Can the White House stop Antibiotic-Resistant Bacteria?

Yesterday, President Barack Obama urged Congress to double the funding to confront the danger of antibiotic-resistant bacteria facing America. Concurrently, the White House released their National Action Plan for Combating Antibiotic Resistant Bacteria (NAP) which outlines a “whole-of-government approach” over the next five years targeted at stopping antibiotic resistance.

I’m working on a blog post responding to the NAP and am curious to anyone’s thoughts. I am skeptical that the NAP will work, to say the least (but would be happy to be proven wrong). Please drop me a line.

Reflections on World TB Day 2015

As an infectious diseases doctor-in-training, I have the following conversation with my ID colleagues on an all-too-frequent basis. “What was that other physician thinking?” we say to each other, our eyebrows raised. “That wasn’t a good clinical decision.”

This case was a doozy. “Jonathan” was a young man from a country with a high burden of HIV. He had been seen in clinic several times over a span of months with fever, cough, and other symptoms, yet he had never even been tested for HIV. Eventually he was tested, found to be positive, and diagnosed with AIDS and advanced tuberculosis (TB).

I wasn’t surprised that the diagnoses of HIV and TB had been so delayed. I had seen it before. These diseases are out of sight, out of mind for many clinicians. With increased access to life-saving HIV drugs, fewer “Jonathan’s” are out there. But HIV and TB still lurk in the shadows of our cities and towns. Because of stigma, a lack of education, and a host of other factors, these diseases remain hidden, yet transmission continues.

I’ve been interested in HIV and TB since I was a college student. In 2002, I had the good fortune of meeting Dr. Hamza Brimah, an HIV doctor working in the Mississippi Delta. In his Greenwood clinic, Dr. Brimah told me of the challenges his patients faced – poverty, discrimination, and unemployment. His clinic was underfunded, as well. “I think we should spend less money on war, and more money on ‘viral terrorists’ like HIV,” Dr. Brimah had told me.

Since then, I’ve devoted my career to taking care of patients with HIV and TB in Philadelphia, San Diego, Mozambique, and Boston. I’ve also worked on HIV and TB at the Centers for Disease Control and Prevention (CDC). And I feel chastened. HIV only pops up in the public’s eye once a year, on December 1st (World AIDS Day). TB only pops up once a year, on March 24th (World TB Day), to a smaller audience.

Take a few minutes and watch the PBS documentaries, “The Forgotten Plague,” about the history of TB in the United States, and “TB Silent Killer,” about drug-resistant TB and HIV in Swaziland. These diseases are frightening, but they are aren’t going away. Although researchers have been trying for decades to develop vaccines for HIV and TB, the scientific barriers are enormous, and we shouldn’t expect effective vaccines anytime soon.

It’s not all hopeless. New diagnostics tests and drugs have been developed for TB. In addition, the scale-up of lifesaving HIV treatment continues around the world. Yet if I’ve learned anything from my work, it’s that local people are far more important than technology or medications. Only local people, like community leaders, health workers, and patients are the ones who can make the changes that needs to be made. This is the same in Boston as it is in Mozambique.

Let me give you an example. In Cape Town, South Africa, an inspiring group of health workers have formed an organization called “TB Proof.” Their goal is to counter the stigma surrounding TB and make their hospitals and clinics safer by reducing nosocomial TB transmission. On World TB Day 2015, they are making progress. Yet TB and HIV are formidable adversaries and they need your help.

As for “Jonathan,” he got started on TB and HIV treatment and has done well. But I hope his story reminds you that these diseases are forgotten but not gone.

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Spring Cleaning: getting rid of the Retweets

I spend a lot of time using Twitter, for reasons I’ve explained previously. Twitter is a great way to learn from others (here’s how to get started if you’re a novice). But Twitter can also lead to procrastination. How to maximize learning while minimizing time-wasting? I’ve come to realize that what I don’t like about Twitter is the Retweets cluttering up my Twitter feed. It takes only a split-scond to retweet, while it takes a some time to write a 140 character tweet (and takes even longer to craft an intelligent, poetic tweet). If the issue being Retweeted is that important, I suspect the retweeter will take more time to compose an original Tweet or MT or HT. (I’ve often been guilty of Retweeting when I didn’t actually read the original article referenced in the Tweet).

Therefore, I decided to “Turn off Retweets” for everyone I follow for the time being, as an experiment. Sadly, Twitter doesn’t let me do this in one step. Therefore, I’ve laboriously gone through my followers, one-by-one, turning off retweets. Another option is to “Mute” accounts from your timeline, which means you won’t see anything tweeted by the account. I tend to Mute accounts that “overtweet” (send out way too many tweets) but I don’t want to unfollow. I turned off retweets for everyone else.

While turning off retweets and muting, I’m also trying to “unfollow” as many accounts as I can, to reduce my number “following” down to a manageable size. (If I unfollowed you please don’t get offended!). While I try to avoid others’ Retweets, I’m also cutting down on my own retweeting behavior. Instead of retweeting your tweet, I’ll probably favorite it and reply to it. I may still retweet, however, since people like it when their tweets are retweeted.

Hopefully this Spring Cleaning will make Twitter more pleasant. Your thoughts? Don’t just Retweet this post, Reply to it!

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Got an infection? Good luck finding an ID doctor

BOSTON, Ma. — It was Christmas Day. I was on call at the hospital and was waiting for my wife and 6-week-old son to come so we could eat lunch together. She was bringing kimbap, sweet potatoes, and avocados. But then my pager buzzed. On the phone was a hospitalist physician.

