Super cool HIV interactive graphic

The New England Journal published the studies of raltegravir's use/efficacy for patients with an optimized background regimen (OBR) recently, and it turns out they also had an online-only interactive graphic that would be great for teaching students and residents visiting on the service. It's online at:

http://content.nejm.org/content/vol359/issue4/images/data/339/DC2/AIDS_Interactive.shtml

Enjoy!

– Christopher Hurt, MD

Sexual Assaults and PEP

There is a protocol that can be obtained from Lynda Bell in clinic regarding the care of survivors of sexual assaults. We will sometimes be called to weigh in on HIV PEP alone, as they have a protocol they follow for everything else. However, if you are ever called about what should be done, particularly if a SANE nurse is not available, here are some basics from the protocol.

Baseline laboratory tests should include:

• HIV Antibody testing
• CBC with differential
• LFTs
• BUN/Creatinine
• STD Screen (gonorrhea, chlamydia, syphilis)
• Hepatitis B serology
• Hepatitis C serology
• Pregnancy test

Prophylaxis against the most frequently diagnosed STDs among sexually assaulted women should be administered:

• Ceftriaxone 125mg IM in a single dose [Gonorrhea]
• Metronidazole 2gms orally in a single dose [BV, Trichomoniasis]
• Azithromycin 1gm orally in a single dose OR Doxycycline 100mg orally twice daily for seven days [Chlamydia]

HIV post-exposure prophylaxis is offered within 72 hours of the assault. If the perpetrator's HIV medical history is unknown, the two preferred regimens are:

• NNRTI-based: Efavirenz plus (Lamivudine or Emtricitabine) plus (Zidovudine or Tenofovir)...usually as Sustiva plus Combivir, or Sustiva plus Truvada.
• PI-based: Lopinavir/Ritonavir (Kaletra), plus Zidovudine or Tenofovir...usually as Kaletra plus Combivir, or Kaletra plus Truvada.

I've been advised typically to use the PI-based regimen unless there is another reason they should be avoided. Keep in mind that if the source patient (in the case of needlesticks) is one of OUR HIV clinic patients, we have access to their genotype and med history, and can formulate an appropriate PEP for the victim based on this information (i.e. you wouldn't want to start someone on PEP that their virus would be resistant to).

All sexual assault cases should follow up with a mid-level provider in the ID Clinic, regardless of whether or not they accept PEP. We usually just send a phone message to Lynda Bell with the patient's general information, and she contacts them to set up a follow up within 48 hours or so.

Risk Assessment

Sometimes, you are asked to comment on the risk, given different exposures (assault, blood splashes in the eye, needlestick, etc.). The risk for HIV acquisition per various acts can be found in the MMWR, January 21, 2005). It is also estimated in the Sanford Guide for the treatment of HIV.

Vaccinations in PEP

Hepatitis B: Patients who are unvaccinated prior to the assault should receive the initial Hep B vaccine, and follow up to complete the series. Unless the offender is known to have Acute Hep B, HBIG is not required. Remember, all patients should have serologies drawn.

Tetanus: If the patient has skin abrasions or other wounds and immunization status is greater than 5 years, give Tetanus Toxoid 0.5ml IM. If the patient has never been immunized, also give Hyper-Tetanus 250mcg IM.

Yvonne Carter, MD

Review of PPDs

We have a lot to learn regarding TB, but regarding the targeted testing for latent tuberculosis infection, here is a VERY QUICK review of what constitues a positive PPD:

>0 mm is considered a positive reaction if the patient:

• Is HIV-positive or immunocompromised AND are recent contacts to known or suspected infectious TB disease, regardless of previous treatment of LTBI
• Is HIV-positive with fibrotic changes on CXR consistent with prior TB who have received inadequate or no treatment for TB disease
• Is a child <5>

>5 mm is considered a positive reaction if the patient:

• Is HIV-positive
• Is a contact to known or suspected infectious TB case identified within the last two years
• Has fibrotic changes on CXR consistent with prior TB and have received inadequate or no treatment for TB disease
• Is Immunocompromised (receiving >15mg per day of Prednisone for one month, other immunosuppressive drugs, organ transplant recipients, persons taking TNF inhibitors)

>10 mm is considered a positive reaction if the patient:

• Is foreign-born from Asia, Africa, Carribean, Latin America, Mexico, South America, Pacific Islands, or Eastern Europe)
• Has converted their TST within two years
• Has a medical condition placing them at high-risk for TB Disease (DM, CRI, Chronic malabsorption syndrome, Leukemias and Lymphomas, Cancer of the head and neck, Silicosis, Weight loss of >10% ideal body weight, gastrectomy or intestinal bypass)
• Is an injection drug or crack cocaine user
• Is a child <4>
• Works in a mycobacterial lab

*Also, this cutoff is used per the clinicians judgement for: residents of long-term care facilities and homeless shelters, are inmates in the DOC, OR are employees in prisons/jails, long-term care facilities, hospitals/health care facilities, adult day-care centers for HIV patients, homeless shelters).

>15 mm is considered a positive reaction if the patient:

• Has NO risk factors for TB

Hope this helps!

Yvonne Carter, MD

HIV, Syphilis, and When to LP

Syphilis is a significantly prevalent STD in North Carolina, particularly in the setting of co-infection with HIV. Screening for syphilis is reviewed in the Syphilis Screening section of the blog. But, a common question that must be addressed in this circumstance is:

When is it necessary to perform an LP in to rule out Neurosyphilis in the HIV-positive patient?

The answer has many answers, but the commonly accepted answer is as follows: "All neurologically asymptomatic HIV-infected patients whose serum RPR titer is greater than or equal to 1:32 should undergo lumbar puncture regardless of syphilis stage." And, of course, any symptomatic HIV-patient with a history of syphilis should undergo LP to rule out Neurosyphilis.

This recommendation is taken from two main studies:

• Marra, et al. J Infect Dis 2004; 189: 369 - 376.
• Libois, et al. Sex Transm Dis 2006. HIV and syphilis: When to perform a lumbar puncture.

Yvonne Carter, MD

MRSA, MRSA me, Staph ain't what it used to be...

Apologies for the title, I couldn't help myself.  :)

ORSA comes up a lot, specifically how to decolonize patients with community-acquired ORSA (CA-ORSA). The UNC hospital epi people put together a brochure, which is sometimes hard to locate. I found this PDF online, from Kaiser Permanente out in California, which outlines I think what's pretty standard for us around here:

http://www.kplearning.com/10_national_site/uploads/B1S3.pdf

Johns Hopkins used to publish this nice periodic newsletter on HIV issues, but they've discontinued it due to time and budget constraints. Nevertheless, there was a nice article in the September 2004 edition that addressed CA-ORSA:

http://www.hopkins-hivguide.org/images/publications/nl_04_sept.pdf

The only caveat I'd put on this is, please know that the conventional dosing of TMP/SMX (Bactrim™, Septra™) at one DS tablet twice a day (as in the Hopkins thing) is now considered insufficient for ORSA treatment (at least around here, anyway). You need TWO DS tabs twice daily, and make sure you adjust for renal function, if reduced.

