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#idtwitter @SHEA_Epi #COVID town hall presentation live now #omicron
#idtwitter @SHEA_Epi
#COVID town hall presentation live now #omicron
#idtwitter @SHEA_Epi
#COVID town hall presentation live now #OmicronVarient
Read 4 tweets
#Remdesivir new trial just published

Here are the clinical implications:
Canadian trial (CATCO) in hospitalized patients with #COVID19 bit.ly/33uktIf
Compared to ACTT-1 trial bit.ly/3msi1In in patients on supplemental O2 as recommended by guidelines
🧵1/
ACTT-1 Highly Significant Mortality Reduction in Patients on Supplemental Oxygen:
bit.ly/3msi1In
2/
Both CATCO and ACTT-1 trials showed
-No liver or renal toxicity with remdesivir, and
-No safety differences between remdesivir and controls in over 2300 patients

Thus, both trials show that remdesivir is safe, prevents intubation, and reduces mortality
3/
Read 9 tweets
Hey #IDTwitter… what are your thoughts on intermittent (e.g. TIW frequency) liposomal amphotericin B (L-AmB) dosing for OPAT?

@MayoPharmRes @MsSmallsO @johnsontannerm @Stevens_AK @SIDPharm #opat #TwitteRx
Let’s look at the evidence… For starters, amphotericin B (AmB) = broad spectrum anti-fungal that binds to ergosterol

1st-line for serious ocular candida, CNS cryptococcus, severe histo/blasto, and mucor

2nd-line for cocci & aspergillosis

pubmed.ncbi.nlm.nih.gov/11801575/ Image
There are 4 formulations of AmB, but the liposomal form (L-AmB) is typically dosed at 3-5 mg/kg/day = ⬇️ nephrotoxicity (vs. deoxycholate) and ⬇️ infusion reactions (vs. ABLC) + liposome allows for ⬆️ tissue conc and a prolonged t1/2.

pubmed.ncbi.nlm.nih.gov/11722981/ Image
Read 10 tweets
#idboardreview 80 M originally from Philippines w/ yearly travel there, presents w/ fever, abd pain, chills, inc LFTs, +liver abscess. BC+ organism? #meded #idmeded #idtwitter
hypervirulent #klebsiella pneumoniae liver abscess Ref academic.oup.com/ofid/article/7…
Infections with #hypervirulent #Klebsiella pneumoniae isolates most frequently occur among pts with an Asian, Pacific Islander, or Hispanic ethnic background, even in absence of travel to high-prevalence areas (eg, Asian Pacific Rim). Diabetes is also a risk factor
Read 5 tweets
#idboardreview 40 M originally from Cameroon, also travel to Ghana & Mali, now w/6 mo progressive weakness requiring wheelchair use,lethargy, 30lb wt loss, confusion. CSF lymphocytic pleocytosis. dx? #meded #idmeded #IDtwitter
Human African #trypanosomiasis endemic to sub-Saharan Africa & fatal when untreated. parasite Trypanosoma #brucei transmitted by tsetse fly (Glossina spp) vector
2 dz forms T #brucei #gambiense West/Central Africa: slowly progressive illness leading to progressive sx & death over mo-yrs
-T brucei #rhodesiense eastern/ southern Africa: more acute illness that evolves over a span of wks, leading to death w/in months
Read 9 tweets
💥Asociaciones frecuentes en Enfermedades Infecciosas💥
Espero que sea tan divertido de leer como fue de preparar 🤣

#MIR2021 #MIR2022 #MedEd #tweetorials #IDTwitter
Abro hilo 🧵
Minociclina (aka poción de Gargamel 🧙‍♂️) ➡️➡️➡️ Hiperpigmentación azulada 👥

Pigmenta piel 💅 🦷por formación de quelatos insolubles con la melanina. Puede ser irreversible 😨

bit.ly/Minociclina
Jardinero 🌹(trauma vegetal) + lesión papulonodular ulcerada que sigue drenaje linfático ➡️➡️➡️ Esporotricosis

