ACP Internist Blog


Monday, February 19, 2018

Essential reading on Candida auris

During my intern rotation on the University of Virginia bone marrow transplant unit, I convinced myself that a Candida krusei epidemic was brewing. One of my patients was infected, and the bug was (and is inherently) resistant to fluconazole, a drug that had only recently been introduced (yes, I'm old—the year was 1990). This never really came to pass. Despite 30 years of widespread fluconazole use, C. krusei still accounts for <5% of invasive candidiasis, and outbreaks are rare.

Now, a Candida species that wasn't even described a decade ago is emerging as a major problem in ICUs around the world. The Candida auris story is fascinating, puzzling, and concerning. For reasons nobody understands, the species emerged (or began to recognized) almost simultaneously on three different continents. Although risk factors for invasive C. auris are similar to those for other causes of invasive candidiasis (ICU stay, antibiotic exposure, device use), it also features high rates of antifungal resistance, persistence on environmental surfaces, resistance to commonly used disinfectants, frequent transmission in ICU environments, and has thus caused several large, difficult-to-control outbreaks.

If you want to catch up on this emerging pathogen without spending hours on a literature review, there's an excellent summary publication now out in Clinical Microbiology Reviews from Anna Jeffery-Smith and colleagues. See Table 4 for a summary of infection prevention recommendations from UK, US, EU, and South Africa.

Daniel J. Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Friday, February 16, 2018

Something beautiful

In my sweet 16-plus years as a Grady doctor, I have never seen it like this. I've never seen the hospital so filled to the brim with sick-sick people in need of our care.

Never.

Waiting rooms have become overflow patient areas. There are mobile units outside. Flu swabs are coming up positive and making even the healthy-healthy ones sick-sick. It's crazy.

At first, I was like, “Why not just close the doors, man?” But with each person I see, I ask myself where they'd go were it not for Grady. And since I know that answer, it pushes me to rally on. That doesn't mean it isn't tough, though.

No, it does not.

Times like this can burn you out. It can leave you walking like a zombie led by the one-eyed stethoscope, aimlessly placing it upon heaving chests. But if you pause for a second, even a second, you snap out of it long enough to see what is beautiful.

Just maybe you can.

Today one of our patients came back to the hospital. I cringed when I ran into him in the ER, thinking of all of the roadblocks it took to move for him to get discharged in the first place. The intern went to investigate it all and came back looking pretty hopeless. Given all the obstacles and low resources, there wasn't much more we saw that could be done.

But.

In stepped one of our Grady Emergency Department senior doctors. In the midst of that busy-busy day caring for the sick-sick humans in that ER, he hit that same pause button. He thought outside of the box and advocated for this patient in a way that almost defied belief, especially for someone who has worked here a long time. He found a teeny-tiny open door and pulled it all the way open. And that patient got a safe discharge and avoided a rehospitalization.

I get tired sometimes. Tired of the list of patients growing and never shrinking and tired of seeing people hurting. But these stories over the last week have sustained me. Intentionally working at this habit of reflection allowed me to see the patient-centered tenacity of a colleague in a time when I'd already given it in to public hospital inertia. I needed to see that today. I did.

Working here isn't for the eternal pessimist. No ‘tis not. But for those who believe deep down that hope can float and that fighting for a life involves more than fists, cardiac shocks and medications? It's just right. That's what I saw today.

And today? I feel like going on.

Yeah.

Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

Patients' Bill of Rights is due for version 2.0

How often do we read or hear, “I have a right to ….” Everyone wants to have his rights respected. Gun owners, prisoners, civil libertarians, union members, non-smokers, protesters and ordinary citizens all want our rights to be validated and respected. What happens when the exercise of my rights encroaches on yours? It is these questions that occupy much of our judges' time and attention. These are not easy calls to make. The fact that so many of our Supreme Court decisions are decided by a 5-4 vote indicates that these issues are controversial, complex, and vexing.

While we all pride ourselves here in America on our individual rights, these may be at the expense of our community's rights. I don't envy societies such as China or Russia where the state's rights are paramount. But, there is no consensus, even here, as to where to draw the line between protecting an individual and society at large. Consider how vigorous the debate has been on the tension between protecting individual civil liberties and national security.

If it were true that reading our e-mails without a warrant would prevent a full stadium from being blown up, would we support this? What if our kids were in this stadium then?

The conflict between an individual's and the community's rights is active in the medical arena. Consider a few examples where one patient's benefit is at other patients' expense.
• Physicians give out free samples of medication to patients, who cherish this giveaway. The cost of this largesse must be borne by the rest of us who must pay higher drug costs. Nothing is really free, is it?
• A man has a right to ride a motorcycle experiencing the thrill of the open road with the wind blowing through his helmetless hair. If a tragedy occurs, who picks up the bill?
• A physician prescribes a biologic treatment for Crohn's disease. It costs $2,500 each month and is to be administered forever. If the drug delivers as promised, which is usually not the case, one individual will benefit. Should the physician consider how many folks could have been helped if these funds were devoted to influenza vaccines, mammograms or smoking cessation?
• Salvage chemotherapy is given to a patient who is unlikely to benefit. The aggregate costs of these kinds of treatments could pay for family health centers in underserved neighborhoods.

