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Conference was a little different this week.  Thanks to all who visited — Sinai EM grad Dr. Roland Merchant of Brown, Professor Paul Klotman, Sinai’s Chair of Medicine, and Dr. Calfee from ID. Also thanks to our own speakers and panelists –Drs. Goodman, Nassisi, Jagoda, Strother and Shoenstein.

Some points I thought bear repeating, or that I want to expand upon:

— Dr. Merchant noted the PEP guidelines for HIV — the CDC’s recommendations are online (2001, 2005), and they summarize the state of the research and how difficult it is to show efficacy of PEP in humans. But as Dr. Merchant noted, we don’t offer PEP to patients with workplace exposures equally. We should — and high-risk workplace encounters shouldn’t deserve a different regard in our minds from high-risk consensual sexual exposures. What kind of HAART is recommended? The CDC explains:

 No evidence indicates that any specific antiretroviral medication or combination of medications is optimal for use as nPEP. However, on the basis of the degree of experience with individual agents in the treatment of HIV-infected persons, certain agents and combinations are preferred. Preferred regimens include efavirenz and lamivudine or emtricitabine with zidovudine or tenofovir (as a nonnucleoside-based regimen) and lopinavir/ritonavir (coformulated in one tablet as Kaletra^®) and zidovudine with either lamivudine or emtricitabine. Different alternative regimens are possible (Table 2).

No evidence indicates that a three-drug HAART regimen is more likely to be effective than a two-drug regimen. The recommendation for a three-drug HAART regimen is based on the assumption that the maximal suppression of viral replication afforded by HAART (the goal in treating HIV-infected persons) will provide the best chance of preventing infection in a person who has been exposed. Clinicians and patients who are concerned about potential adherence and toxicity issues associated with a three-drug HAART regimen might consider the use of a two-drug regimen (i.e., a combination of two reverse transcriptase inhibitors). Regardless of the regimen chosen, the exposed person should be counseled about the potential associated side effects and adverse events that require immediate medical attention. The use of medications to treat symptoms (e.g., antiemetics or antimotility agents) might improve adherence in certain instances.

They’ve also clarified what’s a high-risk exposure vs. a low-risk.

– Ever wonder about that IC alert on IBEX? It stands for “Infection Control” (not “icky”). It’s assigned by ID based on positive MRSA or VRE or other resistant bugs, because colonization of these bugs persists for years. Patients who’ve had C. diff are NOT included on the IC alert because once they’ve recovered, they’re cleared. How many patients have ever had the IC label removed? Well, they’d have to be inpatients here for other reasons who have negative monitoring cultures… In other words, almost no one has shed his or her IC-factor, and probably very few will.

– There’s precious little guidance from the literature or even governing bodies regarding ED isolation (plenty about inpatient and ambulatory care precautions…) So if you’ve got an interest in this topic there are faculty members happy to steer you (one idea that emerged post-conference was to place self-cleaning bathrooms in the ED — and hey, they’re now on sale). Also, on the topic of antibiotic approval, how much time have we lost waiting for a almost automatic rubber-stamp from ID? It may be hard to prove this delay harms patients, but if any enterprising resident is willing to show how often our initial pick gets approved (90% ? 95% ?) it might help scale back the practice.

–   The MSH infection control manual and CDC transmission precaution guidelines are online. I find these useful in discussions with nurses and floor staff. Basically “contact precautions” (needed for MRSA, C. diff, VRE) involve a gown, glove, and single room — but if single rooms are in short supply, we should give priority to those with fecal incontinence or draining wounds, and avoid pairing IC patients with the immunocompromised or those with open wounds. We must ensure that patients are separated by more than 3 feet, however — so in some cases that means they are getting better isolation upstairs in a shared room, compared to our crammed NYC ED.

– The ED pharmacists let us know their phone numbers: SB’s work phone is 646-438-5480, and ER’s is 646-315-5347.

– Also, you can find the list of meds needing ID approval  from the intranet (it took me a while but it’s here). The formal approval process is also described, but summarized below:

From 9-5 if a drug needs approval, page 9407 for adults, 3737 for kids. After hours, fill out the form from IBEX and send it to the inpatient pharmacy, at tube station 39. Drugs that require waking up an ID specialist include amphotericin B, capsofungin, tigecycline, daptomycin, linezolid, and for peds: IV vanc and IV acyclovir.

Posted on Friday, September 26th, 2008 at 3:15 am by Nick. Filed under Post-Conference Letter, Monitoring, Infectious Disease, Blog.
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