September 2018 by San Diego Physician

SEPTEMBER 2018 OFFICIAL PUBLICATION OF SDCMS

THE RISING RISK OF INFECTIOUS DISEASES Latest on Syphilis, Clostridium Difficile Infection & Surgical Antibiotic Prophylaxis

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CONTENTS

VOLUME 105, NUMBER 9

Editor: James Santiago Grisolia, MD Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; Robert E. Peters, MD, PhD; William T-C Tseng, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder OFFICERS President: David E. J. Bazzo, MD President-elect: James H. Schultz, MD Secretary: Holly B. Yang, MD Treasurer: Sergio R. Flores, MD Immediate Past President: Mark W. Sornson, MD, PhD GEOGRAPHIC DIRECTORS East County #1: Venu Prabaker, MD East County #2: Rakesh R. Patel, MD East County #3: Jane A. Lyons, MD Hillcrest #1: Gregory M. Balourdas, MD Hillcrest #2: Thomas C. Lian, MD Kearny Mesa #1: Jamie M. Jordan, MD Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Laura H. Goetz, MD La Jolla #2: Marc M. Sedwitz, MD, FACS North County #1: Patrick A. Tellez, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Veena A. Prabhakar, DO South Bay #1: Irineo “Reno” D. Tiangco, MD South Bay #2: Maria T. Carriedo, MD GEOGRAPHIC ALTERNATE DIRECTORS East County: Heidi M. Meyer, MD Hillcrest: Kyle P. Edmonds, MD Kearny Mesa #1: Anthony E. Magit, MD Kearny Mesa #2: Eileen R. Quintela, MD La Jolla: Wayne C. Sun, MD North County: Franklin M. Martin, MD South Bay: Karrar H. Ali, DO AT-LARGE DIRECTORS #1: Thomas J. Savides, MD; #2: Paul J. Manos, DO; #3: Alexandra E. Page, MD; #4: Nicholas J. Yphantides, MD (Board Representative to Executive Committee); #5: Stephen R. Hayden, MD (Delegation Chair); #6: Marcella (Marci) M. Wilson, MD; #7: Toluwalase (Lase) A. Ajayi, MD (Board Representative to Executive Committee); #8: Robert E. Peters, MD AT-LARGE ALTERNATE DIRECTORS #1: Karl E. Steinberg, MD; #2: Steven L-W Chen, MD, FACS, MBA; #3: Susan Kaweski, MD; #4: Al Ray, MD; #5: Preeti Mehta, MD; #6: Vimal I. Nanavati, MD, FACC, FSCAI; #7: Peter O. Raudaskoski, MD; #8: Kosala Samarasinghe, MD

8 features

ADDITIONAL NON-VOTING MEMBERS Alternate Resident Physician Director: Zachary T. Berman, MD Alternate Retired Physician Director: Mitsuo Tomita, MD San Diego Physician Editor: James Santiago Grisolia, MD CMA Past President: James T. Hay, MD CMA Past President: Robert E. Hertzka, MD (Legislative Committee Chair) CMA Past President: Ralph R. Ocampo, MD, FACS CMA President: Theodore M. Mazer, MD CMA Trustee: William T-C Tseng, MD CMA Trustee: Robert E. Wailes, MD CMA Trustee: Sergio R. Flores, MD

12 Treating and Combating the Increase of Syphilis in San Diego BY WINSTON TILGHMAN, MD

16 Surgical Antibiotic Prophylaxis

BY STEPHEN WEI, PHARM. D.

TeleMental Health and Its Promise

20 Clostridium Difficile Infection BY MICHAEL BUTERA, MD

departments

BY JESSICA THACKABERRY, MD

10 The Safe Homes Coalition Tackles the Supply Side of the Opioid Epidemic BY GREGORY A. STEIN AND SCOTT

CMA TRUSTEES Robert E. Wailes, MD William T-C Tseng, MD, MPH Sergio R. Flores, MD AMA DELEGATES AND ALTERNATE DELEGATES: District 1 AMA Delegate: James T. Hay, MD District 1 AMA Alternate Delegate: Mihir Y. Parikh, MD At-large AMA Delegate: Albert Ray, MD At-large AMA Delegate: Theodore M. Mazer, MD At-large AMA Alternate Delegate: Robert E. Hertzka, MD At-large AMA Alternate Delegate: Holly B. Yang, MD

SILVERMAN

Briefly Noted * Calendar * Professional Development & Education * Drug Prescribing/ Dispensing * Advocacy * Practice Management * Medical Mentorship

Physician Marketplace Classifieds

SEPTEMBER 2018

ADDITIONAL VOTING DIRECTORS Communications Chair: William T-C Tseng, MD Finance Committee Chair: J. Steven Poceta, MD Resident Physician Director: Trisha Morshed, MD Retired Physician Director: David Priver, MD Medical Student Director: Margaret Meagher

28 You Already Know BY DANIEL J. BRESSLER, MD, FACP

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

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/////////BRIEFLY /////////////////NOTED //////////////////////////////////////////////////////////////////////// PROFESSIONAL DEVELOPMENT & EDUCATION

Medical Board Releases Physician License Alert App for Patients

CALENDAR

OCT 11–12: CSU Institute for Palliative Care National Symposium. At Hyatt Mission Bay. OCT 12–14: UCSD School of Medicine Marks Its 50th Anniversary With Alumni Reunion Weekend. OCT 19: Top Doctors Gala at Farmer and the Seahorse. OCT 25: SDCMS Physician Networking Opportunity and Social Mixer, 5:30–8 p.m., Rock Bottom Brewery in La Jolla. NOV 8–10: Cardiovascular, Allergy & Respiratory Summit (CARPS) at Wyndham San Diego Bayside. Optional workshops Nov. 7. NOV 10: Champions for Health Annual 5K Solana Beach Walk/Run. NOV 16–17: Pain Care for Primary Care (PCPC) at Wyndham San Diego Bayside. Optional Addiction Workshop on Nov. 15.

SEPTEMBER 2018

The Medical Board of California recently released its first mobile app, currently available on Apple iOS devices. The technology notifies patients about changes to their physician’s license status, rather than patients having to actively seek out that information. Physician profiles have long been available to the public on the board’s website. The new app will notify users when their physician’s license is updated or there are changes to the physician’s address, practice status, specialty, disciplinary actions, and much more. The California Medical Association (CMA) has long advocated for a comprehensive, effective, and wellfunctioning regulatory process for physicians. CMA believes this new app will make it easier for patients to choose their healthcare practitioner. It also has

the potential to increase transparency and improve patient trust and quality of care. For more information on the app, visit the board’s iOS App webpage. Users can download the app by visiting the Apple Store and searching for “Medical Board of California.” A version for Android devices will be available in the near future. CMA encourages physicians to periodically check their profiles for accuracy and to advise the board of any corrections, especially their addresses of record. The Board cautions physicians about using their home address as their address of record, however, because it becomes widely available on the Internet. If you believe the information on your profile is incorrect, please contact the medical board at webmaster@mbc.ca.gov or (800) 633-2322.

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CMA Advocacy Drastically Reduced Administrative Burdens for Parkinson’s Registry

DRUG PRESCRIBING/DISPENSING

CA Pharmacy Board Launches Drug Take-Back Database The California Board of Pharmacy has launched an online drug take-back tool to help consumers looking for a place to safely dispose of unwanted or expired prescription drugs. The searchable online database includes pharmacies statewide offering drug take-back services authorized by the California State Board of Pharmacy. The drug take-back search tool is available at pharmacy.ca.gov. Users can enter a pharmacy name, city, or zip code to easily find a nearby location for disposing of unused medications. Pharmacies operating take-back programs registered with the Board of Pharmacy may offer two types of services: onsite collection bins and/or envelopes for mailing back medications. Consumers may dispose of prescription drugs — including controlled substances — as well as over-the-counter medications in collection bins and mail-back envelopes. Auto-injectors such as EpiPens and other sharps and needles are not accepted. (The California Department of Public Health has a list of sites that accept home-generated sharps.) Additional drug take-back locations can be found on websites of the federal Drug Enforcement Administration, Don’t Rush to Flush, and the California Department of Public Health.

Effective July 1, 2018, MDs, DOs, PAs, and NPs who diagnose or treat Parkinson’s disease patients (“Reporting Providers”) are required to report cases of Parkinson’s disease to the California Department of Public Health (CDPH) after first registering at https://hie.cdph.ca.gov. The California Parkinson’s Disease Registry collects data to measure the incidence and prevalence of Parkinson’s throughout California, providing more understanding to improve the lives of patients. The California Medical Association (CMA) and other stakeholders worked closely with CDPH to reduce the administrative burden these reporting requirements pose on healthcare professionals, and CMA’s advocacy efforts are reflected in the third version of the Implementation Guide. The latest update dramatically narrows the breadth of data elements that providers must report to the Registry — from 62 data fields to 14 required and three optional fields. Physicians are also no longer required to report information about a Parkinson’s patient’s next of kin, symptomology, medications, surgeries, secondary diagnoses, or patient visit information. CDPH issued an initial guide in April 2018 explaining the reporting mandate, including who is required to report, reporting timelines, and methods to transmit data to the registry. Since the issuance, CMA expressed concerns to CDPH about the scope, breadth, and timing of the new reporting obligation. CDPH had previously revised the guide to address several of these concerns, including limiting the number of reportable ICD-10 codes to only include patient encounters for diagnosis or treatment of Parkinson’s disease or Parkinsonism occurring on or after July 1, 2018. CDPH also extended the reporting compliance date for cases encountered during the first quarter the law is in effect (July 1 to Sept. 30, 2018) from 90 days to 180 days; however, as of Oct. 1, 2018, all cases must be reported within 90 days. Manual entry will remain an option for all providers. Reporting providers and entities are encouraged to review the Implementation Guide carefully to determine which rules apply, as well as to explore CDPH’s fact sheet for more information. SAN DIEGO PHYSICIAN.ORG

/////////BRIEFLY /////////////////NOTED //////////////////////////////////////////////////////////////////////// MEDICAL MENTORSHIP

Mentors Needed for UCSD Health Professions Mentor Program (HPMP) By Robert “Larry” Schmitt, MD