The ethos in the medical profession has been that a physician is solely concerned with the patient in the office, and not the population. This is how I practice. But, the argument that physicians should be concerned with the greater good and a fair allocation of finite medical resources is potent and reasonable. For the time being, my patients understand that my advice is directed to protect only their interests.

When you're in your doctor's office, do you want him to be thinking about you or everyone else?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Thursday, February 15, 2018

Try to avoid vancomycin/pip-tazo

This weekend I started listening to the Curbsiders-end-of-the-year spectacular. Matt's pick of the year was an upcoming meta-analysis about the risk of the vanc/pip-tazo combination. We developed awareness of the renal toxicity from this combination a couple of years ago. At our community hospital program we almost never use the combination.

Several months ago we reviewed this article at our journal club, “Risk of Acute Kidney Injury in Patients on Concomitant Vancomycin and Piperacillin–Tazobactam Compared to Those on Vancomycin and Cefepime“.

This study used a retrospective matched cohort technique, not a randomized controlled trial, but a reasonable methodology.

The article states, “Patients in both VC and VPT groups had similar baseline characteristics in terms of age, length of ICU stay, Charlson comorbidity index score, baseline creatinine, and use of concomitant nephrotoxins.”

The groups had great similarity.

The article continues, “The rate of AKI was higher among patients receiving VPT compared to those receiving VC combination therapy. Based on RIFLE criteria, 81 patients in the VPT group developed AKI compared to 31 patients in the VC group (29.0% vs 11.1%; hazard ratio [HR]=4.0; 95% confidence interval [CI], 2.6–6.2; P<0.0001). Rates of AKI were also higher per AKIN criteria (32% in the VPT vs 14% in the VC group; HR=3.5; 95% CI, 2.3 to 5.2; P<0.0001) and per vancomycin consensus guidelines definition (24% in VPT vs 8.2% in VC; HR=4.4; 95% CI, 2.7 to 7.3; P<0.0001). In multivariate analysis, after controlling for residual differences between the VPT and VC groups (race, gender, admission from home, comorbid conditions, presence of septic shock, baseline serum white blood cell count, and source of infection), VPT was independently associated with RIFLE-defined AKI (HR=4.3; 95% CI, 2.7 to 6.7; P<0.0001).”

The multivariate analysis adjust for major potential confounders, thus the groups are equalized for potential characteristics that might have increased the risk for AKI.

The article states, “The median length of stay after initiation of combination therapy was longer for VPT patients compared to VC patients (8 days vs 6 days; P=0.01). There was no difference in mortality between the 2 groups.”

The cost of increasing LOS by 2 days is huge.

The article conitinues, “Rates of AKI among patients receiving VPT were approximately 3 times greater than rates in patients receiving VC, regardless of type of AKI definition used. In multivariate modeling and controlling for residual differences between these 2 closely matched groups, receipt of VPT was associated with a greater than 4-fold increased risk of AKI. These findings are particularly robust and convincing as, unlike previous analyses comparing toxicity risk in patients on VPT and VC, this analysis was adequately powered and groups were matched on 5 widely recognized risk factors for AKI in patients receiving vancomycin.”

And in the discussion, the article states, “These findings are strengthened by 3 additional important and notable findings. First, among patients who developed AKI, the onset was more rapid in VPT patients compared to VC patients (3 days vs 5 days; P<0.0001.) Second, the daily rate of AKI among the at-risk population remained higher throughout the first week of therapy among VPT patients. This rapid onset and persistently increased AKI risk are both consistent with VPT being more toxic than VC. The third finding supporting an association between VPT and increased toxicity was both interesting and unexpected. Data from this study show discordance in the impact of vancomycin troughs on toxicity in patients receiving VPT compared to those receiving VC. Among patients receiving VPT, there was no discernable impact of vancomycin trough on the incidence of AKI. Conversely, a distinct trough–toxicity association was noted in patients receiving VC.”

While I particularly like this article, other articles have also documented this problem.

In hospital practice in 2018, we should always ask the important question: Do we need both antibiotics? If we are just worried about pseudomonas coverage, cefepime is a satisfactory choice. If we are worried about anaerobes, pseudomonas and MRSA then we might legitimately use the VPT combination – although some would just add anaerobic coverage to VC.

The instinct to order VPT should become muted in 2018. Matt Watto was correct to point this out in the year end podcast.

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.