{"id":9081,"date":"2019-03-24T18:32:43","date_gmt":"2019-03-24T22:32:43","guid":{"rendered":"https:\/\/blogs.nejm.org\/hiv-id-observations\/?p=9081"},"modified":"2019-03-24T19:28:24","modified_gmt":"2019-03-24T23:28:24","slug":"tetanus-case-no-more-mac-prophylaxis-playing-in-dirt-and-low-level-viremia-a-national-puppy-day-id-link-o-rama","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/tetanus-case-no-more-mac-prophylaxis-playing-in-dirt-and-low-level-viremia-a-national-puppy-day-id-link-o-rama\/2019\/03\/24\/","title":{"rendered":"Tetanus Case, No More MAC Prophylaxis, Playing in Dirt, and Low-Level Viremia &#8212; A National Puppy Day ID Link-O-Rama"},"content":{"rendered":"<p><img loading=\"lazy\" decoding=\"async\" class=\"alignright wp-image-9137\" src=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2019\/03\/50274564_blog.jpg\" alt=\"\" width=\"287\" height=\"191\" srcset=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2019\/03\/50274564_blog.jpg 450w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2019\/03\/50274564_blog-300x200.jpg 300w\" sizes=\"auto, (max-width: 287px) 100vw, 287px\" \/>In honor of spring (March 20), and the very important <a href=\"https:\/\/www.nationalpuppyday.com\/\" target=\"_blank\" rel=\"noopener\">National Puppy Day<\/a> (March 23), here are a bunch of ID and HIV-related recent items for consideration, contemplation, and perusal:<\/p>\n<ul>\n<li><strong><a href=\"https:\/\/www.cdc.gov\/mmwr\/volumes\/68\/wr\/mm6809a3.htm?s_cid=mm6809a3_w\" target=\"_blank\" rel=\"noopener\">A life-threatening case of tetanus in an unvaccinated boy highlights the personal and financial cost of the anti-vaccine movement.<\/a><\/strong>\u00a0How deeply embedded are these false beliefs? The parents still aren&#8217;t vaccinating their children.<\/li>\n<li><strong><a href=\"https:\/\/aidsinfo.nih.gov\/guidelines\/html\/4\/adult-and-adolescent-opportunistic-infection\/392\/whats-new\" target=\"_blank\" rel=\"noopener\">Prophylaxis for <em>Mycobacterium avium<\/em> complex is no longer recommended for people who start ART immediately, regardless of CD4 cell count.<\/a><\/strong>\u00a0Have been <strong><a href=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/choosing-wisely-in-hiv-medicine-should-we-stop-giving-mac-prophylaxis\/2016\/03\/20\/\" target=\"_blank\" rel=\"noopener\">advocating for this change long enough<\/a><\/strong> to write, &#8220;I told you so, nah nah.&#8221; Bet it takes a while to extract this from medical school curricula, where somehow MAC prophylaxis has assumed importance way beyond its actual usefulness.<\/li>\n<li><a href=\"https:\/\/wwwnc.cdc.gov\/travel\/page\/zika-travel-information\" target=\"_blank\" rel=\"noopener\"><strong>Travel advice about Zika has dramatically changed.<\/strong><\/a> This is a sensible policy shift &#8212; ongoing transmission is now exceedingly rare, even the regions hardest hit by Zika back in 2015-16. Still, the information may cause ongoing confusion &#8212; sensible discussion <strong><a href=\"https:\/\/www.vox.com\/2019\/3\/22\/18275679\/zika-travel-advice-explained\" target=\"_blank\" rel=\"noopener\">here.<\/a><\/strong><\/li>\n<li><a href=\"https:\/\/www.cnn.com\/2019\/03\/07\/health\/measles-josh-nerius\/index.html\" target=\"_blank\" rel=\"noopener\"><strong>What is it like for an unvaccinated adult to get measles?<\/strong><\/a> This personal account makes it clear that it&#8217;s no picnic &#8212; measles is no mild &#8220;viral syndrome.&#8221; Once again, so impressive when people use their own adversity to try and effect change &#8212; thank you!