In general, we use doxycycline as our second-line agent, followed by clindamycin. Our micro lab will report clindamycin susceptibility separate from erythromycin – but outside labs may not be as reliable. Remember that CA-ORSA may have inducible resistance to the lincosamides (of which clinda is one) that won't show up in microdilution susceptibility testing used in outside hospitals and labs. You can't detect this is unless a "D-test" is performed, with both an e-mycin (15 µg)  and a clinda (2 µg) disk dropped onto the plate:

If the bug has inducible resistance, there'll be a flattening of the zone of inhibition between the two disks, suggesting that the bugs closer to the e-mycin disk have switched on their inducible resistance genes and are now laughing at the silliness of you attempting to use clindamycin to kill them.

Editorial note: The acronym "MRSA," for methicillin-resistant Staphylococcus aureus, is a humongo misnomer, since we don't use methicillin for resistance testing, and haven't in many years. Oxacillin is used on the plates, not methicillin – so you may hear it referred to more often in the micro lab as ORSA, and more often in the community as MRSA. If you're an ID purist, go with ORSA and look smart when someone asks what the hell it is that you're saying. (Or look like a big know-it-all dork. :)   )

 

– Christopher Hurt

Osteomyelitis...

... is the bane of the consult service existence. Well, along with the entire Family Medicine service, most of surgery, the impossibly perky OB-Gyn residents... but I digress. But osteo pretty much sucks. The question comes up pretty often, how do we best diagnose osteomyelitis, especially in the diabetic foot patients? This question was answered I think pretty comprehensively in the August 15, 2008 issue of Clinical Infectious Diseases. You can read it here, through UNC:

http://www.journals.uchicago.edu.libproxy.lib.unc.edu/doi/full/10.1086/590011

and the little editorial blurb that followed it is here:

http://www.journals.uchicago.edu.libproxy.lib.unc.edu/doi/full/10.1086/590012

– Christopher Hurt

Malaria prevention

Malaria stuff we get hit with pretty regularly, especially by student health in the summertime when lots of undergrads and grad students go globe-trotting. The New England Journal published a pretty helpful article in August 2008, on malaria prevention in short-term travelers. You can access it through UNC at:

http://content.nejm.org.libproxy.lib.unc.edu/cgi/content/full/359/6/603

(Plus it has a really sweet picture of the life cycle of malaria, along with where the drugs work.)

– Christopher Hurt

Serologic Testing/Screening for Syphilis

When on consults, we are commonly called to interpret the meaning of serologic testing for syphilis (and other diseases like RMSF and Lyme as well). When evaluating the results of testing, a clinical history is imperative to interpretation. Does the patient have a history of syphilis, to their knowledge? Treated or untreated? If treated, how were they treated?

The following is taken directly from PPID Online (Mandell's), but explains testing well:

Confusion surrounds interpretation of the serologic tests for syphilis, principally because two different types of antibodies are measured: the nonspecific nontreponemal reaginic antibody and the specific anti-treponemal antibody. The test for the former is inexpensive, rapid, and convenient for screening large numbers of sera (e.g., donated blood) and as an indication of disease activity. Specific antibody tests establish the high likelihood of a treponemal infection, either currently or at some time in the past. To establish a diagnosis of syphilis, the two types of serologic tests are most often used together, although attempts to improve the single tests are ongoing. It should be emphasized that serologic test results for syphilis on rare occasions may be negative in active cases, especially in older patients.

Non-Treponemal Tests

A fourfold change in titer using the same test method, either VDRL or RPR, is necessary to demonstrate a clinically significant difference, preferably being performed in the same laboratory at the same time. Nontreponemal antibody tests vary during the course of untreated disease. They reach their highest prevalence and titer during the secondary and early latent stages and decline thereafter, usually to less than 1:4. Over time, at least 25% of untreated persons become VDRL or RPR negative, even without treatment. A persistently high-titered RPR or VDRL result is more common in HIV-infected persons because of the polyclonal antibody stimulation, a manifestation of immune dysfunction often seen in these patients, especially in early HIV disease.

The quantitative VDRL/RPR test should become nonreactive 1 year after successful therapy in primary syphilis and 2 years after successful therapy in secondary syphilis. Most patients with late syphilis should be nonreactive by the fifth year after treatment. The time required for the test to become negative correlates with the interval between contact and institution of therapy and with the severity of illness, especially with the type of skin lesions manifested in the secondary stage (i.e., a patient with a macular rash reverts to a negative titer sooner than does a patient with a papular rash). Therefore, a positive VRDL or RPR response after 1 year in a patient treated for primary syphilis or after 2 years in a patient treated for secondary syphilis suggests persistent infection, reinfection, or a biologically false-positive reaction. A patient with adequately treated late syphilis should have a negative response after 5 years. As with all quantitative serologic tests, only a fourfold or greater change in titer is meaningful.

Specific Treponemal Tests

These tests measure antibodies against specific T. pallidum antigens. The principal specific anti-treponemal antibody tests performed today are the FTA-abs and T. pallidum agglutination tests (TPHA and MHA-TP). These tests would be relatively expensive as screening tests, and if they were applied to a low-risk population, the number of false-positive reactions would increase proportionately. Therefore, their principal use is to verify a positive nontreponemal reaginic test result. Once positive, the patient usually remains positive for life. However, reversion to a nonreactive status may occur in up to 10% of patients, especially in those who are treated early.

When the diagnosis of syphilis is being seriously considered in an individual patient, the TPHA, MHA-TP, or FTA-abs test should be done. Once these have become positive and the diagnosis is established, the usefulness of these tests is limited because they can remain positive for life. A nontreponemal antibody test is very helpful for monitoring the efficacy of therapy. The failure to fall more than fourfold or become negative suggests a persistent infection, reinfection, or a false-positive test.

False Positive Testing

The likelihood of a biological false-positive (BFP) reaction depends on the population being studied. Acute or transient false-positive nontreponemal reaginic test reactions may occur whenever there is a strong immunologic stimulus (e.g., acute bacterial or viral infection, vaccination, intravenous drug abuse, HIV infection). Positive reactions persisting for months occur in the presence of continued parenteral drug abuse; with autoimmune or connective tissue diseases, especially systemic lupus erythematosus; with aging (in up to 10% of those older than 70 years of age); in hypergammaglobulinemic states; and in HIV coinfection. A false-positive nontreponemal reaginic test in this setting tends to be associated with other serum factors frequently associated with autoimmune diseases, such as antinuclear, antithyroid, or antimitochondrial antibodies, rheumatoid factor, and cryoglobulins.