PRACTICE MANAGEMENT

New Medi-Cal Updated Provider Enrollment System Goes Live The California Department of Health Care Services (DHCS) released an update to its Medi-Cal provider enrollment system, called the Provider Application and Validation for Enrollment (PAVE), on Sept. 4. The current iteration (2.0) of the PAVE system, originally launched on Nov. 18, 2016, transformed DHCS’s provider enrollment from a manual, paper-based process to a webbased portal that providers could use to complete and submit their applications and verifications, and to report changes. The original launch included most physicians and allied provider types. The new update (3.0) includes even more eligible provider types, including physician-owned ambulatory surgical clinics. PAVE will eventually replace the paper application process, although a paper option will still be available to those providers who specifically request it from DHCS’s Provider Enrollment Division. Key features of PAVE 3.0 include auto population of data, secured inter-practice communication, screening tools to avoid submission of the incorrect form, real-time status tracking, and multiple “help” functions. According to DHCS, the process for completing an application through the new system is dramatically streamlined, dropping the average time to complete an application from 1.75 hours to .7 hours. DHCS also reports its average provider application processing time has been cut in half, and it expects that time to drop even lower after 3.0’s launch. 6

SEPTEMBER 2018

Adele Savage, who leads the UC San Diego Health Professions Mentor Program (HPMP), spoke recently to the Champions for Health Retired Physicians lunch. HPMP has, during the past 15 years, provided thousands of UC San Diego students the opportunity to meet mentors in healthcare fields of their interest, especially in the area of medicine. Students choose mentors from a list at the HPMP website, which includes a brief bio of the professional. After an orientation from Savage, the student contacts the professional to arrange a first meeting. It can occur at your office or other convenient location. At the end, they jointly decide to continue or stop. If continuing, they agree on the frequency of future meetings. The understanding is that this mentoring relationship will end after four months. However, if is a good fit, they may continue on a personal level. I have maintained contact with a number of my mentees after their acceptance to med school. In 15 years, my mentees included absolute all-stars as well as ones who would do better in another field. Your task, in the latter case, is to gently help them consider alternate career plans. My spirit is lifted with each new mentee. They are hungry to learn aspects of a medical practice. Typically, they arrive with questions, often on a written list. If retired, your reluctance to mentor may be based on the fact that there has been so much recent progress in your specialty. This is understandable, yet unimportant. The core values of a fine physician are the same as when we entered medical school. You will assist them in focusing on the patient, not the diagnosis or the computer. If you are in active practice, you are also encouraged to sign up. Go to hpmp.ucsd.edu, provide basic information about yourself, then sit back and await a call. It may take a few weeks for that first call. It can depend on the time in the school year, but the program has been expanded to run 12 months a year due to the tremendous need. Dr. Schmitt is a retired adolescent and child psychiatrist.

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M E N TA L H E A LT H

TeleMental Health and Its Promise By Jessica Thackaberry, MD

IN MY INTERACTIONS with physicians of various specialties here in San Diego, when I tell them I am a psychiatrist, almost invariably they complain that patients cannot get appointments with a psychiatrist, and they request the ability to send referrals. As physicians, we know this is not an isolated issue in San Diego County, but rather a global issue of a shortage of psychiatrists as well as the inadequate geographic and socioeconomic distribution of specialty services. This is especially prominent in our most rural areas of Southern California â&#x20AC;&#x201D; Imperial County, for example.

SEPTEMBER 2018

TeleMental health, also known as telepsychiatry or teletherapy, is a tool to provide care to patients who otherwise would have minimal access to psychiatric treatment, and is revolutionizing the way patients receive mental healthcare today. Models of care for TeleMental health consist of a wide range of services, including, but not limited to, feefor-service or direct care to patients through a telemedicine platform, consultative services to other physicians through a technological means (either directly seeing the patient via webcam or after reviewing the medical record through a secure link), or asynchronous technology, in which a standardized

interview is performed and recorded, to be reviewed later by a psychiatrist. Today, TeleMental health has been shown to be effective in terms of increasing access to psychiatric care, providing treatment for a wide range of diagnoses and disorders, and is well accepted by both patients and providers who have utilized it. In some settings, such as federally qualified health centers, team-based care including TeleMental health has shown better mental health treatment outcomes than care as usual. The origins of telemedicine date back to the 1950s, when Cecil Wittson of the Nebraska Psychiatric Institute began using closed-circuit television technology to provide training to students in the Nebraska State Hospital in Norfolk, and in the 1960s, when patients were being seen miles away from Massachusetts General Hospital at Logan International Airport for direct care without travel times. With further advancement in the technological field, more recently patients are able to be seen in real time both in clinic and from home by a psychiatrist or a therapist via videoconferencing technology, and in some instances can facilitate a visit from their mobile devices. Feasibility studies have indicated that it is effective and possible to conduct TeleMental health visits in just about any circumstance, from consult/liaison visits in the emergency room or the medical floor to psychiatric visits in a primary care setting, to mobile visits

to patients who are home-bound or disabled and unable to make it to clinic. With a multitude of barriers to care for underserved patients, TeleMental health offers access to many people who previously have been unreachable either due to geographic distances, appointment availability and scheduling issues, or due to the level of disorganization of the patient. Recent evidence indicates that 97% of patients with mental health conditions own a smart device, and some studies have even shown increased pa-

provider, and only 12% of patients actually see a psychiatrist, leaving our primary care colleagues to treat the remainder of patients with mental illness in the U.S. In circumstances such as these, collaboration becomes essential, and TeleMental health is one avenue in which this collaboration is possible. Outside of primary care and specialty offices, patients are becoming increasingly able to access mental healthcare in the palm of their hands through video visits with providers as well as through various mental

With a multitude of barriers to care for underserved patients, TeleMental health offers access to many people who previously have been unreachable either due to geographic distances, appointment availability and scheduling issues, or due to the level of disorganization of the patient. tient satisfaction in the younger generations when seeing a provider through TeleMental health, thought to be largely due to comfort with the technology and the convenience of being able to see a provider anywhere. It has also been suggested that patients who live in small rural communities where physicians and patients have a higher likelihood of knowing each other personally may be more likely to accept mental health services from a distant provider, offering more of a sense of anonymity and reducing stigma. As telepsychiatrists, our goal is not only to treat patients with mental illnesses over a distance, but also to provide support and tools to primary care providers and other specialists over those distances. Particularly imperative to address access to care issues in Southern California, TeleMental health can be used as a tool in collaborative care to work with primary care and other specialties in bringing the best psychiatric care to patients regardless of their ability to access a psychiatrist directly. Virtual connections can be made between specialists via shared electronic health records, which can allow e-consult services and better access to specialist support for many primary care providers. Through video communication, a psychiatrist can see patients in a primary care office, inpatient hospital or emergency room setting, providing psychiatric consultative support. This is especially important; as per Wang et. al in 2005, only 22% of patients with mental illness see a behavioral health

health apps and therapy tools. While the evidence is very limited regarding the use of these apps and tools, it is thought that they may be specifically helpful in substance use disorders, and some have used various mobile apps to track daily moods and medication adherence. There is further research being conducted — and definitely needed — regarding the ethical use of mobile apps, especially when data is being recorded and transferred, but with the speed at which technology develops, this is a highly anticipated area of expansion of TeleMental health. Technology in today’s climate grows at a rapid pace, and in a time when our psychiatric resources are so few and not readily growing, it is important to use these technologies to the best of our ability to reach out to patients where they are. I have highlighted just some of the uses that have been more recently studied, and with hope new research in the future can lead to even better and more innovative uses for technologies that have now become daily staples in our lives and those of our patients. I am anxiously waiting for the use of these technologies to become more of a reality in our day-to-day lives, and look forward to contributing to their development moving forward. Dr. Thackaberry is assistant clinical professor of Psychiatry, clinical lead for the TeleMental-Health Program, and psychiatric

attending for the Community Psychiatry Program and the Psychiatric Mental Health Nurse Practice Clinical Training Program at UC San Diego. References 1. Hilty DM. Marks SL. Urness D, et al. Clinical and educational applications of telepsychiatry: A review. Can J Psychiatry. 2004; 49:12–23. 2. Fortney JC. Pyne JM. Mouden SP, et al. Practice-based versus telemedicinebased collaborative care for depression in rural federally qualified health centers: A pragmatic randomized comparative effectiveness trial. Am J Psychiatry. 2013; 170:414–425. 3. Bashshur RL, Shannon GW. History of telemedicine evolution, context, and transformation; Mary Ann Liebert, New Rochelle NY 2009:384-390. 4. Bashshur, RL, PhD, Shannon, GW, PhD, Bashshur, N, MHSA, Yellowlees, PM, MD. (2016). The empirical evidence for telemedicine interventions in mental disorders. Telemedicine and EHealth. 22(2): 87-113 5. Powell, A.C., PhD, Chen, M., PhD, Thammachart, C., MA. (2017). The economic benefits of mobile apps for mental health and telepsychiatry services when used by adolescents. Child Adolesc Psychiatric Clin N Am. 26:125-33. http://dx.doi. org/10.1016/j.chc.2016.07.013. 6. Pew Research internet project. Pew Research Center, 2018. Mobile Technology fact sheet. 7. Wang, P.S., Lane, M., Olfson, M., Pincus, H.A., Wells, K.B., &amp; Kessler, R.C. (2005). Twelve-month use of mental health services in the United States: Results from the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 629–640. 8. Dahne, Jennifer and Lejuez, C.W. (2015). Smartphone and mobile application utilization prior to and following treatment among individuals enrolled in residential substance use treatment. J Subst Abuse Treat. Nov 2015; 58:95-99. doi:10.1016/j. jsat.2015.06.017 9. Harrison, A.M. and Goozee, R. (2014). Psych-related Iphone apps. Journal of Mental Health. 23(1): 48-50. 10. Chan, S., Godwin, H., Gonzalez, A., Yellowlees, P.M., Hilty, D.M. (2017). Review of use and integration of mobile apps into psychiatric treatments. Current Psychiatry Rep. 19: 96 https://doi.org/10.1007/s11920017-0848-9 SAN DIEGO PHYSICIAN.ORG

OPIOID ABUSE

The Safe Homes Coalition Tackles the Supply Side of the Opioid Epidemic By Gregory A. Stein and Scott Silverman

WITH MILLIONS OF scheduled prescriptions filled each year, it is estimated that hundreds of millions of expired, unwanted, and unused pills still sit in medicine cabinets in every community — and that’s a problem. The Safe Homes Coalition, founded in San Diego in 2014, was formed to be a part of the solution. The mission of the Safe Homes Coalition is to reduce the stigma of drug addiction, educate families, and change behaviors around the safe use, storage, and then disposal of prescription medications. With the help of Sherriff Bill Gore, District Attorney Bonnie Dumanis, San Diego County’s Prescription Drug Abuse Task Force, the San Diego Association of Realtors, and numerous corporate partners and individual donors, the Safe Homes Coalition launched its first Keep Kids Safe program. This firstof-its-kind program built on the unique and trusted relationship between real estate professionals and their customers, and the event of their customer’s “Open House” to distribute 10,000 resealable plastic bags advising homeowners to seal up their medications just as they would their jewelry