bit.ly/3n98vdk
Read 19 tweets
What to make of #COVID Ag tests still + at d 8,10,12, etc? There seem to be a lot of them - no data, just anecdotes. But also no data: predictive value of Ag+ for infectious omicron at these time pts. What advice do we give these folks? Don’t test? Isolate? Go to work?
2/ Good evidence that Ag+ = infectious virus for diagnosis. And @CDCDirector @RWalensky initially said the tests weren’t approved for ending isolation. She’s right, & there aren’t robust data on this (to my knowledge - but educate me, please!) We need these data! #IDTwitter
3/ Pre-omicron viral dynamics (from the NBA) showed rapid viral decline, w vaxxed ppl clearing virus faster than unvaxxed (mean 5.5d v 7.5d). This suggests not likely infectious 10+ day time points.
nejm.org/doi/full/10.10…
Read 8 tweets
1/ Hey #IDTwitter #LabTwitter @ASCLS @ASMicrobiology , I want to take a moment to break down our new study: Endotracheal Aspirate Culture Variability and Antibiotic Use in Mechanically Ventilated Pediatric Patients ja.ma/31f9Zv8 via @JAMANetworkOpen @JAMANetwork
2/ This work was a multidisciplinary effort, & I am REALLY proud of that! I think this is a great example of the cool work we can do when we put our clinical laboratory and infectious disease minds together to answer questions about diagnostic tests and #stewardship #IDtwitter
3/ Dr. Sarah parker (@HandshakeASP @COpedsID ), Dr. Anna Sick-Samuels (@asicksamuels ) and myself all had a similar question: Do hospitals that use more endotracheal aspirate cultures have more days of therapy in their mechanically ventilated patients?
Read 27 tweets
I can't do this anymore! 20-30 years old ,with kids ,unvax,in the icu, all dying. For the love of god for your kids if you're unvax survive for them at least , set politics aside. Be there for your children. The horrors we've seen I can't unsee anymore #COVID19 #GetVaccinatedNow
I am shocked to see this tweet get so many responses and so emotional to see how many people love and support our health care workers. Thank you, we see you. I needed this love. For those saying patients <40 or 45 don't get sick, yes they do. Do they die ? Yes they do. 1/
Do they usually have co morbid / high risk conditions ? Many do, however I've seen a minority who don't. I don't detail this out because I try to keep private info private. All I know is that I saw some things lately - and was just broken. I want young parents to be there 2/
Read 5 tweets
1/ I'm really excited that the @US_FDA has granted an EUA for #Paxlovid - this is a terrific new option for #OmicronVariant and kudos to the scientists, researchers, and developers at Pfizer. So timely, and so necessary as we face a wave of new #COVID19 infections globally.
2/ I went through the fact sheet and it is critical to highlight that many patients with cancer and organ transplant recipients are on medications that will be effected by the #ritonavir component of #paxlovid.
3/ Note black box warning - Co-administration of ritonavir with sedative hypnotics, anti-arrthythmics, or ergot alkaloids are contraindicated.

Pfizer did a great job in compiling potential drug-drug interactions:
Read 15 tweets
With #Omicron rapidly spreading nationwide, I am concerned about all the members of our communities with damage and injury in the immune system, particularly to cell-mediated injury (to T cells and Ab-producing cells). In neutralization studies, most monoclonal Abs used to date
2/ have lost activity to #Omicron and are no longer useful in areas with high attack rates (pretty much everywhere in US right now). There are two possible exceptions. The first is #sotrovimab which was originally isolated from an individual with
3/ #SARSCoV1 (not a typo) back in 2003. The Ab recognizes a conserved glycan motif at the base of the Spike protein (away from the ACE-2 receptor-binding domain). Extremely limited supplies and fairly narrow emergency use authorization, as follows:
Read 14 tweets
1/n @ESCMID guidelines are wonderful resource for clinicians treating MDR GNR infections. Great work @jesusrbano @EveTacconelli and many others!
let's compare to @IDSAInfo guidance (paraphrased recs prn). starting w/ 3GcephR-E
idsociety.org/practice-guide… &
idsociety.org/practice-guide…
2/n
First, @IDSAInfo AMR guidance is explicitly "guidance" not a guideline.
Second, @IDSAinfo focuses on treatment recommendations for antimicrobial resistant infections in the United States.
3/n
Now, let's look at specific recommendations (I will follow order in @ESCMID document).