A false-positive nontreponemal reaginic test can usually be verified (and syphilis excluded) by obtaining a negative specific treponemal antibody test (FTA-abs, TPHA, MHA-TP). However, at times the same illnesses that produce a false-positive nontreponemal reaginic test (e.g., systemic lupus erythematosus) also result in a positive or borderline-positive FTA-abs test reaction. Also, the FTA-abs may be positive when the VDRL is negative and vice versa. This false reaction can often be suggested by noting a beaded pattern of immunofluorescence on the treponemes, but the best definitive way to make the distinction is to obtain the functional but rarely available TPI test, PCR or immunoblotting using specific T. pallidum antigens such as 17-kDa, and so forth. Other spirochetal illnesses, such as relapsing fever (Borrelia spp.), yaws, bejel, pinta, leptospirosis, or rat-bite fever (Spirillum minor), also yield positive nontreponemal and treponemal tests. Infection with Borrelia burgdorferi (Lyme disease) results in a positive FTA-abs test but does not cause a positive nontreponemal reaginic reaction (VDRL or RPR).

Yvonne Carter, MD
http://www.ppidonline.com/content/default.cfm

Working with the Health Department regarding Tuberculosis Management

North Carolina Health Departments are a vital resource for TB evaluation and management. In most cases, Tuberculosis evaluation can be done as an outpatient, and does not require inpatient admission and evaluation, or ID clinic follow up. Each Health Department houses a TB Clinic, whose responsibilities include:

• providing case management to all active cases of TB,


• evaluating all persons suspected of having TB,


• evaluating all contacts of active and suspect cases within the county, and


• providing TB screening to predetermined high-risk individuals, including recent immigrants.

Evaluation, treatment, and care is provided to each patient free of charge. It is important to note that patients can be referred to the Health Department during any part of the workup for TB, from suspicion through post-diagnosis care. If a patient is hospitalized at UNC, and is on isolation for suspicion of TB, and is otherwise ready for discharge, they may be discharged with a mask to follow up with the Health Department. The Health Department, however, MUST be notified of the patient's discharge, and set up an appointment for the patient to be seen by them. There, they can complete sputum collection, PPD placement and reading, and contact investigation. Again, the pt must present to the Health Department with a mask if TB is suspected. If a patient is suspected of having Tuberculosis, but refuses follow-up with the Health Department, that patient's workup should be done as an inpatient.

If a patient has a positive sputum AFB smear, and treatment is initiated, you will need to give the patient enough doses to last them until they can be seen at the Health Department (the next day if during the week, and on Monday if during the weekend). The Health Department will treat TB only, not infections caused by nontuberculous mycobacterium.

A directory of health departments for each county can be found at: http://www.ncalhd.org/county.htm.

Yvonne Carter, MD

Communicable Disease Reporting

Communicable diseases are reported first to the County Health Departments who go on to report to the State. Reporting through the county Health Department is necessary because they typically conduct thorough contact investigations. Traditionally, communicable diseases have been reported through the use of the "North Carolina Communicable Disease Report Card." However, the use of these cards is being phased out by the State, and they are changing to a fully electronic reporting system. The North Carolina Communicable Disease website is: http://www.epi.state.nc.us/epi/gcdc.html, and here, PDF versions of reporting are available for a variety of communicable diseases.

It is expected that laboratories will be responsible for reporting communicable diseases, but the new online forms require a fair amount of clinical background, and therefore, we should be prepared to assist our lab if further information is needed.

The current CDC list of Nationally Notifiable Infectious Diseases can be found at this website:
http://www.cdc.gov/ncphi/disss/nndss/PHS/infdis2008.htm.


Arlene Sena-Soberano, MD, MPH, is the Medical Director of the Durham County Health Department, and is a key connection between UNC and the Health Department. She can be contacted with further questions regarding communicable disease reporting, at email address arlene_soberano@med.unc.edu.


Yvonne Carter, MD

Viral Hepatitis Screening

Testing or screening for Hepatitis will depend on the clinical situation: i.e. whether the patient is asymptomatic, has a history of exposure, has high risk behaviors, or is clinically symptomatic (elevated transaminases, jaundice, nausea, vomiting, etc.). Generally, we'd recommend screening in any symptomatic patient, all HIV patients at the time of diagnosis, and IV drug users. Routine screening (hepatitis panel) should include screening for:

• Hepatitis A, with total antibody to HAV (anti-HAV Ab)* or IgM antibody to HAV (IgM anti-HAV).
• Hepatitis B, with Hepatitis B surface antigen (HBsAg) and IgM antibody to hepatitis B core antigen (IgM anti-HBc).
• Hepatitis C, with Antibody to HCV (anti-HCV).

Special Populations

• Routine screening of pregnant women for HBsAg is done to identify infants of infected women who require post-exposure prophylaxis.
• High risk populations for chronic HBV infection (e.g., STD and drug treatment patients, inmates of correctional facilities, immigrants from countries with a HBsAg prevalence >2%) might benefit from routine HBsAg testing, but the feasibility and cost effectiveness of such testing in various clinical settings has not been determined.
• Recommendations have been developed for routine anti-HCV testing for persons at high risk of HCV infection (i.e., persons who have ever injected illegal drugs, persons who received a blood transfusion or organ transplant before July 1992, persons ever on chronic hemodialysis, persons who received clotting factor concentrates made before 1987, persons with abnormal liver enzyme levels).

Confirmatory Testing

• The presence of other serologic markers of HBV infection (i.e. total anti-HBc or IgM anti-HBc) can be used to evaluate the likelihood that an HBsAg positive test result is a true positive but isolated HBsAg positive test results should be verified by a confirmatory assay (e.g. neutralization assay).
• Anti-HCV positive results by enzyme immunoassay (EIA) should be verified by a supplemental antibody assay (e.g., RIBA), which is available through McLendon labs. Detection of HCV RNA by RT-PCR verifies HCV infection, but the absence of detectable RNA in a single serum specimen does not exclude the possibility of HCV infection.

Yvonne Carter, MD

Vancomycin

Our patients are frequently on Vancomycin, due to the increasing incidence of ORSA in both hospital-acquired infections, and community-acquired infections. ORSA can cause a variety of infections, and we commonly follow patients with ORSA pneumonia, cellulitis, deep soft tissue infections, abscesses, osteomyelitis, bacteremia and endocarditis. Vancomycin does also cover other gram-positives, but is the treatment of choice for ORSA infections. It is the treatment of choice in PCN-allergic patients with gram positive infections. There are several important things to remember when treating a patient with Vancomycin:

1. Weight and renal function (measured by GFR or creatinine clearance). Both will influence the therapeutic dosing of Vancomycin. Generally, Vancomycin is dosed 15-20 mg/kg, and given q12h hours in patients with normal renal function.

