Infectious diseases weigh on primary care (ACP annual meeting)
■ Internists increasingly are managing complex communicable illnesses. The American College of Physicians meeting offered the latest guidance on such diseases.
By Christine S. Moyer — Posted May 13, 2013
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For some infectious disease experts, hepatitis C evokes memories of the early days of HIV/AIDS, when patients were diagnosed in the late stages of the disease and took handfuls of potent drugs every day. Just as in that era, many people with hepatitis C today are unaware they are infected, said San Francisco hepatologist Norah A. Terrault, MD, MPH.
Those who are diagnosed often are in poor health and receive toxic, complicated treatments. Although hepatitis C is curable, it can lead to cirrhosis of the liver, liver cancer and death if left untreated.
“In the last several years, deaths due to hepatitis C have surpassed deaths due to HIV. We expect that to continue,” Dr. Terrault told colleagues during a session of the American College of Physicians annual scientific meeting in San Francisco on April 11-13.
Dr. Terrault's presentation was one of many infectious disease sessions offered at the three-day meeting. The sessions highlighted trends doctors should be aware of, including antibiotic-resistant urinary tract infections and tips on screening for complex communicable diseases. The presentations often were standing room only.
The sessions come as some doctors are becoming more involved than ever in managing complicated infectious diseases, medical experts say. Contributing to that change is the fact that there are too few infectious disease specialists to meet the nation's demand, particularly in rural areas. Another factor is improved treatment that extends the lives of people with diseases such as HIV. As a result, more doctors are treating chronic conditions in patients with complex communicative illnesses.
Physicians face challenges as they take on this expanded role. Those include limited time for office visits and little specialized training in infectious diseases. Complicating matters: growing antibiotic resistance and a lack of new antimicrobials to work against one of the nation's most serious health threats — gram-negative bacteria, which are resistant to all available antibiotics.
But doctors shouldn't have to do this on their own, said infectious disease specialist Daniel P. McQuillen, MD, a senior staff physician at Lahey Hospital and Medical Center in Burlington, Mass. “Infectious diseases experts can work with them and help them manage things and make sure that outcomes are good,” he said.
Collaborating with specialists
One such collaborative effort is Project Echo, launched in 2003 by a New Mexico doctor. The initiative uses real-time videoconferencing to connect primary care physicians with specialists. The specialists train doctors to treat HIV/AIDS and hepatitis C, among other complex conditions.
Data show that the approach is effective. Cure rates of New Mexico adults age 18 to 65 with hepatitis C were 58.2% for people treated by Project ECHO doctors and 57.5% for those cared for at the University of New Mexico's HCV clinic, said a study in the June 9, 2011, issue of The New England Journal of Medicine.
Between 2 million and 4 million Americans are chronically infected with hepatitis C, and 75% are undiagnosed, Dr. Terrault told doctors packed into her ACP session. To put that in perspective, 21% of people with HIV/AIDS are unaware they are infected, said Dr. Terrault, an associate professor in the Dept. of Medicine at the University of California, San Francisco.
Baby boomers are the population most likely to be infected with hepatitis C. They account for 75% of chronic infections among U.S. adults. That high incidence largely is due to risk behaviors baby boomers engaged in during the 1960s and 1970s. A key risk factor for hepatitis C is intravenous drug use.
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In recent years, hepatitis C has surpassed HIV as a cause of death.
Dr. Terrault urged her colleagues to follow the Centers for Disease Control and Prevention recommendation that all adults born between 1945 and 1965 be screened once for hepatitis C.
Existing treatment has significant challenges. The combination of injections and pills is expensive and can cause harsh flu-like symptoms. The medications also have limited efficacy in certain populations, including blacks and transplant recipients. By 2014, new drugs are likely to be available that will be more effective, easier to take and have fewer side effects, Dr. Terrault said.
“Alarming” antibiotic resistance
Perhaps more alarming is the increasing antibiotic resistance of bacteria that cause community-acquired UTIs, a condition that frequently is diagnosed in primary care, said Thomas Fekete, MD, who led a packed session on antimicrobials at the ACP meeting.
Patients with minor UTIs who typically would have received a short course of antibiotics might now need the medications through an intravenous line, medical experts say.
“This is really alarming to a lot of people,” said Dr. Fekete, chief of infectious diseases at Temple University School of Medicine in Philadelphia. Antibiotic resistance is occurring for bacteria that cause a common condition in otherwise healthy people, he added.
Gonorrhea is another infection affected by antibiotic resistance, said infectious disease specialist Lisa L. Maragakis, MD, MPH, who led an ACP session on drug resistance. Neisseria gonorrhoeae has been developing resistance to the oral antibiotics used to treat it for decades. Fluoroquinolones, which have been prescribed for the infection in recent years, no longer are effective, Dr. Fekete said. In Canada, there have been at least nine gonorrhea infections resistant to cefixime, which is the last effective oral antibiotic for the illness, said a study in the Jan. 9 issue of The Journal of the American Medical Association.
In August 2012, the CDC revised its gonorrhea treatment guidance and said cefixime no longer should be a first-line treatment for the disease.
“Now we're stuck with injectables,” Dr. Fekete said. “Gonorrhea is going to be a big problem, because we don't have another backstop.”
One of the few bright spots at the infectious diseases sessions concerned Clostridium difficile. While C. diff rates are expected to increase in the near future due to new requirements that U.S. hospitals report such rates, cases of the disease probably will decrease in the long run, said Dale Gerding, MD, who led a session on the infection. Contributing to the decreased rates will be a C. diff vaccine that is in development and new short-term prevention methods that aren't widely used yet, said Dr. Gerding, professor of medicine at Loyola University Chicago Stritch School of Medicine in Maywood, Ill.
“Even though there's a lot of community-associated C. diff, the majority of those patients have had exposure to health care, if not in the hospital, then in office visits,” Dr. Gerding said. “Properly prescribing antibiotics is the biggest thing primary care doctors can do” to prevent the infection.
Furthermore, Dr. Maragakis encourages physicians to order a culture when they prescribe an antibiotic. A culture offers more information about the infection, including drug resistance, and thus enables doctors to modify treatment if a patient is not getting better, she said.
A recent report shows that although seven antimicrobials are in the pipeline, none would be effective against gram-negative bacteria. And there's no certainty the antibiotics in development will be approved by the Food and Drug Administration, said the report posted online April 17 in Clinical Infectious Diseases.
“There are patients out there right now who we don't have antibiotics for,” said Barbara E. Murray, MD, a report author and president-elect of the Infectious Diseases Society of America. “It is very scary.”