My thoughts on the Future of Infectious Disease and Medicine

"Sepsis Musings" By Steven P. LaRosa, M.D. The data are clear that the mortality of patients who develop sepsis in the hospital is higher than those who present to the ED with sepsis. This undoubtedly is due to delayed identification. It is of critical importance to have an "Early Warning System" incorporated into the EMR to flag patients with sepsis. A review of the literature indicates that the National Early Warning Score (NEWS) has the best combination of sensitivity and specificity for this purpose. SIRS criteria are too sensitive leading to "alert fatigue"while the newly coined qSOFA has great specificity but poor sensitivity. Of all the components of the early sepsis bundle is appears that the early administration of effective antibiotics is the most important. It is critical the ID physicians play a key role in a sepsis team. There is an accumulating data that hyperchloremic "normal saline" is associated with worse outcomes and incre...

Prior to me employed by a non-academic teaching hospital I spent 11 years teaching Infectious Disease to medical students, Internal Medicine residents and ID fellows at 3 different academic teaching hospitals. I had a vast array of clinical pearls that I would share on teaching rounds. In my last 5 years in a non-teaching setting I am often amazed that no one ever taught physicians who are Board Certified in Internal Medicine these important teaching points. I thought it might be useful to share some of my favorite ID teaching points or "pearls" in this blog. 1) oral Beta lactam agents are not adequate treatment of bacteremia 2) Beta-lactam- beta lactamase drugs (Unasyn, Zosyn) and Carbapenems (Ertapenem and Meropenem) have perfectly adequate anaerobic coverage and do not require the addition of Metronidazole 3) Oral vancomycin has no bioavailability 4) Vancomycin is inferior to Beta lactam drugs for the treatment of serious MSSA infections 5) When awaiting sensiti...

This week the much anticipated results of the Euphrates Trial were presented in Vicenza. For those of you not familiar with this acronym, this was the first blinded randomized controlled trial of the Immobilized Polymyxin (PMX) Filter in the treatment of patients with septic shock. This filter known as TORAYMYXIN has been used for years in thousands of patients in Japan and Europe. The mechanism of action is the removal of endotoxin believed to be a noxious mediator of sepsis. This clinical trial was novel in that it included a biomarker, the endotoxin activity assay (EAA), as an inclusion criteria to select patients who had the target of the therapy. Patients were included if they had septic shock and a high EAA level of > or = 0.6. Patients randomized to the treatment arm had hemoperfusion of their blood over the PMX filter during 2 2hour sessions 24 hours apart. Patients in the sham group had the usual standard of care but had a venous catheter layed over their skin...

CMS currently requires that all hospitals have an Antimicrobial Stewardship program in place to assure proper antimicrobial usage. This mandate is part of an effort to stem the ever increasing problem of antimicrobial resistance. These programs are usually comprised on a "physician champion", usually an Infectious Disease (ID) physician as well as an ID trained pharmacist. These programs usually entail some form of prospective audit and feedback to prescribing physicians to ensure appropriate antibiotic choice and duration. Most of these stewardship programs are under-funded in terms of percent time and salaries support such that only a small percentage of patients on antibiotics are reviewed i.e. we barely scratch the surface. A similar shortcoming to stewardship programs is also encountered on most hospital's Infectious Disease Consult services. In hospitals the attending physicians call for consults on cases that they deem to be difficult and require ass...