2. Vancomycin is not absorbed systemically when given orally. Therefore, po Vancomycin is only approved as second-line treatment of C. difficile colitis. Otherwise, it should ALWAYS be given intravenously.

3. Weekly labs. When on Vancomycin, weekly labwork should be checked and should include: CBC with differential, BUN and creatinine, and Vancomycin trough.

4. Goal troughs. Vancomycin is monitored via the collection of troughs, which should be drawn ~30 minutes prior to the next scheduled dose. In general, peak testing is unnecessary. The goal trough will depend on the site of infection (keeping in mind that these goals have been extrapolated from other data, and have yet to be verified in clinical studies):

1. Goal trough of 15-20 mcg/ml is reserved for Pneumonia, Endocarditis, Meningitis, and Osteomyelitis.


2. Goal trough of 10-15 mcg/ml is used for skin and soft tissue infections and Bacteremia.

5. Adverse Reactions.

1. "Red Man Syndrome." A systemic response to the infusion, that includes flushing and sweating. Is not dangerous, and is not an allergy. It can usually be remedied by slowing the infusion rate, and/or diluting the Vancomycin in a larger volume of solute.


2. Ototoxicity. Generally not reversible, and occurs at high levels.


3. Renal failure. Uncommon, except when Vancomycin is given concomitantly with other nephrotoxic agents. If a patient develops ARF while on Vancomycin, you can generally continue Vancomycin, making dose adjustments, while the cause of the ARF is being worked up.

***In terms of when we follow Vancomycin levels, we should follow Vancomycin levels on patients on which we recommended the use of IV Vancomycin when seen as an inpatient AND will follow up with you in ID Clinic. In cases where we do not plan to see the patient in follow up, the team should make arrangements for that patient's outpatient provider to follow labwork. You may volunteer to follow labwork on these patients if they have no provider to do so. BUT, you should NEVER follow Vancomycin levels or labs on patients whom you have not seen. We have been called to follow labs on patients being discharged from various services who are going home or to a SNIF on Vancomycin. The answer to this request should be a firm NO. It becomes a legal liability when following labwork on a patient you don't know and have never seen, and in whom you did not recommend Vancomycin in the first place. What if they develop an adverse drug reaction??? Who is responsible? On paper, you would be, as the ordering physician. So, keep that in mind. Most services have no staff in place assigned to follow labwork on patients on IV antibiotics, and remember, NEITHER DO WE. It is our responsibility as fellows to follow it on our patients only. We should not volunteer to do it as a service for the entire hospital. Just imagine how many labs we would be following if we monitored labs on every patient discharged on Vancomycin from UNC?!?! Please make requesting services aware of this.***

Yvonne Carter, MD

Hospital Follow Ups

When on the inpatient consult service, we are frequently consulted on patients who will need further ID assistance...with continued monitoring, antibiotics management, assessments for cure or improvement, etc. If there is ever a patient who you think may need further ID input after discharge, it is usually best for the patient for them to be scheduled with you in the ID Clinic as an outpatient (particularly if they are on a non-medical service as an inpatient). Use your and your attending's judgement on which patients should be followed as an outpatient.

• In general, if a patient is discharged on antibiotics, and the duration of treatment is not determined prior to discharge, you should see that patient to determine when it is safe to discontinue antibiotics.


• If a patient is discharged on IV or oral antibiotics for an illness where there is a way of determining clinical response to therapy (for example, abscesses and osteomyelitis can be evaluated using imaging), you should see that patient in follow up to assess for improvement or cure.


• If a patient will require long-term suppressive or prophylactic antibiotics (particularly in immunosuppressed patients), you should see that patient in follow up, at least for a few visits, until they are stable on therapy and their PCP can take over.

Remember, once you are responsible for a consult as an inpatient, that patient is YOURS to follow as an outpatient. If you are unable to arrange for follow up with you, and you schedule the patient to be seen by another provider, you MUST communicate this to the provider who will see the patient. If you see a patient in consult who already belongs to an ID provider, you should have that patient follow up with their primary ID provider after discharge (and also communicate this to that provider).

Yvonne Carter, MD

Setting up outpatient consults

When on the inpatient consult team, you receive many calls from outside providers, and from other services, sometimes requesting that their outpatients be seen in the ID Clinic. In terms of triaging these patients, it is best to first discuss the case and question with the ID Attending, to determine if he/she thinks the patient should be seen right away versus scheduling with the next available appointment.

When scheduling outpatient consults, the best days and times will vary, depending on the schedule of the attending, the other fellow, and yourself. Typically, if the attending is available, you should schedule an outpatient to be seen on any morning when you or the fellow you are working with DOES NOT have a regularly scheduled clinic session. After you are called, it is reasonable for the patient to expect to be seen in the next 2-3 days if urgent, and in the next week if you are awaiting any records or data prior to seeing the patient, and it is not urgent.

Of course, most outpatient consults should be scheduled for patients in which seeing an ID specialist will make a difference in thier course or outcome. Outpatient consults should NOT be performed on patients who:

• are under age 18,
• will be admitted to UNC within the next 24 hours,
• are our own HIV patients (as they can be seen in our Walk-In Clinic),
• are being referred for Lyme Disease or Chronic Lyme Disease,
• are being referred for recurrent MRSA abscesses without active disease (as they can be scheduled for a "next available" appointment).

Some examples reasonable referrals for Outpatient Consults have been:

• FUO in a patient with active, ongoing fever with a documented workup
• New diagnosis of HIV (these sometimes can be punted to next available, but typically, it is better to see them quickly to get them set up into care, especially if an opportunistic infection is suspected)
• Acute HIV (talk to Cindy Gay about having these patients seen ASAP)
• Infectious complications in pregnant women
• Fever in returning travelers

Keep in mind, however, that each case should be reviewed on a case-by-case basis. Let your attending know about each case, so that it is "discussed," in case the referring physician wants to go "over your head" to have the patient seen sooner.

The consult can be scheduled by Paul Behe, by sending a phone message (if the pt is a UNC patient), or by providing Paul with the Name, DOB, and reason for visit. Note, that on the billing form at the end of the visit, you should bill the patient for a "Consultation" visit, by checking one of the consultation boxes on the upper right hand side of the form.