“Is this ID? We have a new consult for you,” she said. “This man has a history of dementia. For some reason he has a urinary catheter to empty his bladder. We gave him an antibiotic, but now his urine is growing a resistant bacteria.”

I sighed. Yet another catheter associated urinary tract infection.

I walked up the stairs to his hospital room. He was bald, thin, and sitting alone in bed. The peas and fish on his tray were untouched. There were no gifts or tree in his room. I washed my hands, put on gloves and a yellow isolation gown, and introduced myself.

“How are you?”

“Ok, I guess,” he replied.

“Do you know where you are?”

“I’m not sure.”

“You are in the hospital. Do you know what day today is?”

“No.”

“It’s Christmas Day. Do you have any family coming in today to spend the day with you?”

“I don’t know.”

“Ok. What city are we in, sir?”

“Boston,” he said.

“Correct! Do you know who the President of the United States is?”

“Obama?”

“That’s right.”

I examined him. Then I stood back.

“We are going to recommend that your doctors change your antibiotic. But since today is Christmas, maybe you’d like to sing a carol together? Do you know any?”

“Sing?” he asked. “What would we sing?”

“How about Jingle Bells?”

We started slowly. His head bobbed up and down and his voice was soft but his eyes were bright and he knew the words by heart.

“Jingle Bells, Jingle Bells, Jingle all the way

Oh what fun it is to ride in a one horse open sleigh…”

After we finished, he paused.

“I hadn’t sang that in a long time,” he said. “Thank you.”

Before starting my infectious diseases (ID) fellowship, I spent two years at the Centers for Disease Control and Prevention (CDC) as an Epidemic Intelligence Service (EIS) Officer (“disease detective”). I worked on a variety of infectious diseases including HIV, tuberculosis, and MERS-Coronovirus. Working at CDC, I came to realize that America needs many more ID and public health specialists than we currently have.

Besides being the year of Ebola, 2014 was also the year that President Obama put forth a National Strategy to Combat Antibiotic Resistant Bacteria. The strategy was well thought-out. But there aren’t nearly enough ID and public health doctors to carry out its recommendations.

The story you’ve probably never heard is that ID is in a crisis. During the 2014 fellowship “Match,” 99 of 327 ID fellowship positions went unfilled. Meanwhile, the “procedural subspecialties” like cardiology and gastroenterology did fine in the Match.

There are a number of reasons so few young physicians want to go into ID. Infectious diseases is one of the cognitive specialties. ID doctors spend hours interviewing and examining patients and writing long notes. Unlike cardiac catheterizations or colonoscopies, notes are poorly reimbursed and don’t pay back our large medical school loans. (Singing Jingle Bells with patients also doesn’t pay well, despite the benefits of music therapy).

While modern American medicine is in a rush to admit patients, perform procedures, and bill, bill, bill, an ID consultation is an exercise in deliberation. ID doctors must stop and think, “When did this patient start having fevers? What were the initial symptoms? What is the most likely diagnosis?”

The Infectious Diseases Society of America has responded to the poor Match results by creating a task force on ID recruitment. This task force is examining the match results, other data and existing efforts to recruit young physicians to ID. Another prominent ID physician, Dr. Ronald Nahass, has argued that ID should use business models that incorporate return on investment, margin improvement, and other financial metrics to achieve a proper determination of our value as a specialty.

I don’t regret my decision to go into ID. Every day brings challenges and opportunities.  But I am worried about the future of ID, and you should be too. Will you or a family member ever need surgery? Have cancer and need chemotherapy? Be admitted to a nursing home? If so, there is a major risk for an infection. It’s unclear that there will be an ID doctor out there to take care of you.

I got back on the phone with the hospitalist.

“I think this was a partially treated urinary tract infection. You can get away with a few days of an oral antibiotic, since he’s looking so much better. But what’s most important is that the nursing home avoid placing another Foley catheter in the future unless it’s absolutely necessary.”

Then I went down to the cafeteria to find my wife and son and have a Christmas lunch.

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This was originally posted at The Health Care Blog. Here’s some of the discussion from Twitter that followed the post:

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Nonpurulent Cellulitis — don’t forget to give a beta lactam

Here’s a quick reminder for all my non-ID clinician friends out there. Cellulitis doesn’t always need vancomycin. If the patient has “nonpurulent” cellulitis (no purulent drainage or abscess) s/he should be managed with antibiotics with activity against beta-hemolytic streptococci and MSSA. The patient should usually go on a beta lactam such as cefazolin (we often use 1g q8 for a non-obese patient with a normal eGFR). Of course you have to think about MRSA risk factors as well, but vancomycin monotherapy is not sufficient for these patients.

IDSA guidelines for SSTI and subsequent discussion from Twitter:

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Rest in peace, Dr. Paul Kalanithi

I never met Stanford neurosurgeon Dr. Paul Kalanithi, but was moved by his writing and am saddened that he has died from lung cancer. It’s not only that we are roughly the same age and I also have a young child. Dr. Kalanithi had a unique perspective on life and medicine. Spend some time watching this lecture on hospice and palliative care by Drs. Timothy Quill and Kalanithi. All of us who work in health care should engage with these issues. We rarely do.

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Vote

“We come to Selma to be reminded…” – Rep John Lewis on the 50th anniversary of the Selma to Montgomery march. His speech in Selma and video to young people inspire us to action. Meanwhile, the most powerful and resonant part of President Obama’s speech is his call to action, to protect and expand the vote… this is the only way to restore our democracy. Washington DC certainly won’t do it for us.

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And photos from the trip my wife and I took to Selma and Montgomery one year ago.

On the road to Selma

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On the famous bridge, in Selma

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