Don’t mess with Staph Aureus

Imagine you are an internal medicine resident on call overnight in the hospital. You admit a patient with high fevers of unclear etiology. The patient had blood cultures drawn in the emergency room (before antibiotics, thank goodness) and is started on empiric vancomycin and cefepime. The next day, the micro lab calls you and says that her blood cultures are growing “Staphylococcus Aureus.”

You recall from medical school that Staph Aureus is divided into two groups, the feared “MRSA” and the less-feared “MSSA.” But at this time you don’t know if the patient has MRSA or MSSA. It’s a good thing you have your patient on vancomycin in case the bacteremia is due to MRSA. But is your patient on the correct treatment?

You may not know what’s going on behind the scenes, in the micro lab, and that can help you manage her infection.

After the blood cultures turn positive, a gram stain is performed and the isolate is plated on the appropriate media. Direct non-standardized Kirby-Bauer plates are then performed which can give you a preliminary “hint” if the patient has MRSA or MSSA. If the plate has a small zone of inhibition around “FOX” (oxacillin), and P (PCN), that suggests MRSA (see photo below). If there is a large zone of inhibition, that suggests MSSA.

I suggest you phone the micro lab at this time, and ask for the “blood room” and request that the technician look at the Kirby-Bauer plate. If the isolate looks like it’s likely going to be MSSA, you should continue the vancomycin but add nafcillin (and drop the cefepime). Nafcillin is better than vancomycin or cefepime for MSSA. If the isolate looks like it is going to be MRSA, you should continue the vancomycin (and drop the cefepime). And get 2 more sets of blood cultures.

The next day you will have your official sensitivities in the computer with your quantitative MICs, and you will know if the Kirby-Bauer guess was correct. If it’s MSSA, you can drop the vancomycin and continue nafcillin monotherapy. If it’s MRSA, you can continue vancomycin monotherapy.

Meanwhile, I hope you are looking hard for the source of the bacteremia and are thinking about where staph aureus may have gone (heart valves, bones, joints, abscesses, etc). Get an infectious diseases consultation to help you. If there’s anything I’ve learned in my ID fellowship, it’s “don’t mess with Staph Aureus.”

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Bob Moses here in Boston

It was a powerful evening tonight at the Museum of African-American History with a lecture by legendary civil rights activist Bob Moses. Among the most salient parts of his talk were his emphasis on understanding American history’s three eras, from 1787 to the 1860s, from the 1860s to 1960s, and from the 1960s to present, and his argument that as a country we “lurch forwards and backwards.” Because of recent events (anti-gay legislation, the repeal of parts of the Voting Rights Act, rising inequality, lack of quality public education), America is currently “lurching backwards” in our third era, said Moses. Where will that lead us?

Other parts of his lecture I found especially moving were his frightening description of being “grease-gunned” (machine gunned) in 1963 by the KKK while driving to Greenville, Mississippi (“it kind of tattooed the side of the car”), while the driver Jimmy Travis was shot. In addition, the recent deterioration of the right to vote; and anecdotes regarding many of the iconic leaders from the civil rights movement, including James Meredith, Bayard Rustin, Ella Baker, and Medgar Evers.

Bob Moses received a MacArthur “Genius Grant” and has worked intensively on the Algebra Project, trying to improving public school math education. He argues that “sharecropper education” is alive and well in America and math literacy is a necessary and neglected skill. He asked, somewhat rhetorically, “are we mature enough as a country to talk about if we need a constitutional right to a high quality education?”

Certainly politicians in Washington DC aren’t mature enough. American will only fulfill her promise if citizens organize at the local level, as Bob Moses did in Mississippi in the 1960s, and continues to do to this day.

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Can I get a caramel frappuccino with a side order of insulin?

Iora Health has been in the news recently for its innovative practices, including an article last week in the New York Times. The author of the article, Margot Sanger-Katz, writes, “The ultimate goal is hundreds of practices across the country, a kind of Starbucks for health care. (The company recruited one executive whose last job was opening Au Bon Pain franchises).”

Sounds a bit corporate. Is Iora Health is really the answer to America’s health care woes? How does Iora’s patient population compare to those served by America’s struggling, chronically underfunded network of (not-for-profit) community health centers, for example? I put the question to Twitter.

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The rest of our storified debate

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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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