Same-Day Consults called from a UNC Outpatient Clinic:

One other part of outpatient consults that comes up is if there is a patient in another clinic at UNC, who the provider wants to send over to the ID Clinic or for you to come see right away. First, remember, that the patient is an outpatient, and therefore not ill enough (yet) to warrant an emergent evaluation. First, determine what exactly the question is. If there is time, and the question is simple, sometimes it is okay to swing by to see these types of consults while on rounds, when the entire team is together. If there is not time, and the attending is agreeable, it is also okay to have the pt brought in the next day for a scheduled appointment. Again, this should be discussed with the attending, and the question from the referring team/physician should be clear.

Consults Referred by Dr.Cohen, Dr.Weber, or other Division Attendings:

When you are asked to see a patient by Dr.Cohen or Dr.Weber, do it immediately. Typically, they will ask you to see a patient whom they've been asked to see from another highly regarded physician at UNC. They ask us to see these patients quickly to maintain good working relationships between the ID Department and other departments at UNC. Sometimes, however, it may be a favor for a friend. Either way, they will usually call you directly, or "cc" you on an email regarding the patient, or sometimes have thier secretary call you. Whenever this is the case, you should, of course, ask about any clinically relevant history, and inquire what the question to be addressed is. If you are ever called directly by a patient or another doctor, who uses their name to have a patient seen, verify this with them prior to scheduling the patient (yes, I've been had by scheduling a demanding patient who claimed to have been referred by Dr.Cohen, who knew nothing about the patient). As for the other Division Attendings, the same principles apply. In general, Dr.Cohen just wants the patient to be seen, and he may not ask for any follow up information regarding the patient. Dr.Weber, however, should probably be called if you are seeing a patient he asked you to see, even if you are staffing it with another attending. If not called, you should email him an update on what you found and what you did.

There has sometimes been a breakdown in communication in why we are asked to see some patients. Therefore, it is of high importance that you find out why we are seeing them prior to scheduling them.

Also, each encounter with any patient, even if it is a patient being sent over to the clinic to casually answer an ID-related question, should be (a) staffed with an attending, and (b) documented in the patient's medical record.

Yvonne Carter, MD

General ID Clinic Information

The Infectious Diseases Clinic is located on the 1st floor of Memorial Hospital. Typically, instruct patients to enter the hospital through the Main Doors of Memorial Hospital. Walk straight, to the left of the information desk, and take the escalator up to the first floor. Take an immediate right, and you will be facing the GI Clinic, at which point you should make another right. The ID Clinic will be at the end of the hallway.

The phone number that is best for fellows' to use when contacting the clinic is 966-7199. This leads to an immediate answer. Patients are given the number 966-7198, which leads to several options (including leaving messages for the nurses, financial officer, social work, etc.). When paging teams, putting in 966-7199 is usually the best line to leave. The fax number to the clinic is 966-4587.

Paul Behe is the clinic's front man. He coordinates scheduling patients, entering labs and imaging orders, room assignments during clinic days, and some patient communication. He is an essential part of keeping scheduling a smooth process, and ordering imaging/labs, and sending out letters to patients. He can be helpful in many ways:

• Scheduling appointments: You can send Paul a phone message via WebCis, to request an appointment for a patient in need. In general, in that message you should include the exact or approximate date and time you'd like the patient to be seen, and the diagnosis or reason for the visit. Remember, all fellows have a set schedule for any given clinic day (typically, two new patients, and four return visits). You can override or overbook only by speaking directly to Paul (via WebCis or in person), as overbooking requires your permission, yet is sometimes necessary.
• Ordering labs and imaging: This can be accomplished one of two ways. First, a phone message can be sent to Paul, as above. Always include the indication for the labwork or imaging. If ordering imaging, be specific (include what is being imaged, by what modality, which side...right, left, or bilateral, and if it should be done with or without contrast).
• Sending correspondence to patients: If you'd like to send a patient a letter, for any reason (verifying normal lab results, asking them to come in for labwork, reminding them of the need for the annual PPD, etc.), you can type the letter up in a phone message and direct the message to Paul, asking him to print it out and send it to the patient. This can also be done for correspondence written on a patient's behalf (to another care provider, to insurance company, etc.).

Because he controls the schedule, be sure to "cc" him on any email correspondence when requesting vacation days that will need to result in cancellation of a clinic day (in addition to emailing Dr.Quinlivan, Lynda Bell, and Kirsten Leysieffer).

In addition to the above, Paul is usually helpful in answering most questions involving the ID Clinic, or directing you to the proper person to ask. Be sure to keep him high on the list of persons to treat well, as he can make your life alot easier!!! :)

Yvonne Carter, MD

What about surgical services?

The surgical services are the following:

SRA SURGERY ONCOLOGY
SRC PLASTIC SURGERY
SRE OTOLARYNGOLOGY
SRF SURGERY TRANSPLANT
SRG SURGERY GI
SRH TRAUMA SURGERY
SRM ORAL/MAXILLOFACIAL
SRN NEUROSURGERY
SRO ORTHOPAEDICS
SRT THORACIC SURGERY
SRU UROLOGY
SRV VASCULAR SURG
SRX ADULT BURNS

Who should I call about this patient's recommendations...?

This is a GREAT QUESTION and unfortunately is not easily answered. Despite doing IM residency here and doing lots of consults last year I still have trouble figuring out who's a patient's doctor from time to time. Also, the system changes occasionally so you gotta stay on your toes.

In general, the best way to convey recommendations is to page:

First - the person who paged you. Put the name and pager number of the contact person into the comment section of our ID consult list when they call.

Second - whoever wrote the progress note for today (or yesterday).

Third - whoever is on call for that service - you can find this out using amion (for internal medicine) and the hospital operator / hospital directory for surgical services.



Internal Medicine services are complicated depending on the time of day. They have a night float system and the interns only take overnight call on weekends, but this is roughly how it works.

Each ward team (Med A, B, E1, E2, G, K, U, W) has one resident and two interns. The interns rotate q4 admitting call - you can figure out who's on call through amion. The resident is on call every other day and works 7am-7pm 6 days a week.

At 7pm during weekdays the daytime team (resident and both interns) leaves at 7pm after signing out to the night float. The nightfloat resident for each team (one resident for two teams - A/B, E, G/K, U/W) handles crosscover overnight and admits overnight patients. At 7am the next day the team gets their patients who were admitted overnight as "floats".

On Friday, Saturday, and Sunday nights the intern stays overnight doing crosscover, and admits patients til 11pm.


-Gretchen

Paging People

To page someone from inside the hospital, you can go to the hospital directory:

http://directory.unch.unc.edu/

From outside the hospital there are a few different options.

For internal medicine residents, they have a website:
http://clipper.med.unc.edu/impager/pagerlist.cfm?dept=IM

Family medicine has a website as well:
http://clipper.med.unc.edu/impager/pagerlist.cfm?dept=FPG

If you know someone's pager number and it's a 216-#### number, then you can go to:
http://www.usamobility.com/
and click on 'send a page'. Enter the number with area code and message.