SEPTEMBER 2018

and passports when potential buyers might enter their home. The broader underlying message? Any time anyone other than the patient to whom those medications are prescribed is in your home, lock them away! When you no longer need those medications, make sure they are disposed of safely. Our community has been touched by the misuse and abuse of prescription medications. While it’s easy to demonize the producer, the prescriber, and even the addict, it’s much harder to generate creative solutions to address the issue. It’s the commitment to education and behavioral change that ignites our passion in the Safe Homes Coalition. The initial San Diego program was very successful in raising awareness, and a year later the Safe Homes Coalition stood with Massachusetts Governor Charlie Baker, the MA Medical Society, the Greater Boston Association of Realtors, the MA Dental Association, the MA High School Athletic Association, BCBS MA, and many others to launch a similar 10,000-bag program for that region. Since that time, the SHC has brought its

message of safe use, storage, and disposal to families across the United States, with formal programs in North San Diego County, Seattle, Tampa, and Cincinnati, and organically sponsored programs in multiple additional locations. Yet the problem continues to grow. In 2015, 56,000 people died of opioid overdose. By 2017, the number had grown to 72,000. Substance abuse and addiction are at the root of many of society’s challenges. It is estimated that 15% of Americans are susceptible to addiction, and that each of those people negatively impact seven others every single day. We can’t stand on the sidelines and keep burying our children. Safe Homes Coalition helps reduce the stigma of addiction through education, which we believe will encourage people who need help to seek help. Just as the challenge continues to grow, the SHC Keep Kids Safe program continues to evolve to ever more effectively meet this challenge. It is for this reason that Sherriff Bill Gore, District Attorney Summer Stephan, Supervisor Kristin Gaspar, U.S. Representative Scott Peters, California As-

semblyman Maienschein, and many others have come together once again in San Diego to launch a new Keep Kids Safe program for 2018/2019. This program breaks new ground by conducting the first ever countywide “precinct” walk to bring education directly to families. An estimated 200 real estate professionals, community leaders, family members affected by overdose and addiction, and other volunteers will commit to knock on 50 doors to collectively and directly touch 10,000 members of our community. Not only will families have access to important safety information, but upon request, they will be provided with a DEA-approved, anonymous, pre-addressed, postage paid envelope

front lines of addressing health and welfare issues. The Safe Homes Coalition was recently endorsed by Supervisor Kristin Gaspar, chair of the Board of Supervisors. “Like so many communities in our region and across the country, North County San Diego has been gravely impacted by the opioid epidemic,” Gaspar says. “There is no singular solution to this problem, but we need to prevent opioid dependency before treatment is necessary. Education and practical, community-based solutions are the most effective way to educate parents and children about the dangers of abusing and improperly disposing powerful opioids.” Supervisor Gaspar continues, “The Safe Homes Coalition (“SHC”) — a San Diego

Any time anyone other than the patient to whom those medications are prescribed is in your home, lock them away! When you no longer need those medications, make sure they are disposed of safely.

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that allows them to conveniently and easily dispose of medications otherwise sitting in their medicine cabinets. These medications will be received by a DEA-approved disposal facility, where they will be weighed and then incinerated — eliminating these medications from the waste stream and providing metrics that allow us to measure the effectiveness of this campaign. Additionally, the SHC will undertake a pre- and post-program survey to understand the community’s baseline understanding of the opioid crisis, and then measure change in knowledge and behavior as a result of the program. “I know that prescription drug abuse contributes to the rise in overdoses, overdose deaths and many crimes occurring in our region,” said Sheriff Bill Gore in his endorsement of the Safe Homes Coalition 2018/2019 Keep Kids Safe program. “By making these drugs less accessible to our youth and those they are not prescribed for, we will help to reduce those issues.” The program is designed to be repeatable in communities throughout the country and serve as a model for individuals who want to help, but don’t otherwise know how to address such a complex and often overwhelming problem. San Diego County government is on the

based 501(c)(3) nonprofit — is at the forefront of offering practical solutions to this difficult problem. Indeed, by providing San Diego residents with anonymous, postage paid envelopes, San Diego homeowners and renters can conveniently and discreetly remove their unused prescription drugs from the home and ensure they are properly disposed of. This first-of-its-kind, no-cost, mail-back program is a proactive way to address the opioid epidemic, and I’m honored to lend my full support to its efforts.” The coalition is proud to have also earned the support of the San Diego County Medical Society and other leading San Diego companies and organizations such as American Medical Response, the San Diego Association of Realtors, Confidential Recovery, and Shadowbox Solutions — and asks you to consider sponsoring and/ or walking a precinct and adding your and your practice’s name to the Coalition roster. Mr. Stein serves as CEO of Shadowbox, a healthcare software compliance and automation startup. Mr. Silverman is CEO of Confidential Recovery, an outpatient treatment program supporting professionals overcoming addiction.

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INFECTIOUS DISEASES

TREATING AND COMBATING THE INCREASE OF SYPHILIS IN SAN DIEGO BY WINSTON TILGHMAN, MD

SEPTEMBER 2018

Syphilis, a bacterial infection caused by the spirochete Treponema pallidum, is a systemic disease that can cause significant morbidity both during early and late stages of infection. Over the last two decades, there has been a resurgence of syphilis at the local, state, and national levels. Given the variety of possible manifestations of syphilis, patients can present in a number of different healthcare settings. Therefore, healthcare providers need to be aware of how to appropriately screen for, diagnose, and manage syphilis. This article will review the clinical manifestations, diagnosis, staging, epidemiology, and treatment of syphilis, and provide recommendations to providers to address increasing local rates of infection.

Clinical Manifestations and Staging

Syphilis is a protean infection that, without treatment, progresses through stages of infection that have been designated based on typical clinical manifestations. Primary syphilis, which occurs within 10 to 90 days after infection, is characterized by one or more painless ulcerative lesions (“chancres”) at the site of inoculation, with or without regional lymphadenopathy. Secondary syphilis, which occurs several weeks after resolution of primary syphilis, is the most systemic stage of syphilis due to hematogenous dissemination of T. pallidum. Diffuse maculopapular rash, often with palmar and plantar involvement, is the classic presentation. Other possible manifestations include wart-like lesions called condylomata lata, mucous patches, patchy alopecia, fevers, chills, lymphadenopathy, and headache. Less frequently, hepatitis and nephritis may occur. Tertiary syphilis, the result of years to decades of untreated infection, is rare and includes destructive granulomatous lesions of the bone and skin (i.e., “gummas”), long-term neurological complications such as general paresis and tabes dorsalis, and aortitis. Latent syphilis refers to stages of syphilis during which no signs or symptoms of disease are present, and is characterized based on estimated duration of infection. Early latent syphilis refers to infections that occurred within the last year, and late latent syphilis refers to infections that occurred at least one year ago. Latent infections of unknown duration are managed as late latent syphilis cases. These distinctions have implications for both treatment and risk

of onward transmission. Sexual transmission of syphilis only occurs when lesions are present and is only possible during the first year after infection. Approximately 25% of people with early latent syphilis will relapse to secondary syphilis. People with late latent syphilis are at risk for tertiary syphilis but cannot transmit T. pallidum to sexual partners. Late latent syphilis requires longer duration of treatment than does early latent syphilis as well. Therefore, for the purposes of treatment and prevention of onward transmission, early syphilis includes primary, secondary, and early latent syphilis. Syphilis is associated with multiple complications. Invasion of the central nervous system by T. pallidum (i.e., neurosyphilis) is possible during any stage of infection and can cause acute meningitis, cranial nerve abnormalities, and vasculitis (i.e., “stuttering stroke”). Syphilis also can affect any of the ocular structures, and ocular syphilis can result in visual loss that is sometimes permanent. Congenital syphilis, or transmission of T. pallidum from mother to child in utero or during delivery, can be a catastrophic condition and result in multiple complications during pregnancy and delivery, including stillbirth. After delivery, birth defects, hematologic abnormalities, neurosyphilis, interstitial keratitis, and hearing loss can occur, and, without treatment, risk of complications can extend through puberty. Unlike sexual transmission of syphilis, transmission from mother to fetus can occur during any stage of infection.

Diagnosis and Treatment

Most syphilis cases are diagnosed by serologic testing. T. pallidum can be directly visualized by viewing smears of exudate from chancres or moist mucosal secondary syphilitic lesions under darkfield microscopy. However, this form of testing is not available in most facilities. Syphilis diagnosis in someone without previous history of infection requires both treponemal and non-treponemal testing. Treponemal tests (e.g., TPPA, MHA-TP, FTA-ABS, EIAs, CLIAs) detect antibodies that are specific to surface proteins on T. pallidum. They are frequently positive for life after the first episode of syphilis; therefore, they are not useful once someone has had a documented

episode of syphilis. Non-treponemal tests (e.g., RPR, VDRL, TRUST) detect antibodies that are not specific to T. pallidum and can be falsely positive in a number of conditions (e.g., autoimmune disease, recent vaccination, intravenous drug use). However, non-treponemal antibody titers correlate with disease activity (i.e., they are elevated during active infection, decline following appropriate treatment, and rise again with reinfection).1 Treatment of syphilis is based on stage of infection and presence or absence of neurosyphilis (including ocular syphilis). For early syphilis, including primary, secondary, and early latent syphilis, a single intramuscular dose of long-acting benzathine penicillin G (Bicillin® L-A) 2.4 million units is recommended. For late latent syphilis and latent syphilis of unknown duration, a total of three intramuscular doses of Bicillin® L-A 2.4 million units given at weekly intervals for a total dose of 7.2 million units is recommended. For neurosyphilis, including ocular syphilis, aqueous crystalline penicillin G is recommended at a dose of 18 to 24 million units intravenously per day for 10 to 14 days.1

Epidemiology and Public Health Issues

Reported cases and rates of syphilis reached record lows in the 1990s but have progressively increased since the turn of the millennium. In 2017, a total of 1,130 early syphilis cases were reported in San Diego County, with an overall rate of 34.1 cases per 100,000 persons. This represents a 3,310% rate increase compared to one case per 100,000 in 2000 and a 14.4% increase compared to 29.8 cases per 100,000 persons in 2016 (Figure 1). The early syphilis rate among men in San Diego County was more than 20 times that observed among women (65.0 versus 2.9 cases per 100,000 persons) in 2017. Syphilis is associated with significant health disparities, with gay, bisexual, and other men who have sex with men (MSM) accounting for 85.5% of reported cases in 2017. Among primary and secondary syphilis cases who were MSM, 44% also had HIV infection, which is decreased from around 60% with HIV co-infection in 2012.2 Although reported cases among women were relatively low, with 45 female early syphilis cases reported in 2017, there are