@ESCMID provides several recommendations for Enterobacterales resistant to 3rd gen. cephalosporins. In @IDSAInfo separate recs are provided for ESBL-producers vs. AmpC producers.
Read 21 tweets
Updated chart on early #COVID19 treatment for #Molnupiravir, #nirmatrelvir (#Paxlovid), and #fluvoxamine #IDTwitter
Further summary of early #COVID outpatient treatment options by @DrToddLee including the data on Monoclonal antibodies. #MedTwitter #IDTwitter
When thinking about therpeutics as a MD, fundamental question is: "Does a drug have benefit?"
A medicine that reduces symptom duration = beneficial
A medicine that reduces deaths = also beneficial.
Waiting to recommend a med until there are data that it does all things = silly
Read 3 tweets
@pfizer releases more nirmatrelvir (#Paxlovid) data on #COVID19 final outcomes. Data are consistent, slightly better thant interim analysis. #IDTwitter
▪️ 88% overall hospitalization <=5days
▪️ No deaths in High Risk Trial (EPIC-HR)
▪️ Stopping drug 2.1%
investors.pfizer.com/investor-news/…
Nirmatrelvir (Paxlovid) had 70% ⬇️hospitalizations (2.4% to 0.6%) and 0 deaths in "Standard Risk" EPIC-SR trial among unvax people without risk factors or vaccinated people with a risk factor.
No reduction in duration of illness, per primary endpoint.
RCT ongoing 45% enrolled
EPIC-SR interim analysis has n=673 randomized who have reached >1 month. Total enrollment is 1,140 adults "from North and South America, Europe, Africa, and Asia, and the United States."
(Apparently US is now distinct from North America)
Read 9 tweets
⭐️FIVE Little Allergy/Immunology Lessons from 5 Big Days on Consults ⭐️ @mghaifellows @MGHAllergy. #Urticaria #Angioedema #vaccine reactions eosinophilia and #drugallergy /1
ONE-To treat acute urticaria (hives), antihistamines should be nonsedating and scheduled (not diphenhydramine PRN). Allegra/fexofenadine and Zyrtec/cetirizine have large therapeutic windows and are used safely at 4+ times the daily allergic rhinitis dose/2
TWO-Angioedema in an adult without skin itching/hives/rash—check if they on an ACE inhibitor! Although ~10% get it w/in 30d, many happen after years of uneventfully being on it /3 ncbi.nlm.nih.gov/pmc/articles/P…
Read 8 tweets
#idboardreview patient on chronic steroids with bilateral lung nodules and skin lesions. Skin AFB stain shown. dx? #meded #idmeded #IDtwitter
#Nocardia species form long, branching, beaded filaments. Organisms that stain with #modified #AFB:
Mycobacterium species
Legionella micdadei (in specimens only)
Nocardia species
Rhodococcus species
Tsukamurella species &
Gordonia species
#iddailypearl
Read 3 tweets
#idboardreview 60 F recent travel to Cairns, Australia, had multiple🦟 bites, 1wk later fever, fatigue, headache, myalgia & arthralgia of hands, wrists, feet & ankles. +itchy papular rash on her face, neck and trunk.Dx? #meded #idmeded #IDTwitter Image
Read 6 tweets
#idboardreview Peritoneal dialysis pts with exit site infection outbreak. Aqueous Chlorhexidine with gram negative bacteria. dx? #meded #idmeded #idtwitter ImageImage
#Burkholderia #cepacia is type species of genus Burkholderia & ubiquitous MDR, motile, non–glucose-fermenting, gram-negative organism found in water & soil. Major pathogen in cystic fibrosis & opportunistic pathogen in pts w/ indwelling medical devices & immunosuppression
Read 7 tweets
#idboardreview 60 M 6 months post heart transplant on atovaquone px presents w/ cough, dyspneax10d. CT b/l nodules w/ cavities, l leg mass aspirated. Dx? #meded #idmeded #IDTwitter ImageImage
Risk factors of #nocardia in #SOT

high calcineurin inhibitor trough levels in month before dx

use of tacrolimus

corticosteroid dose at time of dx

patient age

length of stay in ICU after SOT

academic.oup.com/cid/article/63…
Read 7 tweets
#idboardreview Pt w/ LE venous insufficiency found in his camper unconscious and covered in feces and maggots: septic shock, wbc 35k, Cr 6, blood culture w/ gram negative non-motile bacteria. Dx? #meded #idmeded #idtwitter Image
#Wohlfahrtiimonas #chitiniclastica bacteremia Ref wwwnc.cdc.gov/eid/article/27… in this case identified w/ MALDI-TOF; Image Ref jgid.org/article.asp?is…
#Wohlfahrtiimonas #chitiniclastica was first identified in culture from the third-stage larvae of Wohlfahrtia magnifica flies which are known to cause myiasis, commonly in sheep and cattle
Read 5 tweets
#idboardreview 60 F with Myelodysplastic syndrome presents w/ L knee pain, rash on unilateral sole, PET: L iliac artery uptake. Knee fluid 80k 98% PMN, gram stain gram negative cocobacilli. dx? #meded #idmeded #idtwitter ImageImage
Endovascular Infection #Kingella #kingae Complicated by Septic Arthritis in Immunocompromised Adult Patient Ref wwwnc.cdc.gov/eid/article/26…
#Kingella kingae gram-negative coccobacillus,normal flora of upper respiratory tract. Causative agent of osteoartricular infections in kids<4 years. Rarely HACEK IE in adults
R.f poor oral hygiene, pharyngitis, & mucosal ulcerations
Read 6 tweets
#idboardreview 50 M Texan welder w/ diarrhea, cough, dyspnea x2d, presented to ED, sepsis and rapid progression to resp fail & death <8hrs after presentation. CT necrotizing pneumonia. +GPR #idtwitter #meded #idmeded ImageImage
Read 10 tweets
#IdBoardReview sudden onset of fever, bronchitis, pneumonia, severe resp illness outbreak in pts of all ages/immune status that attended a game last week. BAL pleomorphic gm- bacteria. What type of isolation? #IDtwitter #idmedEd #medEd Image
Inhalation #tularemia bioterrorism needs standard precautions as
Not transmitted from person to person
cdc.gov/infectioncontr…
Read 5 tweets
🦠Pulmonary cryptococcus in patients w/ severe COVID-19🦠: A thread!
The CDC doesn't recognize cryptococcus as a common fungal disease complicating COVID-19: How common is it? We don't know! ~10 cases have been reported re: cryptococcus infection in non-HIV/Txplant patients w/ severe Covid
Among these cases, 3/10 had isolated pulmonary🫁disease, 7/10 w/ CNS🧠disease. ALL pts had several RFs incl. 🫁 prolonged mechanical ventilation, 💉immunomodulatory therapies including steroids, toci, and 🦠immune dysregulation 2/2 direct SarsCOV2 viremia and critical illness
Read 7 tweets

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