Jul 21, 2017

Germ center

The story

Watching everyone forget your name makes memory loss look like the most contagious thing going around the hospital this summer. But gonorrhea is known to spread quickly, too. Can vaccines help?

The background

Like your best efforts to finish work in time to make it to happy hour, vaccines targeting gonorrhea just haven't really worked. And the stakes are rising: the WHO estimates that resistance to single agent therapy is so widespread that they now recommend worldwide dual treatment with azithromycin and ceftriaxone, a standard that has been in place in the United States for years. The disease is particularly sneaky in women, where infections are often asymptomatic but can lead to pelvic inflammatory disease and pregnancy problems when untreated.

The study

Like their names suggest, Neisseria gonorrhoeae (the bacteria behind gonorrhea) and Neisseria meningitidis (meningococcal meningitis) are closely-linked genetically. A retrospective study of sexual health clinics in New Zealand found that young adults who received the meningococcus B vaccine had lower rates of gonorrhea infection compared to their unvaccinated peers. The researchers estimated the vaccine to be 31% effective against gonorrhea infection, an effect size that could lead to sweeping public health benefits if applied on a population level.

The takeaway

With growing resistance to antibiotics, vaccines look promising in the fight against gonorrhea. Many hope the results will revive long-dormant efforts to develop a gonorrhea-specific vaccine.

Say it on rounds

When you page a consult in the morning and hear back after you leave work

Even after a long wait, there still may be no payoff. Follow-up analysis of the PIVOT trial, which randomized men with early prostate cancer to radical prostatectomy or active surveillance, found no difference in all-cause or prostate cancer-specific mortality between groups after 20 years. Prostatectomy patients showed a trend towards increased survival that failed to reach statistical significance, but they faced long-term adverse effects like urinary incontinence and erectile dysfunction.

When one drink at resident happy hour quickly turns to three

Combos are always more fun. An RCT of 220 elderly patients who presented with lab-confirmed influenza A compared oseltamivir monotherapy to triple therapy with oseltamavir, clarithromycin, and naproxen. The combo treatment improved 30 and 90-day mortality and led to faster reductions in viral load, fewer ICU admissions, and shorter hospital stays. Clarithromycin and naproxen are thought to decrease inflammation in infected patients. 

When you're sure you have MDR-everything

Turns out you don't, at least intestinally-speaking. An observational study of over 400 health care providers (HCPs) with patient contact found no difference in the rate of colonization with multi-drug resistant (MDR) organisms compared to providers who did not have patient contact, even though 70% of the patient-facing HCPs reported MDR organism exposure. Perirectal swabs were used to find the MDR bugs and presumably make the HCPs second guess their decision to participate. At around 4%, overall rates of MDR colonization were much lower than expected.
Clin Microbiol Infect

Brush up

Infective endocarditis

If your echo techs honor STAT requests, call right away when you see fever and a new murmur. The 1-year mortality for infective endocarditis (IE) remains around 30% despite advances in treatment. Staph and strep, the usual suspects, account for 80% of cases, while individuals with congenital heart disease, prosthetic valves or other implanted cardiac devices are at highest risk. Use the Duke Criteria to frame your diagnosis. 

What's the evidence

For urgent surgical intervention in IE? 2012's EASE trial looked at individuals with left-sided endocarditis, a  > 10 mm vegetation, and severe valvular disease and found that valve surgery in the first 48 hours reduced death by any cause compared to conventional therapy. Urgent surgery also reduced systemic embolic events, which occur in about one-third of patients with IE. Patients with severe congestive heart failure, heart block or annular abscesses were not included in the study since surgery for these patients was already standard-of-care per AHA guidelines

Survival guide: Part III

Because the training process never ends, we've got you covered with our top tips on the fellowship interview process. Check it out here.

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