You can always call the hospital operator (919) 966-4131 and ask them to page someone, or give you a pager number.

Intro to UNC Medicine Residency

to find out who's on call, go to this website:

www.amion.com
login: uncmed

this will show which residents and interns are on call for the UNC internal medicine inpatient services (including MICU and CCU). It also shows who's supposed to be on ID consults (but often these people have clinic or other responsibilities, so it's not foolproof).

Teams are (grouped by "sister services" - meaning they admit on alternate days):

Med A - Geriatrics inpatient service, age >65 - 8BT is home base
Med B - Nephrology inpatient service, ESRD on HD, new ARF, also vasculidities and rheumatology patients - 3 west is home base

Med C/D - Cardiology inpatient service, this includes floor patients and CCU patients. There are 4 inpatient teams who rotate overnight call. - 3anderson and CCU are home base

Med E1/E2 - Hematology/Oncology Inpatient service - 6East and 5And are home base

MedT - Bone Marrow Transplant Service - this is staffed by the attendings and heme/onc fellows only, no residents

Med G - Pulmonary Inpatient Service - CF patients, COPD, IPF. 6BT is home base
Med K - Infectious Disease Inpatient Service - our best friends. When a patient is admitted to medK they will have an ID attending overseeing all their care. They do not require an ID consult. 6BT is home base.

Med U - General Medicine inpatient service, staffed by the UNC Hospitalist attendings with Residents (teaching service). Home base is 8BT/3West.
Med W - General Medicine inpatient service, staffed by the UNC Internal Medicine attendings with Residents. Home base is 8BT/3West.

MedH - General Medicine inpatient service - staffed by UNC Hospitalists, no residents, nonteaching service. Home base is 6West.

MedI - MICU inpatient service. Closed MICU service that sees pts in MICU and CCU, staffed by pulmonary/critical care attendings. Home base is MICU.

Important notes:
There is no inpatient GI service, so gen med frequently has ESLD patients and GI bleeds with a GI consult.

Gretchen's Page

http://gshaughn2004.googlepages.com/

This website was designed for purely selfish reasons and for that reason it's disorganized and incomplete. But you're welcome to use it if it's helpful.

Things ID Fellows Need

Long Distance Code
White Coat
Business Cards
ID Badge
Computer Access - this should include WebCIS, WebPACS, PACS, CPOE (?), email
Key to clinic consult rooms
Key to locked file cabinet
Badge Access to ID clinic AND bioinformatics
Parking
Place to sit
Place to call patients (secure and HIPAA compliant location)
-if you need to call patients from your home or cell phone you can call the hospital operator (919) 966-4131 and ask them to place to call to eliminate *69 occurances or pts keeping your cell #.
Laptop access for Bioinformatics, UNC campus, AND hospital access
A pager, and a listing on the hospital directory

Wednesday conference form

Feel free to use this blank form for taking notes during Wednesday case conferences. I put it together early on (when I had lots of spare time, being without a license in North Carolina and all).

http://www.unc.edu/~churt/downloads/wednesday_conf_form.pdf

– Christopher Hurt

A little about Ryan White and ADAP

The AIDS Drug Assistance Program (ADAP) is funded through federal monies that are distributed under Part B (formerly Title II) of the Ryan White AIDS Care Act, which was renewed (thankfully) and "modernized" in 2006. For more information about the RWACA, see the Health Resources and Services Administration's website at http://hab.hrsa.gov, and for specifics about the individual parts (formerly "titles"), see http://hab.hrsa.gov/aboutus.htm. Our clinic receives direct funding for our nurses to follow individual at-risk patients closely by phone, under Title II/Part B. If you have someone who needs a little more attention, ask someone about how to get them onto Title II.

Below is an email sent to the division by Rhonda Stephens, the clinic's financial counselor, back in March 2008:

Each year clients are notified with 2 letters from the state ADAP program and 2 letters from the ID clinic financial counselor regarding their renewal with the ADAP program.

The letters consist of advising the clients to renew their ADAP application prior to deadline, what to bring to an appointment of renewal and whom to contact with questions.

Clients are asked to bring documentation of income which may consist of W-2, tax returns, pay check stubs, and/or benefit statements. This information is needed for everyone in the household. If client is unemployed-no letter is needed stating who is supplying their financial support. If client is employed and is not receiving a pay check stub they may return a letter from their employer stating amount of income received either monthly or annually. If this information is not returned prior to ADAP deadline, they are contacted by the ID clinic financial counselor or the ID social worker. We have made repeated contact with clients either by phone or when they were in the clinic to obtain this information.

Clients are provided with a self addressed stamped envelope which is included with the reminder letters and/or given out at clinic appointment to return requested documentation. Clients are also advised they may fax the information to the ID clinic.

Some clients have chosen to have their applications completed by an outside agency, these clients are asked to provide the ID financial counselor or ID social worker with the contact name of the person or agency completing the application so that we may stay in contact and make sure the applications are completed prior to deadline.

When clients come to their appointments, they may sign the application but many of them have failed to bring the required documentation; therefore, the application is not complete. Clients are advised that with incomplete information, the application will be delayed and they stand to have a delay in getting medication for the upcoming months. We contact the clients to remind them that their ADAP benefits will run out. Many of the clients on the list have failed to return requested documentation of income.

There are times when these clients who needed to renew their ADAP benefit were missed during their clinic appointment. These clients may not have wanted to wait to see a counselor. Transportation may have been an issue. They may have forgotten to have asked to see a counselor or they may have had other appointments they needed to attend. These clients were also contacted by phone by the counselors in hopes of capturing them prior to ADAP deadline.

We use the help of the front desk staff and the nurses to assist in capturing the clients before leaving the clinic.

– Christopher Hurt

Anal Paps for Everyone!

Although we haven't made it official, making anal Pap smear testing routine for everyone is becoming more and more important. Data from several studies in 2007 and 2008 showed (shockingly!) that heterosexuals get anal HPV just like men who have sex with men do. There are a handful of patients with whom I've dealt in-house who had abdominoperineal resection (APRs) or pelvic exenterations for advanced-stage anorectal carcinomas that could have been avoided with screening.

UCSF has sort of pioneered the "new" science of screening for cancer of the anus, and their website is I think the reference for how to do it: http://www.analcancerinfo.ucsf.edu/screening/philosophy.html . Take a quick look at their anatomy page, too, just to refresh your memory: http://www.analcancerinfo.ucsf.edu/screening/anatomy.html .

