A skeptical and financially conscious group of clinical pharmacologists or healthcare economists should review this. They would focus on poor resource allocation and the high costs associated with both bureaucratic non-compliance and the use of clinically useless diagnostic testing.
Abstract:
This installment of the "Puscast" delivers a highly critical review of recent infectious disease (ID) literature (August 2019), focusing heavily on systemic inefficiencies, clinical mismanagement by non-specialists, and poor resource utilization. Key points include the proven failure of bureaucratic, multi-step hand hygiene protocols (1:12), the unacceptable inaction of the IDSA against the anti-vaccination movement (2:51), and the consistent rejection of expensive, non-actionable inflammatory markers like procalcitonin (4:22, 20:17). The episode highlights the profound morbidity of streptococcal prosthetic joint infections (21:11) and the demonstrated clinical harm (C. diff, delayed diagnosis) resulting from gross physician non-adherence to guidelines for catheter-associated urine cultures (23:58). Finally, the discussion touches on the unexpected ecological consequences of antibiotics (resistance propagation) and deworming programs (potential increase in Type 2 Diabetes) (25:09, 26:50).
Summary of ID Literature Review (August 2019)
1:12 Hand Hygiene Protocol Failure: Bureaucratic 6-step hand hygiene protocols (WHO) result in poor adherence. A simpler 3-step protocol achieved higher compliance. Takeaway: As far as I can tell, simpler protocols ("Foam in, foam out") are effective in eliminating nosocomial infections, rejecting complex, non-compliant systems.
2:51 ID Society Failure on Vaccines: The Infectious Disease Society of America (IDSA) has displayed negligible involvement in combating the anti-vaccination movement, contributing to the ongoing measles epidemic. Takeaway: Institutional failure to address major public health threats is unacceptable.
4:22 Useless Inflammatory Markers: Inflammatory markers (ESR, CRP, Procalcitonin, suPAR in AIDS) are rejected because they rarely alter therapy. suPAR, for instance, predicted mortality in AIDS patients but offered no actionable intervention. Takeaway: Tests that do not modify patient behavior or therapy are a waste of resources, potentially driving patients into bankruptcy.
6:01 Influenza and Pregnancy: One study suggested babies born during flu season had a slower lifetime income (interpreted as "not as bright"). Modern data shows influenza in pregnancy increases hospitalization sevenfold but does not increase mortality or ICU admissions in this specific cohort. Takeaway: Increased hospitalization is likely precautionary institutional bias, not severe morbidity. The "not as bright" premise is surprising and warrants intense skepticism regarding causation.
8:37 Hepatitis D Prevalence: Hepatitis D (delta virus) requires Hepatitis B to replicate. A US study found that 42% of Hepatitis B surface antigen-positive patients also had antibodies to the delta virus. Takeaway: Hepatitis D co-infection risk is high (nearly half) and should not be ignored.
10:10 Eculizumab Risk Expansion: Eculizumab (terminal complement inhibitor) is known to increase Meningococcal risk 1,000β2,000 fold. New cases demonstrate it also increases the risk of disseminated Neisseria Gonorrhoeae (GC). Takeaway: If a patient is on Eculizumab, assume disseminated Neisseria species are a severe risk.
13:14 Staph Aureus Dynamics: New strains of MSSA and MRSA constantly enter and spread in communities (e.g., CC398 in France, PVL+ ST22 in China), suggesting infectious waves are driven by clonal replacement.
14:24 Diabetes and Staph Bacteremia: Diabetics face double the risk of metastatic infection from S. aureus bacteremia (SAB). They require aggressive/extended duration of treatment (I double therapy length, as far as I can tell).
15:12 Daptomycin vs. Vancomycin (Bone): Daptomycin at 6mg/kg achieves good bone penetration in diabetic patients, confirming efficacy and relative cost-efficiency for osteomyelitis compared to high-dose Vancomycin, which demonstrates "diddly squat" tissue penetration.
16:17 Physician Competence Failure: French data showed non-ID specialists used the wrong definitive antibiotic therapy in 17% (almost one in five) of documented Enterococcal bacteremias. Crucial Takeaway: Ampicillin/Amoxicillin is the superior antibiotic for susceptible Enterococcal bacteremia, yet clinicians preferentially use inferior agents like Vancomycin or Linezolid.
18:38 Protocolized Sepsis Care: Mandated protocolized sepsis care (e.g., in New York) achieved greater mortality reduction than non-protocolized care. Takeaway: Protocol adherence demonstrably prevents physician cognitive failures and saves lives, even if it is irritating to competent practitioners.
21:11 Streptococcal PJI Failure Rate: Studies (e.g., Denmark) indicate that streptococcal prosthetic joint infections (PJI) treated with debridement and implant retention (DARI) fail at an alarming rate (51.4%), especially Group B Strep. Takeaway: Aggressive surgical exchange is required; short IV courses (14 days) and lack of chronic suppression may explain the high failure rates observed in the literature.
23:58 Inappropriate Urine Cultures: Adherence to IDSA guidelines for culturing urine in catheterized patients is only 14%. Inappropriate culturing (e.g., based on odor/color) resulted in adverse events (including C. diff and delayed management) in 11% of patients. Takeaway: Inappropriate testing directly causes iatrogenic harm; protocols exist precisely because human judgment fails.
25:09 Antibiotic De-escalation Urgency: Prolonged use of anti-pseudomonal beta-lactams increases the risk of C. difficile and colonization by Carbapenem-Resistant Organisms (CROs). Takeaway: Infectious diseases is applied evolution; rapid de-escalation is necessary stewardship to minimize selection pressure.
26:50 Hygiene Hypothesis and Diabetes:Strongyloides parasitic infection was associated with beneficial modulation of Type 2 Diabetes (T2D) markers, and treating the parasite worsened T2D. Takeaway: Deworming programs may have the unintended consequence of increasing T2D incidence due to altering the host microbiome/immune modulation. (No good deed ever goes unpunished.)