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INFECTIOUS DISEASES trends toward increasing cases and rates among women of childbearing potential (i.e., women aged 15 to 49 years) and pregnant women over the last five years. In 2017, there were 146 and 43 cases of any stage of syphilis among women of childbearing potential and pregnant women respectively in 2017, with rates of 18.3 and 5.4 cases per 100,000 persons respectively. These represent 31.7% and 86.2% rate increases compared to 2016 that were statistically significant. In 2017, there were 11 reported cases of congenital syphilis (i.e., infants whose mothers had untreated or inadequately treated syphilis at the time of delivery) in 2017. The rate of congenital syphilis was 25.2 cases per 100,000 births in 2017 and progressively increased from 2013 to 2017, although these increases were not statistically significant. One stillbirth that was likely due to syphilis was also reported in 2017.2 Reported cases of congenital syphilis in California have increased by more than 700% since 2013, with the Central Valley and Los Angeles regions accounting for the majority of increases. In 2017, a total of 278 congenital syphilis cases were reported statewide, including 30 stillbirths (fetal deaths).3 Many cases were associated with late or no prenatal care and substance use. Although increases of this magnitude have not been observed in San Diego County, there is a trend toward increased syphilis cases among women of childbearing potential and pregnant women, and congenital syphilis and stillbirths do occur. Between 2013 and 2017, a total of five stillbirths were reported in San Diego County. As infection rates among MSM continue to rise, so does the risk of involvement of other segments of the population. This risk, in the setting of a surge in female and congenital syphilis elsewhere in California, highlights the need for a proactive approach to congenital syphilis prevention and the importance of timely diagnosis and treatment of syphilis in pregnant women. Congenital syphilis is completely preventable through timely maternal diagnosis and treatment. In order to prevent congenital syphilis, pregnant women who are diagnosed with syphilis must receive stagespecific treatment recommended by the

SEPTEMBER 2018

Figure 1: Early Syphilis Cases and Rates by Year, San Diego County, 1998â&#x20AC;&#x201C;2017

Centers for Disease Control and Prevention, and must initiate treatment at least 30 days prior to delivery. Treatment recommendations for pregnant women are more stringent than those for non-pregnant adults with syphilis. Benzathine penicillin G is the only antimicrobial agent that has been demonstrated to prevent congenital syphilis, and is the only antibiotic recommended for treatment of pregnant women with syphilis. Penicillin-allergic pregnant women must be desensitized, as there are no alternatives. Also, pregnant women with syphilis who require the three-dose regimen of BicillinÂŽ L-A must adhere to the seven-day interval between doses. If more than seven days elapse between doses, the series must be restarted.1

Recommendations for Providers

Providers can prevent congenital syphilis by screening all pregnant women for syphilis. California state law mandates syphilis screening during the first prenatal visit. However, many women either do not access prenatal care or access it late during pregnancy, which may prevent timely diagnosis and treatment. Pregnant women who have not accessed routine prenatal care should be tested wherever they present for services (e.g., emergency rooms, urgent care centers). Also, additional screening during the third trimester at around 28 weeks of gestation and at delivery should be considered for high-risk women (e.g., women with multiple partners or partner(s) with concurrent partner(s), women who engage in transactional sex, and women from high-

prevalence areas). No infant should be discharged from the hospital after delivery without the syphilis status of the mother having been documented. Providers can help to address rising rates of infectious syphilis and prevent complications by having a high index of suspicion for syphilis in patients who present with clinical manifestations suggestive of the infection who are at risk for sexually transmitted infections (STIs). Atypical presentations are common, so absence of the classic findings outlined above does not exclude syphilis. Also, it should be noted that about 25% and 10% of patients with early primary syphilis will have negative non-treponemal and treponemal tests respectively, so empiric treatment and repeat testing in 1â&#x20AC;&#x201C;2 weeks should be considered in cases of typical signs and symptoms of primary syphilis and negative initial testing. Also, screening according to national guidelines is critical to decrease time between infection and treatment, and to decrease the risk of onward transmission. Annual screening for syphilis is recommended for sexually active MSM, and more frequent screening (i.e., every three to six months) is recommended for those at higher risk of infection. Screening also is recommended for women and men with only female sexual partners who have risk factors.1 Routine sexual history-taking is necessary for providers to accurately assess risk and screen appropriately for syphilis and other STIs. All patients with syphilis who have neurological (including ocular) symptoms

and/or abnormal neurological examination should be evaluated for neurosyphilis with a cerebrospinal fluid (CSF) examination (for total protein, glucose, cell count, and VDRL), and patients with ocular symptoms should receive urgent ophthalmologic evaluation. Patients with confirmed ocular syphilis on ophthalmologic examination should receive treatment for neurosyphilis, regardless of CSF examination results.1 Providers also should report cases of syphilis to the local health department within 24 hours of diagnosis and notify women of childbearing age with any stage of syphilis and men with primary and secondary syphilis that they will be contacted by the local health department to protect them and their partners from future infections and complications. This can help to facilitate the work of public health employees to limit onward transmission in the community. There also are a number of resources available through the public health department. Syphilis histories, including prior positive tests and treatment information, can be obtained for continuity of care by calling (619) 692-8501. Expert clinical consultation also is available by paging (877) 217-1816. More resources for providers, as well as data reports, are available at http://www. stdsandiego.org. Dr. Tilghman is a senior physician/STD controller for the County of San Diego Health and Human Services Agency, Division of Public Health Services, HIV, STD, and Hepatitis Branch. References: 1 . Department of Health and Human Services Centers for Disease Control and Prevention. “Sexually transmitted diseases treatment guidelines, 2015.” MMWR 2015;64(3). 2. County of San Diego Health and Human Services Agency, Division of Public Health Services, HIV, STD, and Hepatitis Branch. September 2018. Sexually Transmitted Diseases in San Diego County, 2017 Data Slides. Accessed 08/29/2018 from www. STDSanDiego.org. 3. California Department of Public Health, Sexually Transmitted Diseases Control Branch. Sexually Transmitted Diseases Data. Accessed 08/29/2018 from https:// www.cdph.ca.gov/Programs/CID/DCDC/ Pages/STD-Data.aspx.

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INFECTIOUS DISEASES

Antibiotic Selection

SURGICAL ANTIBIOTIC PROPHYLAXIS BY STEPHEN WEI, PHARM.D.

n 2010, an estimated 16 million operative procedures were performed in acute care hospitals in the U.S.A.2 Figures compiled by the Centers for Disease Control (CDC) show an overall surgical site infection (SSI) rate of 1.9% between 2006 and 2008. However, a recent CDC healthcare-associated infection prevalence survey found that there were an estimated 157,500 surgical site infections associated with inpatient surgeries in 2011.2 Though rates are low, SSIs negatively impact patient outcomes by increasing the risk for prolonged hospital stay, morbidity, and readmissions for hospitalassociated infections.1 Hospitals incur non-reimbursed financial expenditures for SSIs, and SSI rates are publicly reportable. Consequently, it is imperative to follow

SEPTEMBER 2018

standard infection prevention practices, which includes the proper use of prophylactic antibiotics. Generally, the use of prophylactic antibiotics is dependent upon the likelihood of an infection without antibiotics in respect to the level of microbial contamination associated with the procedure. At minimum, prophylactic intravenous antibiotics should be administered in all procedures that are classified as “cleancontaminated” or require the elective opening of internal tracts.3,4 While “clean” procedures have the lowest rate of infection even without the use of antibiotics, patient-specific SSI risk factors may warrant the use of antimicrobial prophylaxis because of their likelihood of developing a postsurgical infection.

When selecting an appropriate antimicrobial agent and dose, the antibiotic should cover the anticipated organisms near the surgical site associated with causing postoperative infections, achieve adequate tissue concentrations at the surgical site, and cause minimal side effects5. SSIs most commonly include skin wound infections; therefore, the most common bacteria that need to be covered are Staphylococcus and Streptococcus species. A first-generation cephalosporin, such as cefazolin, will provide reliable coverage for these organisms. Though cefazolin will cover most procedures, coverage of methicillin-resistant staphylococcus aureus (MRSA) should be considered for patients with known MRSA colonization or in patients with risk factors for MRSA colonization (recent/ prolonged hospitalization, nurse home residents, prior MRSA infections, etc.).5,12 Additional coverage for Gram-negative and anaerobic bacteria is warranted in surgeries that involve the gastrointestinal, genitourinary or hepatobiliary tracts. Some prophylaxis agents that cover Gram negative and anaerobic organisms include but are not limited to cefotetan/cefoxitin, ceftriaxone + metronidazole, or piperacillin-tazobactam.

Antibiotic Selection in Setting of Penicillin Allergy

For patients with a reported penicillin, it is imperative to make a distinction if it is a true anaphylactic (Type I) reaction or intolerance to the medication. Even if there is a true penicillin allergy, a common misconception perpetuated by older studies is certain antibiotic classes (e.g. cephalosporins, carbapnems) are contraindicated. More recent literature shows true cross-reactivity is less than 1% and highly dependent upon the similarity in side chains of the drugs’ chemical structures. Recent studies concluded second- to fifth-generation cephalosporins (e.g. cefotetan, ceftriaxone, cefepime, and ceftaroline, with the exception of cefoxitin) can be safely administered in penicillin allergic patients, including those with anaphylactic reactions.7 Cefazolin is generally not advised in Type 1 penicillin allergic patients, but can safely be administered in non-anaphylactic reactions.6 If a

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Generally, the use of prophylactic antibiotics is dependent upon the likelihood of an infection without antibiotics in respect to the level of microbial contamination associated with the procedure.

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Timing of Pre-Operative Antibiotics

When indicated, antibiotic doses should be administered within 60 minutes before surgical incision, though some agents (e.g. vancomycin, fluoroquinolones) require longer infusions (one to two hours), which require administration within 120 minutes before incision. Studies have shown optimal administration of pre-operative prophylactic antibiotics (at least within two hours of surgical incision) was associated with the lowest rate of surgical wound infection.8,9 Earlier (greater than two hours) or delayed (three hours after incision and beyond) antibiotic administration was associated with higher rates of SSIs, with the rate of wound infection increasing each hour that passed after surgical incision.8 Thus, timing of administration of pre-operative antibiotics is critical to ensure adequate serum and tissue concentration are achieved prior to skin incision for proper prophylaxis.