I think (and probably most of the attendings would agree) that at the very least, all sexually active men who have sex with men should have annual or every-other-year screening, a la sexually active women getting Pap smears. The British HIV Association in 2008 published guidelines for cancer screening that included a bit about anal cancer, but the USPSTF and DHHS haven't weighed in yet on things. The BHIVA's guidelines are a little wishy-washy about how to screen, and UCSF's clinic actually does anoscopy (akin to a colposcopy) on their patients, with acetic acid prep and biopsy for diagnosis - rather than cytology.

Our clinic's as-yet-unpublished chewing-gum-and-paper-clips guidelines go something like this:

• Open and nonjudgemental discussion with male and female patients about sexual risks on a routine basis, including having receptive anal sex with or without condoms
• Annual or biennial (QOY) screening with female cervical Pap kit's cytobrush inserted into the anal canal and then sent to Pathology in the supplied fixative
• If no dysplasia is identified, then likely can fall into an algorithm along the lines of female Paps, with spacing-out of tests if a couple of negative tests are obtained and patient is in a monogamous relationship
• For any dysplasia, referral to general surgery for consideration of anoscopy with biopsy for staging and additional management (just like sending to Gyn for a colpo with ASCUS, LSIL, or HSIL)

It's unclear whether or not insurance carriers will cover the Pap testing, but as with other tests we do, I think that good medicine shouldn't be impaired by the billing department. Lynda Bell and others in the clinic are working on trying to sort out those issues.

The younger guys will balk at this, and probably many women will, too. Also be aware that in the Latino community, there's a significant and well-described social desirability bias that keeps women (and sometimes men) from owning up to having anal sex. In a perfect clinic setting (which we're not), all male and female patients would be screened. Just like with your residency continuity clinics, it's difficult sometimes to work in primary and secondary prevention into visits where the patients are sick as stink or come in with specific complaints. Just do your best! :)

– Christopher Hurt

Staying Up-to-Date (without Up-to-Date)

NATAP
The National AIDS Treatment Advocacy Project (NATAP) is headed up by Jules Levin, who's been living with HIV and hepatitis C for many years and decided to take his interest in patient advocacy directly to the scientific community by attending research meetings. He has a small staff of dedicated writers who travel with him to all (literally) of the major conferences, from CROI to AIDS to the liver meetings, and provides a free service that's essentially a digest of the findings from these conferences. Daily emails (often many a day, especially during a conference) also keep you up on both scientific and lay press publications related to HIV issues from the political to the molecular. It's overwhelming at first, but it's worth taking a look at the headlines at least, every once in a while. It will sort of flood your inbox, but I think it's worth it if you want to stay up on current HIV news. You can sign up at http://www.natap.org/emaillist.htm .

eToCs
I'd recommend signing up for the electronic tables of contents (eToCs) for the major journals, which are really JID, CID, AIDS, and JAIDS. (Links below). It's helpful too to stay up on your internal medicine stuff in some limited way, with either the New England Journal, JAMA, or Annals of Internal Medicine (if you're an ACP member). As a new fellow, you qualify for free membership in the IDSA for your first year, along with free subscriptions to both JID and CID. Generally speaking, JID is more bench/lab-science based, while CID deals more with epidemiology and clinical or bench-to-bedside application research. You might also consider getting Lancet Infectious Diseases' eToC, too. It has excellent reviews of clinically applicable topics.

JID – http://www.journals.uchicago.edu/toc/jid/current

CID – http://www.journals.uchicago.edu/toc/cid/current

AIDS – http://www.aidsonline.com/pt/re/aids/etocs

JAIDS – http://www.jaids.com/pt/re/jaids/etocs

NEJM – http://www.nejm.org/aboutnejm/etoc.asp

JAMA – http://pubs.ama-assn.org/cgi/alerts/etoc

Annals – http://www.annals.org/subscriptions/etoc.shtml

Lancet ID – http://www.thelancet.com/account/alerts


If you're a techie and know what an RSS feed is, these are the links for the journals' feeds:

JID – http://www.journals.uchicago.edu/action/showFeed?ui=1zv&mi=0&ai=s1&jc=jid&type=etoc&feed=rss

CID – http://www.journals.uchicago.edu/action/showFeed?ui=1zv&mi=0&ai=sb&jc=cid&type=etoc&feed=rss

AIDS – http://feeds.feedburner.com/wolterskluwer/aids/toccurrentrss

JAIDS – http://feed.jaids.com/wolterskluwer/jaids/toccurrentrss

NEJM – http://content.nejm.org/rss/current.xml

JAMA – http://jama.ama-assn.org/rss/current.xml

Annals – http://media.acponline.org/feeds/annalstoc.xml

Lancet ID – http://multimedia.thelancet.com/rss/laninf_current.xml


Getting to UNC Libraries online, from home
If you know the journal you're after, click on this:
http://www.hsl.unc.edu/Journals/EJSearch.cfm

If you don't know the journal, or are doing a general lit search, the UNC proxy for PubMed can be found at:
http://www.ncbi.nlm.nih.gov.libproxy.lib.unc.edu/sites/entrez?holding=uncchlib_fft_ndi

You'll need your email login information before you can get to those resources, but you have access to everything at home that you do on campus, except two notable items: no Up-to-Date at home, and when you log into New England Journal, you can't download their pre-fabricated PowerPoint slides (unless you're a subscriber yourself).

– Christopher Hurt

Online Resources

Both Gretchen and I have pages of links to give you quick access to references that are used frequently. Mine is online at:

http://www.unc.edu/~churt/

– Christopher Hurt

Antiretrovirals and Resistance

So this is a big topic, and I had put together a PowerPoint (with the "script" in the notes section beneath each slide) for a School of Pharmacy class in 2008 on antiretroviral resistance testing. It's at a level that I think is good for people getting acquainted with the principles of resistance tests:

http://www.unc.edu/~churt/downloads/ARV_Resistance_Hurt.ppt

This covers the basics of:

• why HIV mutates so readily
• principles of the techniques involved for resistance testing
• who needs to get a test (by the 2007/08 DHHS guidelines)
• what happens to your patient's blood sample once you order a test
• the differences among phenotypic, genotypic, and "virtual phenotype" testing
• a tangent on why certain positions (like K103N or M184V) are so significant, but other positions aren't (the answer is tertiary protein structure)

I'd welcome any questions or comments on this. The top 5 gurus for ARV resistance here (in order of who you should talk to if you have a significant, burning question) are:

1. Joe Eron
2. Joe Eron
3. Joe Eron
4. David Margolis
5. David Wohl

The thumbnail version
Basically, HIV mutates so quickly because it's crappy at proofreading itself. The reverse transcriptase (RT) has poor (but present) proofreading activity, so if it mismatches a nucleotide base-pair, it can't stop, back up, and excise the mismatch. Instead it blows through the copy, generating many, many point-mutations in the sequence of each copy. Poor fidelity in the copying process means more mutations, some of which are fatal to the protein/enzyme, rendering it useless - but others are fortuitous and confer resistance to a medication. The selection pressure of the ARVs drives natural selection in a beautifully Darwinian way. This is an important point, because without the selection pressure, the most "fit" (able to copy itself readily) version (aka "quasispecies") of HIV in the body will overgrow all others. This is usually referred to as "wild-type," meaning there's no native resistance. However, keep in mind that if a patient is infected with resistant virus at the outset (transmitted drug resistance), then that is their wild-type. Some mutations will revert back towards wild-type over time, through back-mutations, but others may persist for months-t0-years after acute infection. This is the underpinning for why the DHHS recommends now that all patients newly entering HIV care have some baseline assessment of antiretroviral resistance.

