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

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