Prophylactic Antibiotic Dosing

If dosed and timed correctly, a single dose of pre-operative antibiotics will cover the duration of most surgeries. However, redosing may be necessary for optimal effect depending on the length of the procedure and volume of intraoperative blood loss. For longer procedures, re-dosing is indicated when the length of surgery exceeds two half-lives of the antimicrobial agent or sooner if the patient has altered pharmacokinetics, which may increase clearance of the antibiotic (e.g. extensive burns, trauma, etc.).5 For example, in patients

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INFECTIOUS DISEASES Recommended Doses/Re-dosing Intervals for Commonly Used Antibiotics for Surgical Prophylaxis5 Antibiotic

Recommended Dose

Half-Life (Normal Renal Function) (hr)

Recommended Re-Dosing Interval (From Time of Pre-Op Dose) (hr)

Cefazolin

2g (3g for patients >120kg)

1.2–2.2

Cefoxitin

0.7–1.1

Cefotetan

2.8–4.6

Ceftriaxone

5.4–10.9

N/A*

Clindamycin

900mg

2–4

Ciprofloxacin

400mg

3–7

N/A*

Levofloxacin

500mg

6–8

N/A*

Metronidazole

500mg

6–8

N/A*

Piperacillin/Tazobactam

3.375g

0.7–1.2

Vancomycin

15mg/kg (not to exceed 2g)

4–8

N/A*

*Recommended re-dosing intervals are marked as N/A (not applicable) based upon typical case length. These agents have a longer half-life in comparison to other agents, and re-dosing is only needed in unusually long procedures.

with normal pharmacokinetics, another dose of cefazolin should be administered prior to the fourth hour if the procedure extends beyond four hours. Intraoperative blood loss exceeding 1500ml also necessitates re-dosing for particular antibiotics such as beta-lactams and clindamycin.5,12 Other patient-specific factors requiring alternative dosing of pre-operative antibiotics include: obesity (higher doses may be warranted to ensure adequate serum and tissue concentrations, e.g. cefazolin 3g for patients >120kg) and renal impairment (re-dosing intervals may be prolonged or unnecessary/unsafe for potentially nephrotoxic antibiotics like vancomycin).5 Consult a pharmacist for questions related to perioperative dosing adjustments.

Post-Operative Prophylactic Antibiotics

While properly dosed and timed pre-operative doses have been shown to decrease the rate of surgical site infections, continuation of antibiotic prophylaxis post-operatively and its recommended duration remains a debatable issue. Newer updates in guidelines published by the World Health Organization (WHO) and

SEPTEMBER 2018

CDC do not recommend postoperative antibiotics in most surgeries in patients without an active infection. These recommendations are supported by evidence complied from large meta-analyses that do not show benefits from prolonging antibiotic prophylaxis.11 Guidelines by the American Society of Health-System Pharmacists (ASHP), Infectious Disease Society of America (IDSA), and Society for Healthcare Epidemiology of America (SHEA) recommend that any postoperative antibiotic prophylaxis be stopped within 24 hours after the end of procedure.5 While there is some lower quality evidence showing post-operative antibiotics may be beneficial in cardiac, vascular, and orthognathic surgery, the possible harm (e.g. increased risk for drug toxicity, resistance, and C. difficile) and costs associated may outweigh the benefits.11 Certain meta-analyses investigating cardiac surgery patients (primarily coronary bypass and valve replacement surgeries) showed a shorter duration of prophylaxis (<24 hours postoperatively) was associated with higher rates of sternal wound infection compared with longer durations, but no advantages were observed in regimens

lasting >48 hours post operation.10 Despite these findings, there is inconclusive evidence supporting the use of a prolonged postoperative prophylaxis for cardiac procedures in other meta-analyses.5,12 In addition, the American Heart Association (AHA) does not recommend the use of postoperative antibiotics for cardiovascular implantable electronic devices based upon limited data.13 SSIs continue to be a common nosocomial infection resulting in patient harm and increased hospital costs, yet may have degrees of preventability. Although antibiotic prophylaxis remains a key tool in preventing these infections, proper use of these agents (appropriate selection, timing, dosing, and re-dosing) is necessary for optimal prophylaxis and to prevent antibiotic misuse. Hospitalspecific standard/procedures should be developed to address these factors. Perioperative antimicrobial prophylaxis is only one component of the necessary steps in preventing SSIs; proper surgical technique and preoperative antisepsis must be accomplished as part of a bundled SSI risk reduction strategy12. Finally, though evidence is available to support limiting

the use of antimicrobial agents postoperatively, further studies are warranted to determine if any procedures may benefit from an extended duration of antibiotics, especially in areas where research is limited (e.g. emergent surgeries, compromised preoperative antisepsis, and surgical oncology). Dr. Wei received his doctorate from the University of Southern California and is currently a PGY1 pharmacist resident for Sharp Healthcare. References: 1. O’hara LM, Thom KA, Preas MA. Update to the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Guideline for the Prevention of Surgical Site Infection (2017): A summary, review, and strategies for implementation. Am J Infect Control. 2018;46(6):602-609. 2. CDC. Surgical Site Infection (SSI) Event. Centers for Disease Control. https://www.cdc.gov/nhsn/pdfs/

pscmanual/9pscssicurrent.pdf 3. Woods RK, Dellinger EP. Current guidelines for antibiotic prophylaxis of surgical wounds. Am Fam Physician. 1998;57(11):2731-40. 4. Salkind AR, Rao KC. Antibiotic prophylaxis to prevent surgical site infections. Am Fam Physician. 2011;83(5):585-90. 5. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. 6. Park MA, Koch CA, Klemawesch P, Joshi A, Li JT. Increased adverse drug reactions to cephalosporins in penicillin allergy patients with positive penicillin skin test. Int Arch Allergy Immunol. 2010;153(3):268-73. 7. Campagna JD, Bond MC, Schabelman E, Hayes BD. The use of cephalosporins in penicillin-allergic patients: a literature review. J Emerg Med. 2012;42(5):612-20. 8. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med. 1992;326(5):281-6.

9. Steinberg JP, Braun BI, Hellinger WC, et al. Timing of antimicrobial prophylaxis and the risk of surgical site infections: results from the Trial to Reduce Antimicrobial Prophylaxis Errors. Ann Surg. 2009;250(1):10-6. 10. Lador A, Nasir H, Mansur N, et al. Antibiotic prophylaxis in cardiac surgery: systematic review and meta-analysis. J Antimicrob Chemother. 2012;67(3):541-50. 11. World Health Organization. Global guidelines on the prevention of surgical site infection, 2016, Available from: http://www.who.int/gpsc/ssi-prevention-guidelines/en/. 12. Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Am Coll Surg. 2017;224(1):59-74. 13. Baddour LM, Epstein AE, Erickson CC, et al. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation. 2010;121(3):458-77.

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INFECTIOUS DISEASES

CLOSTRIDIUM DIFFICILE INFECTION Tackling the Growing Threat BY MICHAEL BUTERA, MD

SEPTEMBER 2018

Overview /Epidemiology

Clostridium difficile infections (CDI), can cause life-threatening diarrhea and is listed as an urgent threat in the CDCs 2013 “Antibiotic Resistant Threats “document. More recent data suggest that this organism is present in 3–14% of admitted hospital patients, with an estimated 500,000 cases, 29,000 deaths, and $4.8 billion in excess hospital cost per year. (2, 3) Inflammation of the colon occurs when Clostridium difficile bacilli are present as colonizing flora, and can overgrow and produce cytotoxic exotoxins that affect intestinal epithelial cell integrity and function. Factors that affect the competing normal bacterial flora and bile acid balance within the colon predispose to the development of symptomatic disease in colonized patients. Clostridium difficile has the ability to form spores that are

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INFECTIOUS DISEASES impervious to antimicrobial treatment and most disinfectants. The persistent colonization of the spore form allows this organism to spread efficiently and rapidly in the hospital environment, and to cause a relapsing illness. These infections occur mostly in both recent medical care and antibiotics; with 65% of the cases being nosocomial. More than 90% of the deaths occur in people greater than 65 years of age, with mortality rates 14% in this age group.(8) The NAP 1/027 strain, among others, has been identified since 2000, and is a “hyper virulent” strain associated with higher levels of toxin formation, higher morbidity, mortality, and relapse rates, and is less responsive to traditional therapy. Death rates due to Clostridium difficile disease increased 400% between 2000 and 2007, and the frequency of multiple relapsing disease is increasing, in part related to the emergence of these strains. (4, 5). The likelihood of severe disease depends on the virulence of the organism, but also on host risk factors, including concomitant or subsequent antibiotic exposure, age over 65, low serum albumin, underlying medical conditions, G.I. surgery, immune compromised, prolonged hospitalization or long-term care, healthcareacquired CDI, prior episodes of CDI, and renal impairment. Relapse rates after the first episode of CDI range from 25-41%, with decreased cure rates and higher risk of subsequent relapsing symptomatic disease in patients who have had a relapse and other risk factors for multiple relapsing CDI, which include most of the conditions listed above.(5,6,7) Antibiotic exposure is the primary risk factor, and studies indicate that risk increases with duration, total cumulative dose, and number of antibiotics agents exposed to.(9). Fluoroquinolones have been found to be one of the primary predisposing antimicrobials in recent studies. The NAP1 strains are usually resistant to fluoroquinolones and are multidrug resistant; this may be a factor in the emergence of this pathogen. Classes of antibiotics considered high-risk include Aminopenicillins, clindamycin, and second- and third-gen-

SEPTEMBER 2018

eration cephalosporins, with carbapenams and beta-lactam/beta lactamase inhibitors in the medium risk, and macrolides tetracyclines and trimethoprim sulfa in a lower-risk group.(10). Gastric acid suppression with PPIs may be a risk factor for initial and relapsing CDI. Prudent use of antimicrobial agents in healthcare settings, fostered by a robust antibiotic stewardship program, and in combination with appropriate algorithms and protocols for diagnosis, enhanced infection control measures, contact precaution, environmental cleaning, and handwashing measures are imperative to prevent and control healthcareassociated disease and outbreaks due to this organism. In California, reporting of healthcareassociated CDI has been required by state law since 2011 with the passage of Nile’s Law (1288.55) which requires each healthcare facility, each quarter, to report all cases of healthcare-associated Clostridium difficile infection which are publically reported by hospital and accessible on the HAIP website. Furthermore, as of January 2013, hospitals participating in the Centers for Medicare and Medicaid Services’ Inpatient Prospective Payment System Quality Reporting Program are required to report facility-wide CDI events via the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN). Rates of C. difficile infection also factor into hospital reimbursement through the value-based payment program, and thus a favorable impact of mandatory reporting in value-based payment is that our healthcare facility administrators have strong incentive to support robust measures for prevention identification treatment and control of CDI. From the Infection Control perspective, one would want to properly identify active cases for the purposes of appropriate isolation, treatment and prevention spread within the institution. Alternatively, from the administration perspective, one would want to minimize any false positive test, which would result in higher reportable rates of CDI and adverse impacts both on finances and perception of quality/reputation.

