In Infectious Disease Puscast #94, Doctors Griffin and Dong review recent literature focusing on evolving antimicrobial resistance and key public health threats. Critical data suggests that DoxyPEP significantly increases high-level tetracycline resistance in N. gonorrhoeae, while fluconazole resistance in Candida parapsilosis has rapidly accelerated. Mechanistically, they explore the finding that Epstein-Barr virus (EBV) actively drives Systemic Lupus Erythematosus (SLE) by reprogramming B cells. Clinical alerts include a major US outbreak of infant botulism linked to a specific formula, and a fatal case of delayed anaphylaxis (alpha-gal syndrome) triggered by red meat. Finally, real-world data confirms malaria vaccine efficacy, and a systematic review strongly supports the safety of Ivermectin in small children, challenging current contraindications.
Infectious Disease Puscast #94: Literature Review (Nov 2025)
1:34 EBV and Lupus: A critical paper in Science Translational Medicine links Epstein-Barr Virus (EBV) not just epidemiologically, but mechanistically to Systemic Lupus Erythematosus (SLE). EBV infects and reprograms autoreactive B cells, turning them into antigen-presenting cells that drive T-cell activation and autoimmunity. EBV-infected B cells are 25 times more frequent in SLE patients.
4:09 Hep B Reactivation Risk: A case series shows Hepatitis B reactivation in HIV patients (4-12 months post-switch) after stopping Tenofovir-containing Antiretroviral Therapy (ART), even when transitioning to 3TC-based regimens. Takeaway: Thoroughly screen for Hep B PCR/surface markers before dropping Tenofovir, especially since primary care often handles these switches.
6:18 DoxyPEP Drives Resistance: A substudy of the ANRS174 DOXYVAC trial confirms that Doxycycline Post-Exposure Prophylaxis (DoxyPEP) use tripled the rate of high-level tetracycline resistance (via the tetM gene) in N. gonorrhoeae. It also increased decreased susceptibility to cefixime threefold. The concern about increasing Antimicrobial Resistance (AMR) is valid.
9:32 PrEP and STI Incidence: Observational data suggests that PrEP use does not increase incidence of gonorrhea or chlamydia in MSM, contrary to common medical bias ("risk compensation"). Increased routine testing (every 3 months) likely mitigates any potential behavioral increase in risk.
11:29 Improving Maternal Sepsis Outcomes: A large NEJM cluster randomized trial in Africa found that a multicomponent intervention (APT-Sepsis, including a FAST M bundle) significantly reduced severe maternal infection outcomes (1.4% vs 1.9%, P<0.001). Key detail: FAST M stands for Fluid, Antibiotics, Source control, Transfer, Monitoring.
15:13 Public Antibiotic Knowledge: A systematic review showed that while the public generally knows antibiotics treat bacteria, only 42% recognized they are ineffective against viral infections. I don't care about their confusion, but quantifying that a quarter of people don't grasp basic AMR concepts is useful data.
18:14 Infant Botulism Outbreak: An ongoing US multi-state alert (Nov 2025) links 31 infant botulism cases to specific lots of ByHeart Whole Nutrition Infant Formula. The source is C. botulinum spores. Takeaway: Immediate recall is in effect; clinicians need high suspicion, as symptoms are non-specific ("floppy baby").
21:40 Vitamin D and CAP Mortality: Vitamin D deficiency was associated with a 3.5-fold higher risk of 90-day mortality in patients with Community-Acquired Pneumonia (CAP), but not 30-day mortality. The correlation is delayed. Likely confounding: sick/frail patients often have low Vitamin D status, as far as I can tell.
23:00 Bat-Associated Mycoplasma: Immunosuppressed children in Spain tested positive for Hemotropic Mycoplasma strains identical to those found in bats (Miniopterus schreibersii). This raises concerns about zoonotic transmission (vector-borne or otherwise), even without a history of direct bat exposure.
27:09C. auris Resistance Evolution: A case report demonstrated that Candida auris developed resistance to multiple antifungals (fluconazole, caspofungin, amphotericin B) during treatment in a lung transplant patient, emphasizing the speed of resistance evolution under selective pressure.
28:51C. parapsilosis Resistance Surge: Fluconazole resistance in C. parapsilosis isolates in the US surged from 8.2% to 20.3% between 2015 and 2024, with a notable acceleration since 2021. The trend is clearly unfavorable.
30:05 Fatal Alpha-gal Syndrome: A case of fatal anaphylaxis 4 hours after eating beef was linked to high IgE antibodies to alpha-gal, typically acquired via tick bites (e.g., Lone Star tick). Key detail: The severe, delayed reaction is often misattributed, hindering diagnosis.
34:40 Real-World Malaria Vaccine Data: Phase 4 real-world data (Ghana, Kenya, Malawi) on the RTS,S/AS01E malaria vaccine confirmed strong efficacy: a 58% reduction in severe malaria and a 36% reduction in malaria-related hospitalizations over one year. This supports its routine use as an additional tool.
38:58 Ivermectin Safety in Small Children: A systematic review found that Ivermectin administration to 1,088 children weighing less than 15kg (currently contraindicated) was safe, with only 1.4% experiencing mild, self-limiting adverse events. Takeaway: The current contraindication should be reconsidered to ensure access for Neglected Tropical Diseases (NTDs).
40:38 IL12RB1 Deficiency: The largest North American series (14 patients) of this rare immunodeficiency confirmed that in the absence of BCG vaccination, it presents as severe, disseminated, and frequently fatal infections with NTM (MAC), Salmonella, and Candida. Clinicians must be alerted to this possibility in severe intracellular infections. (Mortality rate 29% in this cohort.)