<\/li>\n<li><a href=\"https:\/\/www.npr.org\/2019\/03\/06\/700617424\/18-year-old-testifies-about-getting-vaccinated-despite-mothers-anti-vaccine-beli\" target=\"_blank\" rel=\"noopener\"><strong>And along a similar theme, thank you to this teenager who has publically sought vaccines for himself<\/strong><\/a> &#8212; even though his parents remain anti-vaxxers, and have <strong><a href=\"https:\/\/vaxopedia.org\/2019\/03\/09\/the-ethan-lindenberger-story-isnt-over\/\" target=\"_blank\" rel=\"noopener\">publicly criticized him.<\/a><\/strong><\/li>\n<li><a href=\"https:\/\/academic.oup.com\/cid\/article\/68\/7\/1160\/5104942\" target=\"_blank\" rel=\"noopener\"><strong>ID consultation improves outcomes and saves money for people receiving outpatient parenteral antibiotic therapy (OPAT).<\/strong><\/a>\u00a0From the abstract:\u00a0 &#8220;ID consultations during OPAT are associated with large and significant reductions in the rates of ED admission and hospital admission &#8230; as well as lower total healthcare spending.&#8221; Here&#8217;s\u00a0a bold idea &#8212; let&#8217;s ask insurance companies and other payers to <em>pay<\/em> ID doctors for this important service, which right now is often done gratis!<\/li>\n<li><a href=\"https:\/\/www.sciencedirect.com\/science\/article\/pii\/S0196655319301063\" target=\"_blank\" rel=\"noopener\"><strong>In community-acquired pneumonia, starting treatment that includes combination therapy directed at <em>Pseudomonas aeruginosa<\/em> is associated with higher mortality.<\/strong><\/a> Retrospective studies like this one can be tripped up by unmeasured confounders &#8212; such as whether those who received combination therapy were sicker in ways that could not be accounted for &#8212; but given the absence of data supporting combination therapy, here one must assume that less is more.<\/li>\n<li><a href=\"https:\/\/www.jacionline.org\/article\/S0091-6749(18)30934-5\/abstract#.XJZ1njJeH6U\" target=\"_blank\" rel=\"noopener\"><strong>Playing in the dirt improves the gut microbiome and reduces the risk of allergies.<\/strong><\/a> How&#8217;s that for prematurely drawing conclusions about the clinical implications of a mouse study? You&#8217;re welcome. Still &#8212; it wouldn&#8217;t surprise me a bit if it turns out to be true.<\/li>\n<li><a href=\"https:\/\/t.co\/OumPX6B3dc\" target=\"_blank\" rel=\"noopener\"><strong>Medical history buffs and antibiotic geeks will appreciate this detailed account about antibiotic development, bacterial resistance, and vancomycin.<\/strong><\/a> Even though it&#8217;s 240 pages (!) long, rest assured that the &#8220;font&#8221; is large, it&#8217;s double-spaced, and once you start reading, it&#8217;s hard to stop! I like this sentence about the 1950s: &#8220;The antibiotics aureomycin, terramycin, tetracycline, and chloramphenicol formed the closely related group known as <em>broad-spectrum antibiotics.<\/em>&#8221; Ha. (H\/T to Dr. David Aronoff for this find.)<\/li>\n<li><a href=\"https:\/\/academic.oup.com\/cid\/article\/68\/2\/338\/5050260#.XFkqfTEw7cI.twitter\" target=\"_blank\" rel=\"noopener\"><strong>This sensible review finds no evidence that patients with sacral pressure ulcers need long-term treatment for underlying osteomyelitis.<\/strong><\/a>\u00a0This does not mean withholding antibiotics from cases where there is evidence of acute infection (fever, purulent drainage, surrounding cellulitis), but is does mean that empiric 6 weeks of IV antibiotics for an equivocal MRI finding is of questionable value. A good read for everyone who does inpatient ID consults.<\/li>\n<li><a href=\"https:\/\/academic.oup.com\/ofid\/article\/6\/3\/ofz026\/5368165\" target=\"_blank\" rel=\"noopener\"><strong>These ID doctors argue that our specialty should have a voice in the &#8220;This Is Our Lane&#8221; movement to reduce gun violence in our country.