Diagnosis and Testing

Case definition of CDI case: “A positive laboratory test result for C. difficile toxin A and/or B (e.g. molecular assays and/ or toxin assays), or a toxin-producing C.difficile organism detected by culture or other laboratory tests performed on an unformed stool specimen.” The positive and negative predictive value of testing for CDI depends on the incidence of actual disease in the population tested. Institutions should develop testing protocols to minimize the risk of false positive and false negative tests and to maximize the likelihood of true positive and true negative results. Culture for toxigenic C diff bacteria in the stool and cytotoxin assays for detection of toxin in the stool are the most sensitive and specific but these are expensive, and labor- and time-consuming. Older EIA assays for toxin lack sufficient sensitivity and negative predictive value to be relied upon. Newer Molecular methods for the detection of the toxin B gene in stool are very sensitive but less specific for true active CDI. Multiple studies demonstrate increased CDI rates reported from institutions using only toxin B gene molecular methods. (11–18). An analysis of population-based surveillance data from catchment areas in three states demonstrated that switching from toxin EIA to NAAT for C. difficile diagnosis increased CDI incidence rates by 43–67%.(11) Longton et al concluded: Performing PCR instead of EIA/CCA is associated with a >50% increase in the CDI incidence rate.(12) Complication rates were higher in the group that was positive for antigen and toxin by EIA and PCR compared to PCR alone, suggesting false positives or asymptomatic colonization among a proportion of the PCR-only positive group. CDI testing by molecular methods alone are discouraged unless the institution has strict guidelines and algorithms for specimen collection and processing. EIA uses monoclonal or polyclonal antibodies to detect C. difficile toxins, and there are numerous commercial assays available of varying sensitivities and performance. C diff. antigen detection using the glutamate dehydrogenase im-

munoassays detects the highly conserved metabolic enzyme (common antigen) present in high levels in all isolates of C. difficile. Since this antigen is present in both toxigenic and nontoxigenic strains, GDH immunoassays lack specificity. There is a high positive predictive value for an EIA test that is toxin and antigen positive, and a high negative predictive value (97%) if there is a negative toxin and negative antigen by EIA. Discordant results with a positive antigen but negative toxin remain an area of debate. Testing for toxin B by molecular methods is generally performed on these discordant specimens and a negative toxin by molecular methods generally means CDI is not present and isolation and treatment not necessary. For EIA AG+/toxin-/PCR +isolates: Controversy still exists with regard to the management of these patients.(7, 16–18) The literature suggests that these patients may be much less likely to spread their organisms in a healthcare setting, but isolation precautions are still appropriate.

Some would also argue that these patients are only colonized and may not require treatment, and that patients with EIA toxin negative but PCR toxin gene positive tests are less likely to have severe disease and complications. In a study by Polage et al, the authors conclude that toxin EIA positivity was a better predictor of CDI-related complications and deaths, and outcomes in patients who were PCR positive alone were comparable with those in patients who were negative by both tests. The use of molecular tests alone is likely to lead to over diagnosis and overtreatment. K Roe and colleagues studied the relationship between symptomatic Clostridium difficile infection and Ribotype 27, age, detectability of toxin A or B with rapid testing, severe infection, and mortality. Among 1,144 cases in which CDI was diagnosed, 426 were EIA toxin+/AG+, but 718 were discordant but had a positive molecular test for toxin B gene and therefore considered a CDI case. Severe CDI occurred in 7.9% of patients, and death occurred

within 30 days and 7.8% of patients. The presence or absence of toxin detection by rapid methods did not correlate with the likelihood of severe CDI or mortality. Severe cases occurred in both groups, and those factors associated with an adverse outcome or death included infection with ribotype 27, and prior episodes of CDI, concurrent antibiotic use, PPI use, and age in the presence of underlying malignancy were all important predictors of likelihood for mortality and severe disease in multivariant predictive models. Therefore, the diagnosis of C. difficile associated infection and decisions regarding need for treatment is a clinical decision which must be based not only on the results of laboratory testing but on an understanding of patients’ underlying risk factors and clinical presentation by a knowledgeable physician. Some common-sense best practices • Ensure only patients with clinically significant diarrhea are tested for CDI. (Three liquid stools in a 24-hour

SAN DIEGO PHYSICIAN.ORG

INFECTIOUS DISEASES

systemic antimicrobial treatment and avoid other antibiotic exposure — do not treat asymptomatic colonization. • Non-liquid stool submitted for testing will be rejected; higher false positive rate. • Maintain contact precautions in patients with discordant results.

• •

•

• • •

period without another definable cause, and after discontinuing stool softeners and laxatives.) Ensure specimens are collected and transported promptly to the laboratory. Repeat testing (i.e. as a test of cure) is not recommended. Routine screening of asymptomatic carriers is not recommended. Treatment of colonization is not indicated per guidelines. The results of this test must be interpreted within the context of clinical findings. Investigate for alternative etiologies for diarrhea. Do not resubmit samples within seven days of a negative result. If feasible, discontinue concomitant

SEPTEMBER 2018

New Treatment Guidelines (19, 20 )

Newly published IDSA guidelines include several significant changes compared to 2010. Chief among them is that oral metronidazole is no longer considered firstline therapy for mild to moderate firsttime disease, nor for relapsing disease. Treatment recommendations for an initial episode of CDI with mild to moderate disease (white counts less than 15,000 and serum creatinine less than 1.5) include vancomycin 125 mg four times daily for 10 days, or Fidaxomicin 200 mg twice daily for 10 days. The same regimen is recommended for initial episodes of severe disease. (WBC>15K/creat>1.5.): In the setting of

fulminant disease with hypotension or shock, ileus or megacolon-Vancomycin 500 mg four times daily by mouth NG tube or rectal installation combined with metronidazole 500 mg Q8 hours remains the treatment of choice. For first relapse in which metronidazole was used as initial treatment, vancomycin 125 mg four times a day for 10 days with a prolonged taper or fidaxomicin can be used. Fidaxomicin 200 mg for 10 days is recommended if vancomycin was used for the initial episode. For second and subsequent recurrences recommended options include a prolonged taper of vancomycin/ pulse regimen versus 10 days of vancomycin followed by rifaximin 400 mg TID for 20 days, or fidaxomicin 200 mg for 10 days with strong recommendations for consideration of fecal transfer for a second or subsequent recurrences rather than waiting from multiply relapsing disease. With any treatment modality, avoiding subsequent antimicrobial therapy or other disturbances of the normal bowel fecal flora remains of utmost importance in preventing relapsing disease. Among patients with relapsing infection, many will actually have strains that are different from the initial causative strain, suggesting that these organisms are ubiquitous in the mainstay of prevention — maintaining the integrity of the host, and bolstering nutrition, immune competence, mucosal immunity, and maintaining a robust competing normal fecal flora. IDSA guidelines found insufficient data to make any confident recommendations regarding PPIs and probiotics, but discontinuing PPIs and zinc supplements, and continuing probiotics, may be helpful adjunctive treatments for management of CDI and prevention of relapses. Bezlotoxumab has been FDA approved for use in initial episodes of CDI and associated with a decrease in relapse rates in selected populations. (20) Dr. Butera is an infectious disease specialist in San Diego with more than 35 years of diverse medical experience, particularly in internal medicine and infectious disease. References: 1. https://www.cdc.gov/drugresistance/ threat-report-2013 2. Lessa et al NEJM.372(9)825.”Burden of Infection in the United States”. 3. Alasmira,F et al Clinical infectious

Diseases 2014; 59 (2): 2 16–22,” Prevalence and risk factors for asymptomatic Clostridium difficile carriage” 4. See,et al. Cid2014;58(10):13941400,”NAP1 strain type predicts outcome from Clostridium difficile infection.” 5. Ma GK et al. Ann Intern Med. 2017;167(3):152-158. 6. McFarland LV et al. Renewed interest in a difficult disease: Clostridium difficile infections—epidemiology and current treatment strategies. Curr Opin Gastroenterol. 2008;25:24–35. 7. Rao K et al. Clinical Infectious Diseases® 2015;61(2):233–41 “Clostridium difficile Ribotype 027: Relationship to Age, Detectability of Toxins A or B in Stool With Rapid Testing, Severe Infection, and Mortality 8. Miller M. CID2010;50(2):194-201 9. CID2008;46Suppl1:S25.”Antimicrobial use and C.diff infection”. 10. Stevens V, et al CID2011;53(1):43-48 “Cumulative antibiotic exposure over time and the risk of Clostridium difficile infection.” 11. Carolyn V. Gould,et al Clinical Infectious Diseases 2013;57(9):1304–7 Effect

of Nucleic Acid Amplification Testing on Population-Based Incidence Rates of Clostridium difficile Infection 12. Longtin Y, Trottier S, Brochu G, et al. Impact of the type of diagnostic assay on Clostridium difficile infection and complication rates in a mandatory reporting program. Clin Infect Dis 2013; 56:67–73. 13. Goldenberg, SD. Public reporting of Clostridium difficile and improvements in diagnostic tests. Infect Control Hosp Epidemiol 2011; 32:1231–2. 14. Fong KS, Fatica C, Hall G, et al. Impact of PCR testing for Clostridium difficile on incident rates and potential on public reporting: is the playing field level? Infect Control Hosp Epidemiol 2011; 32:932. 15. Williamson DA, Basu I, Freeman J, Swager T, Roberts SA. Improved detection of toxigenic Clostridium difficile using the Cepheid Xpert C. difficile assay and impact on C. difficile infection rates in atertiary hospital: a double-edged sword. Am J Infect Control 2013; 41:270–2. 16. 185. Planche TD, Davies KA, Coen PG, et al. Differences in outcome according to Clostridium difficile testing method: a

prospective multicentre diagnostic validation study of C difficile infection. Lancet Infect Dis 2013; 13:936–45. 17. Polage CR, Gyorke CE, Kennedy MA, et al. Overdiagnosis of Clostridium difficile infection in the molecular test era. JAMA Intern Med 2015; 175:1792–801. 18. Humphries RM, Uslan DZ, Rubin Z. Performance of Clostridium difficile toxin enzyme immunoassay and nucleic acid amplification tests stratified by patient disease severity. J Clin Microbiol 2013; 51:869– 73. 19. L. Clifford McDonald,et al, Clinical Infectious Diseases® 2018;66(7):e1–e48 Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) 20. Thomas J. Louie, et al. N Engl J Med 2011;364:422-31. Fidaxomicin versus Vancomycin for Clostridium difficile Infection 21. M.H. Wilcox,et al.N Engl J Med 2017;376:305-17.Bezlotoxumab for Prevention of Recurrent Clostridium difficile Infection

WANT TO REACH PHYSICIANS

IN SAN DIEGO COUNTY?

