus<\/i><\/b><b> (PSSA) can be treated with penicillin.\u00a0<\/b><\/a><span style=\"font-weight: 400\">This presumes that the laboratory has definitively concluded it&#8217;s susceptible; since not all labs do this, however,\u00a0<\/span><strong><a href=\"http:\/\/circ.ahajournals.org\/content\/132\/15\/1435#sec-38\">the endocarditis guidelines recommend oxacillin or nafcillin for PSSA<\/a><\/strong><span style=\"font-weight: 400\">, even though penicillin is more active <\/span><i><span style=\"font-weight: 400\">in vitro<\/span><\/i><span style=\"font-weight: 400\">. (We tend to use penicillin at our hospital.)<\/span><\/li>\n<li style=\"font-weight: 400\"><a href=\"https:\/\/www.thelancet.com\/journals\/lancet\/article\/PIIS0140-6736(17)32456-X\/abstract\"><b>Adjunctive rifampin does not improve outcomes in <\/b><b><i>Staph aureus<\/i><\/b><b> bacteremia.<\/b><\/a>\u00a0R<span style=\"font-weight: 400\">ifampin still has a role in prosthetic valve endocarditis, as it targets bacteria in biofilms which could induce <\/span><i><span style=\"font-weight: 400\">late<\/span><\/i><span style=\"font-weight: 400\"> relapse. However, there is no need to use rifampin to clear the initial bacteremia, and giving it with a high burden of infection could select for resistance.<\/span><\/li>\n<li><strong><a href=\"https:\/\/clinicaltrials.gov\/ct2\/show\/NCT01792804?term=oral&amp;cond=Staph+Aureus+Bacteremia&amp;rank=1\" target=\"_blank\" rel=\"noopener\">There is an ongoing clinical trial comparing IV to oral antibiotics in uncomplicated <em>Staph aureus<\/em> bacteremia.<\/a> <\/strong>Called SABATO (for &#8220;<strong>S<\/strong>taph <strong>a<\/strong>ureus <strong>Ba<\/strong>cteremia <strong>T<\/strong>reatment <strong>O<\/strong>ptions&#8221; <span style=\"font-weight: 400\">\u2014<\/span> clever!), the trial will enroll patients after 5&#8211;7 days of IV therapy, randomizing them to continued IV versus oral TMP\/SMX. If they have sulfa allergies, MSSA patients will get clindamycin, and MRSA patients will get linezolid.<\/li>\n<li><a href=\"https:\/\/wwwnc.cdc.gov\/eid\/article\/22\/7\/15-1319_article\"><b>Mortality from <\/b><b><i>Staph aureus<\/i><\/b><b> pneumonia remains high.<\/b><\/a><span style=\"font-weight: 400\"> This is especially true when it&#8217;s a complication of influenza. And if it&#8217;s pneumonia due to MRSA,<strong> <a href=\"https:\/\/academic.oup.com\/cid\/article\/54\/5\/621\/325602\" target=\"_blank\" rel=\"noopener\">linezolid may be preferable to vancomycin<\/a><\/strong>.<\/span><\/li>\n<li><strong>For surgical prophylaxis when concerned about MRSA<\/strong><b>, <\/b><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed?term=21768763\"><b>vancomycin alone isn&#8217;t enough<\/b><\/a>. <span style=\"font-weight: 400\"> Vancomycin plus cefazolin is recommended. And count this as additional evidence that vancomycin has <em>many<\/em> weaknesses.<\/span><\/li>\n<\/ul>\n<p>Hey, this list of medical\/surgical specialties and classic rock songs left off Infectious Diseases!<\/p>\n<p>https:\/\/twitter.com\/VinnyFrancio\/status\/1017755243260542978<\/p>\n<p>Here&#8217;s the obvious answer (with apologies to Peggy Lee and her\u00a0<a href=\"https:\/\/www.youtube.com\/watch?v=EYxoAJ3Boyc\" target=\"_blank\" rel=\"noopener\">very different song of the same name<\/a>):<\/p>\n<p><iframe loading=\"lazy\" title=\"Fever - The Black Keys lyrics\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/XaEi0GtEgKI?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<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>I&#8217;m currently on-service for the inpatient ID consult team, and this is July. At a teaching hospital.\u00a0 Here&#8217;s where some would play scary music.\u00a0After all, the interns and fellows have just started!\u00a0YIKES! But no scary music for me \u2014 I love working with the July newbies. Because whatever they lack in experience or efficiency, they [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,4,5,6],"tags":[408,423,482,528,630,1175,871],"class_list":["post-8797","post","type-post","status-publish","format-standard","hentry","category-health-care","category-hiv","category-infectious-diseases","category-medical-education","tag-hcv","tag-hiv","tag-id-fellowship","tag-iris","tag-mrsa","tag-pssa","tag-staph-aureus"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/8797","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=8797"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/8797\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=8797"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=8797"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=8797"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}