<\/strong> <\/a>Certainly survivors of gun violence frequently have numerous infectious complications, especially those with spinal cord injuries. That the authors come from Louisiana &#8212; a state with a <a href=\"https:\/\/www.cdc.gov\/nchs\/pressroom\/sosmap\/firearm_mortality\/firearm.htm\" target=\"_blank\" rel=\"noopener\"><strong>particularly high rate of firearm related deaths<\/strong><\/a> &#8212; adds to the importance of their message.<\/li>\n<li><strong>A couple of additional studies add to the the evidence that persistent low-level viremia in HIV may mean something clinically &#8212; but we still don&#8217;t know what to do about it.<\/strong> In <strong><a href=\"https:\/\/academic.oup.com\/cid\/advance-article-abstract\/doi\/10.1093\/cid\/ciz129\/5321813#.XHF3rM58ZcE\" target=\"_blank\" rel=\"noopener\">this paper<\/a><\/strong>, 50-199 was associated with subsequent failure; in <strong><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/29543636\" target=\"_blank\" rel=\"noopener\">this one,<\/a><\/strong> the problem level didn&#8217;t kick in until &gt; 200. I&#8217;m convinced that for those that are 100% adherent to meds, it doesn&#8217;t mean much; for those that have low-level viremia due to irregular adherence, it does! For more on this topic:<\/li>\n<li><a href=\"http:\/\/www.croiwebcasts.org\/p\/2019croi\/23\" target=\"_blank\" rel=\"noopener\"><strong>Here&#8217;s a new explanation for detectable HIV in patients on suppressive therapy &#8212; &#8220;repliclones&#8221;.<\/strong><\/a>\u00a0These are large cell clones carrying intact proviruses, and don&#8217;t represent replication in the traditional sense &#8212; but can contribute to low-level detectable virus. (The <a href=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/really-rapid-review-croi-2019-seattle\/2019\/03\/10\/\" target=\"_blank\" rel=\"noopener\"><strong>RRR&#x2122; of CROI 2019<\/strong><\/a> was two weeks ago; I should have highlighted this study.) A good further description of the study is <a href=\"https:\/\/www.sciencemag.org\/news\/2019\/03\/curing-hiv-just-got-more-complicated-can-crispr-help\" target=\"_blank\" rel=\"noopener\"><strong>here<\/strong><\/a>, along with what it means for cure research.<\/li>\n<li><a href=\"https:\/\/www.washingtonpost.com\/politics\/2019\/03\/21\/gop-governor-doesnt-believe-chickenpox-vaccines-he-took-his-nine-kids-pox-party-instead\/?utm_term=.54d028bbd785\" target=\"_blank\" rel=\"noopener\"><strong>This politician takes his kids to chicken pox parties,<\/strong><\/a> and <strong><a href=\"https:\/\/www.washingtonpost.com\/health\/2019\/02\/27\/lawmaker-promoting-anti-vaxx-bill-suggests-measles-can-be-treated-with-antibiotics-it-cant\/?utm_term=.0351dfa2046e\" target=\"_blank\" rel=\"noopener\">this one believes that antibiotics work against measles.<\/a><\/strong> Hmmm &#8230; trying to think of something funny to write, but words <em>completely escape me.<\/em> And that&#8217;s rare.<\/li>\n<li><a href=\"https:\/\/twitter.com\/rloganjonesmd\/status\/1092779883040632833\" target=\"_blank\" rel=\"noopener\"><strong>A second-year medical resident put together this informative and entertaining &#8220;Tweetorial&#8221; on MRSA precautions.<\/strong><\/a>\u00a0Should be required reading for any institution considering the need for contact precautions for this organism. Wondering if he&#8217;s going into ID, seems like a natural!<\/li>\n<\/ul>\n<blockquote class=\"twitter-tweet\" data-width=\"500\" data-dnt=\"true\">\n<p lang=\"en\" dir=\"ltr\">Because this tweet seemed to strike a nerve among so many;.