Seeking FM/DO/IM Physicians in San Diego and Orange Counties

Abracadabra….

WE CAN MAKE IT EASIER THAN PULLING A RABBIT FROM A HAT. CONTACT DARI PEBDANI TO LEARN MORE. 858.231.1231 DPebdani@SDCMS.org

Position: Full-time and part-time. Full benefits package and malpractice coverage is provided by clinic. Requirements: California license, DEA license, CPR certification and board certified in family medicine. Bilingual English/Spanish preferred. Send resume to: hr@vistacommunityclinic.org or fax to 760-414-3702

Vista Community Clinic is a private, nonprofit outpatient community serving people who experience social, cultural or economic barriers to health care in a comprehensive, high quality setting.

www.vistacommunityclinic.org EEO/AA/M/F/Vet/Disabled

SAN DIEGO PHYSICIAN.ORG

CLASSIFIEDS VOLUNTEER OPPORTUNITIES

SURGEONS NEEDED FOR EXPANDING NATIONWIDE SURGICAL PRACTICE FT/PT positions available. Competitive pay and flexible schedule with complete autonomy. Add revenue to your current practice. For more information, contact us: P: 1-877-878-3289 F: 1-877-817-3227 or email CV to: JOBS@ADVANTAGEWOUNDCARE.ORG www.AdvantageWoundCare.org PHYSICIANS: HELP US HELP IMPROVE THE HEALTH LITERACY OF OUR SAN DIEGO COUNTY COMMUNITIES by giving a brief presentation (30–45 minutes) to area children, adults, seniors, or employees on a topic that impassions you. Be a part of Champions for Health’s Live Well San Diego Speakers Bureau and help improve the health literacy of those with limited access to care. For further details on how you can get involved, please email Andrew.Gonzalez@ ChampionsFH.org. CHAMPIONS FOR HEALTH PROJECT ACCESS: Volunteer physicians are needed for the following specialties: endocrinology, ENT or head and neck, general surgery, GI, gynecology, neurology, ophthalmology, orthopedics, pulmonology, rheumatology, and urology. We are seeking these specialists throughout all regions of San Diego to support those that are uninsured and not eligible for Medi-Cal receive short term specialty care. Commitment can vary by practice. The mission of the Champions for Health’s Project Access is to improve community health, access to care for all, and wellness for patients and physicians through engaged volunteerism. Will you be a health CHAMPION today? For more information, contact Andrew Gonzalez at (858) 300-2787 or at Andrew.Gonzalez@ChampionsFH.org, or visit www. ChampionsforHealth.org. [282] SHORT-TERM MEDICAL VOLUNTEERS NEEDED FOR HAITI: Global Health Teams is looking for physicians, mid-level providers and nurses for one-week, primary-care medical clinics in rural Haiti every February, June, and October. This is a rewarding and fun opportunity to work with the people of Haiti and provide care in a rural clinic in a medically under served area. GHT is an experienced U.S.-based nonprofit and has been operating these clinics since 1998. We coordinate all in-country travel and logistics. Please contact Bob Downey at (619) 905-7157 or at bob@globalhealthteam.org if you are interested in applying. Visit www.globalhealthteam. org to see what we do and learn about the clinics and volunteer experience. PHYSICIAN OPPORTUNITIES PRACTICE OPPORTUNITY: Internal Medicine and Family Practice. SharpCare Medical Group, a Sharp HealthCare-affiliated practice, is looking for physicians for our San Diego County practice sites.

SharpCare is a primary care, foundation model (employed physicians) practice focused on local community referrals, the Patient Centered Medical Home model, and ease of access for patients. Competitive compensation and benefits package with quality incentives. Bilingual preferred but not required. Board certified or eligible requirement. For more info visit www.sharp.com/sharpcare/ or email interest and CV to glenn.chong@sharp.com PART-TIME MEDICAL DOCTOR WANTED IMPERIAL RADIOLOGY: Our company is an outpatient diagnostic radiology facility in search of a part-time Medical Doctor to help cover contrast administration. All Candidates must have an active California Medical License. Please contact via email info@carlsbadimaging.com with your resume if this position is of interest to you. FAMILY PRACTICE/INTERNAL MEDICINE PHYSICIAN NEEDED: Primary care physician wanted for established private practice in San Diego. La Jolla Village Family Medical Group has been caring for patients of all ages for 29 years in the UTC/La Jolla area of San Diego. We provide comprehensive preventive medicine, illness management, travel medicine, sports medicine, evidence-based chiropractic care, weight management, and more. Call responsibilities minor, hours consistent with a healthy work/life balance. Our office is modern, clean, and well appointed. Our staff is supportive, cohesive, and friendly. This a real family practice. Board-certified, California licensed MD and DO physicians who are passionate about medicine and interested in this opportunity should send their CV and cover letter addressed to Tricia at officemanager@ljvfmg.com. Let us grow your practice according to your unique specialty interests and style. Responsibilities include: Provide excellent care, become part of a cohesive team, light call, maintain accurate and detailed medical records using HER, comply with all laws applicable to family practice/internal medicine, including HIPAA, recommend lifestyle changes as appropriate to improve quality of life. Full-time. Part-time. MEDICAL DIRECTOR, CALIFORNIA CHILDREN’S SERVICES: The County of San Diego invites qualified individuals to apply for the position of MEDICAL DIRECTOR, CALIFORNIA CHILDREN’S SERVICES (Job Classification: Public Health Medical Officer). Under the direction of the Deputy Public Health Officer or designee, this unclassified management position will be responsible for the medical oversight of County of San Diego, Health & Human Services Agency, California Children’s Services Division. Residency in Pediatrics or Family Medicine is highly desirable. Please view the detailed brochure for information regarding the position, duties, and benefits. | Job Number 18412807CCSU | CLICK HERE to apply. PHYSICIAN NEEDED: Family Practice MD. San Ysidro Health is looking for an MD for our Family Practice center. The Family Practice MD manages and provides acute, chronic, preventive, curative and rehabilitative medical care to patients and determines appropriate regimen in specialized areas such as family practice, prenatal OB/GYN, pediatrics and internal medicine. Bilingual preferred but not required. Medical school graduate, CPR, CA MD and DEA License, board certified or eligible in primary care specialty. For more info on San Ysidro Health, visit: http://www.syhealth.org/ If interested, please email CV to Meagan.underwood@syhealth.org.

DERMATOLOGIST NEEDED: Premier dermatology practice in beautiful San Diego seeking a full-time/ part-time BC or BE eligible Dermatologist to join our team. Existing practice taking over another busy practice and looking for a lead physician. This is a significant opportunity for a motivated physician to take over a thriving patient base. Work with two energetic dermatologists and a highly trained staff in a positive work environment. We care about our patients and treat our staff like family. Opportunity to do medical, cosmetic and surgical dermatology (including MOHs) in a medical office with state of the art tools and instruments. Please call Practice Administrator at (858) 761-7362 or email jmaas12@ hotmail.com for more information. PRACTICE FOR SALE INTERNAL MEDICINE PRACTICE FOR SALE: Internal Medicine practice for sale near SDSU and College Area that has been in practice for thirty years. This practice has great street exposure and very accessible parking. For immediate consideration, forward your details including your contact phone, your specialty and current professional status to: chandrasmreddy@gmail.com. Only Doctors will be considered, no brokers. HIGHLY PROFITABLE MEDSPA NOW AVAILABLE TO LICENSED PHYSICIAN: Southern California | Asking Price: $1,050,000 | Cash Flow: $410,419 | This profitable and expandable company performs non-invasive cosmetic procedures, including dermal fillers, Botox, and laser treatments. Experienced staff plans to stay, and protects current physician/ owner at 30 hours/week max. If you’re ready to see online financials, a studio-quality video of their story, an industry-leading assessment, and more – visit: https://goexio.com/med-spa-landing-sd for a summary. Interested? Click on “Private Access” to sign an instant nondisclosure and unlock the entire story. Full financials available on request. Prefer a personal touch? Contact Doug Miller: (208) 7623451. doug.miller@goexio.com. OB/GYN PRACTICE FOR SALE IN SAN DIEGO: Asking $480,000,00. FY 2017 Gross $1,445,688,00. Established practice for 38 years. Suburban district. Easy freeway access. Dedicated and experienced staff able to stay on board through sale. Situated within a modern, high-end building. The region’s fastgrowing population assures for an expanding client base. Features 3200 sq ft of working space; 6 fully equipped patient rooms (5 exam & 1 surgery rooms with surgical lighting and fully adjustable treatment tables). Furnished waiting room and reception area; doctor’s private office, sterilization area, staff lounge and storage. ADA compliant. Contact: dixon@ cwmc4women.com PRACTICES WANTED PRIMARY OR URGENT CARE PRACTICE WANTED: Looking for independent primary or urgent care practices interested in joining or selling to a larger group. We could explore a purchase, partnership, and/or other business relationship with you. We have a track record in creating attractive lifestyle options for our medical providers and will do our best to tailor a situation that addresses your need. Please call (858) 832-2007. PRIMARY CARE PRACTICE WANTED: I am looking for a retiring physician in an established Family Medicine or Internal Medicine practice who wants to transfer the patient base. Please call (858) 257-7050.

TO SUBMIT A CLASSIFIED AD, email Editor@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $150 (100-word limit) per ad per month of insertion.