At UNC, our test of choice is the "virtual phenotype" or VIRCOtype, provided by Virco, a company with an office in the RTP but whose main offices (and labs) are in Belgium. This test combines a repository of straight-up nucleotide sequence data with one of phenotypic resistance information as lab-cultured viruses are exposed to drugs and their replication measured. Although it has some warts, it's pretty good at predicting what meds will work and which won't. It can't predict synergy, however, and that's a significant drawback.

The mutations are alphabet soup and will be for a while. Don't freak out, it's supposed to be that way – and I never feel bad about looking at one of the IAS-USA resistance cards in the clinic, since even people like Joe Eron and Amanda Corbett refer to them routinely. Realistically, you don't need to memorize any mutations. The ones that make a difference will be repeat customers and you'll come to know them by repetition. Others are less important and you have other stuff to fill your brain up with as things get going for you here. (Plus as each new med comes out of the pipeline, a new set of mutations will become apparent as more and more people get on them.)

– Christopher Hurt

Antimicrobials Cheat Sheets/Primers

Back in residency, during long boring nights at The Miriam Hospital as a 3rd year night float, I decided to go and look up the mechanisms of the major (current) antibacterials, antifungals, and antimycobacterials. Here are links to those sheets, for your reference. The antibacterials one has been fairly widely circulated at Brown and here at UNC, so feel free to use it, mark it up, use it for teaching or for quick reference. The antifungals and antimycobacterials sheets are just plain Word documents, but the antibacterials one is a PDF.

http://www.unc.edu/~churt/downloads/Antibacterials_11-2005.pdf
http://www.unc.edu/~churt/downloads/Antifungals.doc
http://www.unc.edu/~churt/downloads/Antimycobacterials.doc

– Christopher Hurt

Lyme Disease

Whenever a patient or outside hospital physician calls and requests an outpatient consult for chronic lyme disease or chronic fatigue syndrome (including chronic EBV) these patients records must be reviewed by the ID clinic director prior to scheduling an appointment.

Tips for calling an ID consult

General Stuff

Please try to call us with new consults before 1:00 pm, as we go down to the microbiology lab for plate rounds at 1:30, and it's helpful to be able to see their plates, etc. while we're there.

Please don't call us for oral recs on the day of discharge, if at all possible. We don't like to hold up people's exit from the hospital when we tell you they need a PICC line and 2 weeks of bug juice.

HIV Patients

In 2007, the ID division requested from all admitting services that a special HIV consult be called for any and all patients with HIV admitted to UNC, on any team. The purpose of this is to reduce the number of errors in antiretroviral medications prescribed, and so that the clinic providers know their patient is admitted. Unless there's an ID issue you need help with, we'll usually leave a brief note outlining their ARV doses, and then not actively follow the patient. If you want us to follow them, please let us know that up front.

When you call us with one of these, please tell us why they're being admitted, what their most recent CD4 count and viral load are, who their clinic provider is (and if they're not followed here, where they go), and what antiretroviral medications they're taking (if any).

Helpful ID Pearls of Wisdom

The first rule of ID is, don't catch what they have. Don't be ashamed to go dig out a green N95 mask or put on a gown to go talk to a patient, if you don't know what their diagnosis is.

If you stick yourself:

(1) stop whatever you're doing,

(2) wash your hands with soap and water,

(3) call the occupational health clinic, at 966-9119 (or after-hours, 966-7890)

There is no data supporting the use of oral antibacterials for treating a bacteremia in adults - all of them require parenteral therapy, for at least 14d (assuming it's uncomplicated - no endocarditis, indwelling lines, etc.)

Staph aureus in the urine is ALWAYS A BAD THING. It should never be considered a contaminant, and you should call us to help with a general workup for an occult bacteremia.

If you have Staph aureus in the blood, they need an echocardiogram. We're always going to ask for one if you call us with a positive Staph aureus blood culture.

Coag-negative Staph (epidermidis) should always be considered oxacillin/methicillin-resistant (ORSE/MRSE), but doesn't require contact precautions.

For fevers of unknown origin, please make sure you really have no idea where it's coming from - so make sure you have a chest film, urine and blood cultures, and sputum cultures (if appropriate) cooking before you call us.

If you're calling for antibacterial recs, please try to have an idea of what they've been on to-date, when it was started, and the most recent culture data. Microbiology labs at outside hospitals are usually pretty friendly and helpful if you call for data.

If you think your patient has necrotizing fasciitis or a deep-seated tissue infection like pyomyositis, call general surgery FIRST and THEN call us. We'll help with antibacterials, but the treatment is ALWAYS surgical. Clindamycin for the first 72h of true nec fasc may save the patient's life by shutting off bacterial toxin production. Add it if you think they're not doing so hot - and then call us.

For TB rule-outs, you don't have to get sputum samples only from the first-thing-in-the-morning sputum - you can get 3 serial samples, if they're spaced at least 8 hours apart. One bronch sample counts for 3 induced or expectorated sputa.

For questions about contact precautions, etc., we're happy to help - but the best resource is actually hospital epidemiology, whose number is 966-1636. Someone's always on-call for them, too.

New antibacterials

Linezolid is a nasty medication, and shouldn't be used willy-nilly! It can causes a reversible, isolated thrombocytopenia in up to half of patients who receive it, and whole-marrow suppression in up to 25% of those on it. It also has MAOI-like properties, so drug-drug and drug-food interactions are significant - including serotonin syndrome if co-administered with SSRIs, and hypertensive crises if taken with some foods. If you have a question about whether or not to use it for a patient, just call us.

Tigecycline makes people ridiculously nauseous, and that's by far its limiting side effect. It cannot be used for bloodstream infections, since it's static and doesn't concentrate in the blood. Great for tissue, bad for blood.

Daptomycin causes rhabomyolysis, so you need to follow CPKs on patients while on therapy. It can be used for bloodstream infections, but not pneumonias - since lung surfactant inactivates the drug. Great for blood, bad for pneumonias.