<\/p>\n<p>Suppose its <a href=\"https:\/\/twitter.com\/hashtag\/tweetorial?src=hash&amp;ref_src=twsrc%5Etfw\">#tweetorial<\/a> time to evaluate the evidence supporting, or not, the use of contact precautions (CP) to prevent the transmission and infectious complications of <a href=\"https:\/\/twitter.com\/hashtag\/MRSA?src=hash&amp;ref_src=twsrc%5Etfw\">#MRSA<\/a> <a href=\"https:\/\/t.co\/BdwLxvQ4f6\">https:\/\/t.co\/BdwLxvQ4f6<\/a><\/p>\n<p>&mdash; R Logan Jones, MD FACP (@rloganjonesmd) <a href=\"https:\/\/twitter.com\/rloganjonesmd\/status\/1092779883040632833?ref_src=twsrc%5Etfw\">February 5, 2019<\/a><\/p><\/blockquote>\n<p><script async src=\"https:\/\/platform.twitter.com\/widgets.js\" charset=\"utf-8\"><\/script><\/p>\n<ul>\n<li><a href=\"https:\/\/www.bmj.com\/content\/364\/bmj.l525\" target=\"_blank\" rel=\"noopener\"><strong>We hear a ton about overtreatment of bacteriuria in the elderly, but might we sometimes be undertreating them?<\/strong><\/a>\u00a0The study found\u00a0no antibiotic therapy for UTIs was associated with a significant increase in bloodstream infection and all-cause mortality. The paper has already stirred up extensive controversy among antibiotic stewardship-types, not surprisingly.<\/li>\n<li><a href=\"https:\/\/academic.oup.com\/cid\/advance-article\/doi\/10.1093\/cid\/ciy1121\/5407612\" target=\"_blank\" rel=\"noopener\"><strong>And in case you&#8217;re wondering, yes there are new guidelines for management of asymptomatic bacteriuria.<\/strong>\u00a0<\/a>To those who don&#8217;t practice medicine, let me assure you &#8212; this is not always an easy assessment to make, especially in the elderly in particular those with cognitive impairment! It&#8217;s still not quite clear what we should do with worsening incontinence, or when patients only note cloudy or &#8220;bad smelling&#8221; urine &#8212; a limitation acknowledged in the paper.<\/li>\n<li><a href=\"https:\/\/academic.oup.com\/ofid\/article\/6\/3\/ofz033\/5371475\" target=\"_blank\" rel=\"noopener\"><strong>Think of infection with\u00a0<em>Mycoplasma hominis<\/em>\u00a0and (in particular)\u00a0<em>Ureaplasma urealyticum\u00a0<\/em>in immunocompromised patients with unexplained hyperammonemia.<\/strong><\/a> That these organisms are so difficult to culture and also harbor unpredictable resistance patterns makes diagnosis and management tricky.<\/li>\n<li><a href=\"https:\/\/academic.oup.com\/cid\/advance-article\/doi\/10.1093\/cid\/ciz200\/5381064\" target=\"_blank\" rel=\"noopener\"><strong>ID has significant disparities in academic achievement and faculty rank by sex.<\/strong><\/a> Fascinating paper by one of our fellows (Dr. Jennifer Manne-Goehler), with perhaps the most interesting part being that the disparity is greater in ID than cardiology &#8212; why might that be? It is particularly important to understand these disparities in ID since women account for more than 50% of those entering our field.<\/li>\n<li><a href=\"https:\/\/www.npr.org\/sections\/health-shots\/2019\/02\/26\/697786766\/cat-bites-the-hand-that-feeds-hospital-bills-48-512\" target=\"_blank\" rel=\"noopener\"><strong>Rabies prophylaxis after a cat bite can cost you a lot.<\/strong><\/a> There&#8217;s nothing wrong with the medical management here; it&#8217;s the way our very peculiar healthcare system adjudicates the cost of care. In this example, a woman received a bill for <em>$48,512<\/em> after a two-hour visit to an emergency room, which included shots of rabies immune globulin plus the vaccine, and a dose of an antibiotic. &#8220;My funeral would have been cheaper,&#8221; she said.<\/li>\n<li><a href=\"https:\/\/www.myscriptrewards.com\/\" target=\"_blank\" rel=\"noopener\"><strong>United HealthCare is offering patients two $250 prepaid debit cards every 6 months to &#8220;offset medical expenses&#8221; if they go on certain less expensive HIV regimens.