SEPTEMBER 2018

OFFICE SPACE / REAL ESTATE AVAILABLE

KEARNY MESA MEDICAL OFFICE - FOR LEASE 7910 Frost Street. Class A medical office building adjacent to Sharp Memorial and Rady Children’s hospitals. Suites ranging from 1,300-5,000 SF. For details, floor plans and photos contact David DeRoche (858) 966-8061 | dderoche@rchsd.org OFFICE SPACE/REAL ESTATE AVAILABLE: Scripps Encinitas Campus Office, 320 Santa Fe Drive, Suite LL4. It is a beautifully decorated, 1600 sq. ft. space with 2 consultations, 2 bathrooms, 5 exam rooms, minor surgery. Obgyn practice with ultrasound, but fine for other surgical specialties, family practice, internal medicine, aesthetics. Across the hall from imaging center: mammography, etc and also Scripps ambulatory surgery center. Across parking lot from Scripps Hospital with ER, OR’s, Labor and Delivery. It is located just off Interstate 5 at Santa Fe Drive, and ½ mile from Swami’s Beach. Contact Kristi or Myra 760-753-8413. View Space on Website:www.eisenhauerobgyn.com. Looking for compatible practice types. SHARED OFFICE SPACE: Office space, beautifully decorated, to share in Solana Beach with reception desk and 2 rooms. Ideal for a subspecialist. Please call 619-606-3046. SHARED OFFICE SPACE AVAILABLE: Shared Office Space: Very attractive 1 or 2 exam rooms available, medical spa office ‘Exquisite Md Spa’ in Bankers Hill near Balboa Park. Available 5 days per week. Reasonable rates. Call Claudia at 619-501-4758. OFFICE SPACE AVAILABLE: La Jolla (Near UTC) office for sublease or to share: Scripps Memorial medical office building, 9834 Genesee Ave-great location by the front of the main entrance of the hospital between 1-5 and 1-805. Multidisciplinary group and available to any specialty. Note we are in great need of a psychiatrist. Excellent referral base in the office and on the hospital campus. Please call (858) 455-7535 or (858) 320-0525 and ask for Sofia or call Dr. Shurman, (858) 344-9024. OFFICE SPACE FOR RENT: Multiple exam rooms in newer, remodeled office near Alvarado Hospital and SDSU. Convenient freeway access and ample parking. Price based on useage. Contact Jo Turner (619) 733-4068 or jo@siosd.com.

clientele. Just a few blocks from Tri-City Medical Center and across from the urgent care. Includes: Digital X-ray suite, multiple exam rooms, access to a kitchenette/break room, two bathrooms, and spacious reception area all located on the property. Wi-Fi is NOT included. Contact Harish Hosalkar at hhorthomd@gmail.com or call/text (858) 243-6883. SHARED OFFICE SPACE AVAILABLE: Established orthopedic group seeks additional orthopedic surgeon for partnership or overhead sharing opportunity. Our office is centrally located in Kearny Mesa near Highway 163 and Balboa, easy access to freeways, affiliations with Sharp, Scripps. Extensive referral base, EMR/”paperlight” office, experienced MA/surgery scheduler/ referral coordinator. Please call Lisa Vaughn, practice administrator, at (858) 278-8300 or email lmvomg@yahoo.com. MEDICAL OR DENTAL SPACE AVAILABLE: For lease a medical or dental related practice or business in a small boutique office space located in the center of “Hillcrest/Bankers Hill”. Just renovated! The second story of this beautiful two story building is available for lease. A private gated entrance leads to a 1,139 square foot upstairs with 4 to 5 consultation rooms, waiting room with adjoining private deck and full bathroom. Additional security gate and mailbox. Separate address. Wood floors, refinished windows, natural light, quiet street, walkable to restaurants. On-site parking with up to 8 parking spaces available! Asking: $3,000/month. Terms are negotiable. This will rent fast so hurry! Please contact: hillcrestofficerental@gmail.com | (858) 775-5075 OFFICE SPACE FOR RENT: La Jolla -- LEASE -- Medical or dental related practice or business in a small boutique office space located in the center of beautiful La Jolla, California. Perfect opportunity for Psychiatrist, Psychologist, Counselor, Dentist, Physician, Surgeon. Any dental or medical related occupation welcome. Located in medical/dental building. Come join these great practices. Classy second floor suite with elevator. Perfect for entrepreneur. Partially equipped for dental or surgical practice. Terrific opportunity. | 612 sq feet | $4.90/sq ft per month | triple net lease. Contact Kevin Gott: dynamold@aol.com OFFICE SPACE / REAL ESTATE WANTED MEDICAL OFFICE SPACE SUBLET DESIRED NEAR SCRIPPS MEMORIAL LA JOLLA: Specialist physician leaving group practice, reestablishing solo practice seeks office space Ximed building, Poole building, or nearby. Less than full-time. Need procedure room. Possible interest in using your existing billing, staff, equipment, or could be completely separate. If interested, please contact me at ljmedoffice@yahoo.com.

OFFICE SPACE AVAILABLE IN MISSION VALLEY: Unique space for lease in Mission Valley. 1300 sq. ft office space in medical/surgical office building, single story, ample free parking. Is currently in use as physical therapy suite with reception area, small waiting room, private treatment room, separate office, bathroom in suite and hook ups for washer/dryer. Easy access to all freeways. Available approximately August 1, 2018. Please contact Joan McComb, Executive Director, CA Orthopaedic Institute. (619) 291-8930 or cell (619) 840-0624.

HIGH TECH FACIAL IMAGING FOR SALE: New Reveal® Imager for sale. Ideal for MedSpa or cosmetic practice. The Reveal® Imager clearly demonstrates sun damage, brown spots, red areas and more. Create a personalized printed treatment record for the patient. Contact info@ restoresdplasticsurgery.com or 858-224-2281 if interested.

NORTH COUNTY MEDICAL SPACE AVAILABLE: North County Medical Space Available: 2023 W. Vista Way, Suite C, Vista, CA 92083. Newly renovated, large office space located in an upscale medical office with ample free parking. Furnishings, décor, and atmosphere are upscale and inviting. It is a great place to build your practice, network and

MEDICAL EQUIPMENT AVAILABLE FOR DONATION: Carlsbad Imaging has medical equipment available for donation, including Afinion HbA1c-Used, Siemens clinitek status+Used, FastPack-Used. Please contact info@ carlsbadimaging.com if interested. .

MEDICAL EQUIPMENT / FURNITURE FOR SALE

NON-PHYSICIAN POSITIONS AVAILABLE PLASTIC SURGERY AND FRONT DESK COORDINATOR: The ideal position for someone with a background in plastic surgery, dermatology, ophthalmology, or medical spa. Will consider those with a background in a high-end hospitality setting. The Coordinator is primarily responsible for the day-to-day creation of an office environment that fosters highly personalized customer service. Responsible for the front/back office daily operations including patient care, scheduling, and optimizing surgical closure rates and sale of skin care lines. Contact info@restoresdplasticsurgery. com with resume. Salary commensurate with experience. (Posted 9/4/2018) MEDICAL OFFICE MANAGER/CONTRACTS/ BILLING PERSON: MD specialist leaving group practice, looking to reestablish solo private practice. Need assistance reactivating payer contracts, including Medicare. If you have that skill, contact ljmedoffice@yahoo.com. I’m looking for a project bid. Be prepared to discuss prior experience, your hourly charge, estimated hours involved. May lead to additional work. PRODUCTS / SERVICES OFFERED DATA MANAGEMENT, ANALYTICS AND REPORTING: Rudolphia Consulting has many years of experience working with clinicians in the Healthcare industry to develop and implement processes required to meet the demanding quality standards in one of the most complex and regulated industries. Services include: Data management using advanced software tools, Use of advanced analytical tools to measure quality and processrelated outcomes and establish benchmarks, and the production of automated reporting. (619) 9137568 | info@rudolphia.consulting | www.rudolphia. consulting A VALUABLE EDUCATIONAL RESOURCE: Extensive Medical Articles File for sale. Charts, illustrations, articles. Emphasis on Emergency Medicine and Internal Medicine. Collected since 1973. Fills a large filing cabinet. (Cabinet not included.) Would make a useful gift for a medical student or resident. Best offer takes. Will accept offers for 30 days after the publication of this newsletter. View in person at a North County location by appointment. (858) 451-6517. PHYSICIAN OFFICES IN NEED OF ASSISTANCE FOR MEANINGFUL USE ATTESTATION of their electronic health records can avail themselves of technical assistance from Champions for Health, the sister organization to SDCMS. Practices attesting on the Medi-Cal Incentive Program with at least 30% of patients billed to Medi-Cal can receive free assistance thanks to a federal funding source. Medicare practices can receive the same great service at a very reasonable rate, and SDCMS-CMA members receive a discount. For more information, email Barbara.Mandel@ChampionsFH.org or call (858) 300-2780. [559]

SAN DIEGO PHYSICIAN.ORG

POE TRY AN D M EDICIN E

You Already Know by Daniel J. Bressler, MD, FACP

ONE OF THE FEW incontrovertible facts of a life is its finitude. Although we humans share this feature with all other earthly creatures, we are unique in our awareness of it. All our roles, jobs and housing are temporary. We are visitors here, and all visits have an ending. The phrase “for whom the bell tolls” comes from an essay written by the English poet John Donne in 1624. Its topic was what we might now call human interdependence, how all of humanity is one family, joined in its finitude. Donne asks, on hearing a church bell ringing an announcement of someone’s death: “Never send to ask for whom the bell tolls. It tolls for thee.” The essay is also the source of another memorable expression of human solidarity, “no man is an island.” It served as the anchor phrase for a corny inspirational song from my elementary school chorus, which fit the idealism of the era: “No man is an island/no man walks alone/each man’s joy is joy to me/each man’s grief is my own.” In 35 years of primary care medicine, I’ve had the chance to practice the art of both identifying with and maintaining separation from my patients’ pains and griefs. In moments of reflection, away from the clinic, I’ve come to realize that it is only a matter of luck and a matter of time until their suffering and my own merge via our shared humanity. In those moments, I do already know. Dr. Bressler, SDCMS-CMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and a longtime contributing writer to San Diego Physician.

SEPTEMBER 2018

“You Already Know” For LS When the ambulance siren wails, it screams for you When the remembrance candle is lit, it flickers for you When the cop pronounces the homeless man, he declares for you When the young mother weeps in the neonatal ICU, she cries for you When the neighbor admits his wife passed in her sleep, he reports for you When the memorial carves three thousand names, it spells out for you When the ER doctor terminates the code blue, she stops for you When the coroner inscribes the certificate, he signs for you When the obituary details, it explains for you So, do not ask for whom the bell tolls. You already know.

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