Bugs that bug us – Part II

You recall that Part I of this blog briefly referenced several recent developments in infectious diseases. Part II, here, will delve into a few that deserve greater attention.

Hepatitis C – There has been a revolution in the treatment of HCV that has great success in cure of this previously chronic disease. Cure rates of greater that 90% have been achieved with oral, interferon-free regimens anywhere from 8 to 24 weeks (with most being 12 weeks). Unfortunately, the cost is high at more than $100,000/case. This makes following the CDC recommendations for testing all Baby Boomers at least once all the more important. When will the last Baby Boomer turn 50? Somewhere just prior to midnight, December 31, at the end of this year – probably in Hawaii or American Samoa (airline passengers notwithstanding).

Ebola grabbed much deserved headlines including Time magazine’s Person of the Year (Ebola Fighters). First described in 1976, the current epidemic made its way to population centers of six Western African countries, killing more than 9,000 people. The UN was slow in recognizing and bringing to bear the needed aid to the epidemic. Heroic Ebola fighters, Doctors without Borders, and others risked their lives to treat those infected. Infected workers were brought back to the U.S. and tested our readiness for caring for these few individuals, touching off a storm of fear and costly preparation for a local outbreak that did not happen. Unproven treatments were given. Two health care workers in the U.S. contracted Ebola and survived. At current count the ratio of U.S. Ebola cases to U.S. lawsuits about Ebola stands at 2:1

Clostridium difficile generated two stories on interest. The first is that about one-third of all cases in the U.S. are community acquired and, of those, 82% can be connected to outpatient visits to health care facilities, both hospitals and offices. 64% of the community cases had received outpatient antibiotics – often not indicated and 36% trended to the use of PPIs. Sanitation, hand washing, and appropriate use of antibiotics are the lessons. The second is the use of, yes, fecal transplants. This technology, if one can call it that, has a reportedly very high success rate and the IDSA guidelines offer this for consideration after two relapses. The success appears to be regardless of administration by scope, rectal enema, or orally (really?). The FDA has claimed providence over stool used in this fashion although enforcement…  Hmm, many off-color jokes for the blog today. The biome strikes again.

Acute skin and skin structure infections – A number of antibiotics have been developed for these types of cellulitis and other infections, typically caused by MRSA. Of great interest are two, dalbavancin and oritavancin. Both are infused and have prolonged activity allowing for treatment without placement of a PIC or other long-term IV line. The drugs’ advantages include treatment in the ED to prevent admission and earlier discharge to home to avoid both SNF and home IV infusion services. Unfortunately they are not useful for osteomyelitis nor endocarditis.

HIV pre-exposure prophylaxis or PrEP – the story here is: if taken regularly daily, it appears to be highly effective at the prevention of sexually (both MSM and heterosexual) acquired HIV (>90%) and possibly effective against acquisition through IVDU (74%). Not addressed is the very low sexual transmission rate if the source partner already has a treated undetectable HIV viral load. The CDC has published guidelines on offering PrEp: to whom, how to monitor, and the importance of ongoing education, safe sex practices, and testing.

Marshall Kubota, MD


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