<\/strong> <\/a>Consider this the converse of the &#8220;co-pay cards&#8221; provided by the pharmaceutical industry for brand-name drugs. The main problem I have with these programs is lack of transparency &#8212; here, what is United HealthCare making off this deal? Odds are it&#8217;s more than the cost of those debit cards, especially if those cards are used for services provided by United HealthCare anyway. Further information on this program from IDSA&#8217;s perspective is <a href=\"https:\/\/my.idsociety.org\/idsanews\/home\/march6-2019\/unitedhealthcare-03062019\" target=\"_blank\" rel=\"noopener\"><strong>here<\/strong><\/a>,<\/li>\n<li><a href=\"https:\/\/academic.oup.com\/jid\/advance-article\/doi\/10.1093\/infdis\/jiz066\/5385524\" target=\"_blank\" rel=\"noopener\"><strong>On the topic of drug costs, here&#8217;s authoritative and interesting review of drug pricing in ID.<\/strong><\/a>\u00a0All the favorites are covered, from the shocking HCV drug prices to the mind-boggling pricing of generics such as pyrimethamine, albendazole, and even penicillin. The senior author is my long-time friend and colleague Dr. Rochelle Walensky &#8212; who appears to be far less cynical about that United HealthCare plan than I am!<\/li>\n<li><a href=\"https:\/\/twitter.com\/FungalDoc\/status\/1108465908899557376\" target=\"_blank\" rel=\"noopener\"><strong>If you want a quick update on investigational antifungal agents, start right here with this summary.<\/strong><\/a>\u00a0Wow, that&#8217;s quite a pipeline! And thank you, Dr. Andrej Spec (<a href=\"https:\/\/twitter.com\/FungalDoc\" target=\"_blank\" rel=\"noopener\">@FungalDoc<\/a>), who was rewarded for this great work by receiving a commission (from me) for a full review paper.<\/li>\n<li><a href=\"https:\/\/www.newyorker.com\/news\/california-chronicles\/trumps-potty-obsession-and-the-streets-of-san-francisco\" target=\"_blank\" rel=\"noopener\"><strong>San Francisco has a poop on the streets problem.<\/strong><\/a> And no, it&#8217;s not just dogs and puppies &#8212; it&#8217;s also human feces on the street, the result of stark disparities of wealth readily apparent when walking around that city. From the piece:\u00a0 &#8220;An infectious-disease specialist &#8230; has compared\u00a0certain parts of San Francisco\u2014where contaminants include a proliferation of discarded needles\u2014to slums he\u2019s studied in the developing world. The slums were cleaner.&#8221; Thanks to Dr. Monica Gandhi for first alerting me to this problem!<\/li>\n<\/ul>\n<p>Too bad it&#8217;s another year until National Puppy Day returns.<\/p>\n<p>Until then, enjoy this:<\/p>\n<p><iframe loading=\"lazy\" title=\"Puppy teaching Puppy to go down stairs!  SO cute! - ORIGINAL VIDEO! (from owner)\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/fDKDC_IUnOA?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>In honor of spring (March 20), and the very important National Puppy Day (March 23), here are a bunch of ID and HIV-related recent items for consideration, contemplation, and perusal: A life-threatening case of tetanus in an unvaccinated boy highlights the personal and financial cost of the anti-vaccine movement.\u00a0How deeply embedded are these false beliefs? [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3,4,5,10],"tags":[565],"class_list":["post-9081","post","type-post","status-publish","format-standard","hentry","category-health-care","category-hiv","category-infectious-diseases","category-research","tag-link-o-rama"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/9081","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=9081"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/9081\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=9081"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=9081"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=9081"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}