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Transcript

Lee Tetreault:

Hello and welcome to frequently asked questions from the session: Cases in infectious diseases, how the recent medical literature might influence your practice. I'm joined today by Dr. Richard Martinello. Doctor, could you give just a main pointer for the audience to come away with after today's session? 

Richard Martinello: 

Sure, I think one of the real key pointers here is that, as research goes on and we're understanding more about how to effectively treat patients, we're also developing a better understanding of what isn't helping our patients and where can we shorten durations of specific antibiotics where can we be more precise in how we prescribe antibiotics for when we suspect our patient has an infection and also Are there tests that we do that may lead to inappropriate antibiotic use, that really don't provide any value for our patients, so I think as time goes on and this research is being performed we're developing really a better understanding of what works and what doesn't.

Lee Tetreault:

Great, so let's get into some of these frequently asked questions. What is the ideal duration for metronidazole treatment for a trichomonas? 

Richard Martinello: 

A multi-center randomized control trial that was published in Lancet Infectious Diseases in 2018 by Dr. Patricia Kissinger and her team showed that patients who were randomized to receive seven days of treatment with metronidazole rather than just a one-time dose, actually had a higher rate of cure, when they were tested four weeks after treatment while the compliance rate was slightly lower in those prescribed seven days of treatment versus those who were only received a single dose of treatment. For those who received seven days of treatment, their compliance was still a very impressive 96% and the side effects that they experienced were really no different than those who had received just the single dose of metronidazole. While the latest CDC guidelines for the treatment of sexually transmitted infections, published back in 2018, still favors the use of single-dose treatment for trichomonas, this study from the Lancet Infectious Disease journal in 2018 really provides compelling evidence that seven days of treatment is both well-received by our patients and more effective.

Lee Tetreault:

Should I routinely check urinalysis and culture in patients scheduled for elective surgery?

Richard Martinello: 

Here the answer is a very clear no. In persons who are lacking any signs or symptoms suggestive that they may have a urinary tract infection, it was found that there was really no value in routinely checking a urinalysis or performing a urine culture prior to elective surgery. There was a large retrospective analysis of Veterans Affairs data, performed by Dr. Gallegos Salazar and colleagues which was published in JAMA surgery in 2018, it was shown that screening for asymptomatic bacteriuria provided no value as a treatment of either asymptomatic bacteriuria neither affected the rates of surgical site infections or the rate of urinary tract infections, in most cases, bacteria that were cultured from the patients in the pre-operative setting and from patients with asymptomatic bacteriuria differed from the bacteria found to be causing surgical site infections when they did occur. So with the exceptions of routine screening among pregnant women and our patients who will be undergoing invasive genital urinary tract surgery, we should not routinely be screening other surgical patients for asymptomatic bacteriuria.

Lee Tetreault:

In patients at risk for the acquisition of HIV, should I still consider prescribing PREP if they have a substance use disorder?

Richard Martinello: 

Yes, pre-exposure prophylaxis also known as prep, should still be considered for these patients, prep has been shown to be highly effective for the prevention of HIV in persons with ongoing risk factors for HIV or other... For HIV. In a study by Hoenigl and colleagues, they found that Tenofovir drug levels were no different among persons who did or did not abuse alcohol, or among those who did or did not have another substance use disorder, they did find that other sexually transmitted infections, which prep does not protect against were common, especially among those using stimulants. We should still consider prep use among patients with substance use disorders.

Lee Tetreault:

Are certain opioid medications immuno-suppressing and are they an additional risk factor for pneumonia? 

Richard Martinello: 

We know that the use of opioid pain medication suppresses the respiratory drive one's cough reflex and it inhibits bronchial mucus secretion. These in their own rights, are risk factors for pneumonia, but also certain opiate medications such as codeine, dihydrocodeine, fentanyl and morphine have also been shown to suppress certain aspects of innate immunity. Dr. Jennifer Edelman and her colleagues used the veterans aging cohort study database to perform a retrospective investigation to assess the risk for pneumonia among those receiving opiates and among patients both with and without HIV, they were able to show that in fact there is significant risk related to the dose of opiate medications and there's also additional risk of when our patients are using these immuno-suppressing opiates.

These findings were true for both persons with and without HIV. Not surprisingly, the risk impact was even greater in persons though who are living with HIV. For person's receiving high doses of immuno-suppressing opiates, their risk for pneumonia was about threefold greater when compared to persons not taking these medications. This study shows yet another reason why we need to be most cautious when prescribing opiate medications for our patients.

Lee Tetreault:

I know that many of your patients have a reported penicillin allergy, how may this impact their health?


Richard Martinello: 

Allergies to penicillin are one of the most common listed allergies among our patients. When patients have been assessed by allergists up to 95% of these individuals have been found to be not allergic to the penicillin antibiotic class. This is important, as patients with listed allergies to penicillin are much more likely to receive other classes of antibiotics. Not only may these other classes be not as effective for treatment or prophylaxis for the condition there are being prescribed for but a recent study by Dr. Ken Blumenthal showed that these patients are about 25% more likely to develop an infection due to the Clostridioides difficile and nearly 70% were likely to develop an infection due to MRSA when compared with their counterparts who did not have a Penicillin allergy listed. It has become my practice to selectively work with our allergist colleagues to assess patients labeled as having a penicillin allergy, to determine if they have a true allergy. I especially focus this effort for patients who have upcoming elective surgery and those with serious infections such as endocarditis, where we know the outcomes with beta-lactam antibiotics is superior to other classes of antibiotics.

Lee Tetreault:

And lastly doctor, what is the best timing for your patients and all of us to get a flu shot.

Richard Martinello: 

Over the past years, there has been a number of studies investigating this question. It's an important one, because we know that the level of antibodies developed after vaccination decrease after they peak post-vaccination, it is known that there are many other aspects of the immunity that impact the effectiveness of protection against influenza by Vaccination and these go well beyond just simply the antibiotic body levels, but there has been growing concern that flu vaccination given too early may fail to protect our patients late in the flu season. This year, 2019 to 2020. The CDC has updated their guidance to recognize more recent research. The focus of CDC's updated evidence is to have all persons vaccinated, by the end of October, recognizing that younger children may require two doses and that other patients may have not had the opportunity to get vaccinated it is important to start early for those who need two doses of vaccine, we should be getting the first dose of vaccine into those children as soon as possible. For our older patients who only require a single dose of vaccine, we should be waiting until perhaps September 1st, before vaccinating them but vaccinating our population aggressively so that everybody gets vaccinated by the end of October.

Lee Tetreault:

This is great information, Doctor, thank you so much for your time today.