October 2019 by San Diego Physician

OCTOBER 2019

Official Publication of SDCMS

Annual Infectious Diseases Focus HIV Prevention Strategies and Getting to Zero  Health Screening Asylum Seekers in San Diego  Reassessment of the Risks and Benefits of Surgical Antibiotic Prophylaxis  Resistance to Gonorrhea: a Growing Threat

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OCTOBER

CONTENTS

VOLUME 106, 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: James H. Schultz, MD President-elect: Holly B. Yang, MD Secretary: Sergio R. Flores, MD Treasurer: Toluwalase (Lase) A. Ajayi, MD Immediate Past President: David E. J. Bazzo, MD GEOGRAPHIC DIRECTORS East County #1: Heidi M. Meyer, MD (Board Representative to the Executive Committee) East County #2: Rakesh R. Patel, MD Hillcrest #1: Kyle P. Edmonds, MD Hillcrest #2: Steve Koh, MD Kearny Mesa #1: Anthony E. Magit, 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 #2: Maria T. Carriedo, MD GEOGRAPHIC ALTERNATE DIRECTORS Kearny Mesa #2: Eileen R. Quintela, MD La Jolla: Wayne C. Sun, MD North County #1: Franklin M. Martin, MD South Bay: Karrar H. Ali, DO AT-LARGE DIRECTORS #1: Thomas J. Savides, MD; #2: Paul J. Manos, DO; #3: Irineo “Reno” D. Tiangco, 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: Karl E. Steinberg, MD; #8: Alejandra Postlethwaite, MD

ADDITIONAL VOTING DIRECTORS Communications Chair: William T-C Tseng, MD Finance Committee Chair: J. Steven Poceta, MD Young Physician Director: Obiora “Obi” Chidi, MD Resident Director: Vishnu Parthasarathay, MD Retired Physician Director: David Priver, MD Medical Student Director: Grace Chen

features

ADDITIONAL NON-VOTING MEMBERS Alternate Young Physician Director: Brian Rebolledo, MD Alternate Resident Director: Nicole Herrick, 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

Antimicrobial Resistance in Neisseria Gonorrhoeae: A Growing Threat BY MINJI KANG, MD

8 Biomedical HIV Prevention Strategies and Getting to Zero BY MICHAEL L. BUTERA, MD, AND M. WINSTON TILGHMAN, MD

departments

CHRISTINE THORNE, MD, MPH

Briefly Noted: Yang Welcomes Medical Students • PHC Applications for CalMedForce GME Grants • CMA Presidential Gala • Prop. 56 Supplemental Payments • Calendar

Prescribing Antibiotics to Prevent Infection: A Reassessment of the Risks and Benefits of Surgical Antibiotic Prophylaxis

Physician Classifieds

BY SHIRA ABELES, MD

BY ADAMA DYONIZIAK

Development of a Program for Health Screening of Asylum Seekers in San Diego BY LUCY E. HORTON, MD, MPH, AND

OCTOBER 2019

AT-LARGE ALTERNATE DIRECTORS #1: Mark W. Sornson, 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

Reconnecting With Life

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

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.]

t hank you

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PHC Announces Second Application Cycle for CalMedForce GME Grants

MEDICAL STUDENTS

Yang Welcomes Class of 2023 at UC San Diego’s White Coat Ceremony Dr. Holly Yang, President-elect of the San Diego County Medical Society, represented the Medical Society in giving welcoming remarks to the incoming class of 2023 at the UC San Diego School of Medicine’s White Coat Ceremony on August 30.

Physician Networking Opportunity and Mixer PHYSICIANS: Come mingle, socialize and network with your fellow San Diego County physicians. SDCMS members and non-members are welcome and encouraged to attend. Complimentary hors d’ouvres and hosted wine and craft beer will be provided.

Thursday, November 7, 5:30–8:00 p.m. Rock Bottom Brewery 8980 Villa La Jolla Drive, La Jolla, CA 92037 This event is generously sponsored by the Cooperative of American Physicians. For questions please contact Jen Ohmstede at JOhmstede@SDCMS.org

OCTOBER 2019

PHYSICIANS FOR A HEALTHY California (PHC) is excited to announce the second cycle for the graduate medical education (GME) grant program, CalMedForce, which will award approximately $38 million to primary care and emergency medicine residency programs in California. The application will be released Sept. 23, 2019, and is due by Oct. 28, 2019, at 11:59 p.m. (PST). Priority will be given to programs in medically underserved areas and programs that serve medically underserved populations. All applications submitted will receive a preliminary score. The preliminary scores will be sent to the primary contact and program director as provided in the application. Applications submitted by Oct. 11, 2019, 11:59 p.m. (PST) will have the opportunity to edit their application, if needed. Early application submission is strongly encouraged. Applications submitted between Oct. 12, 2019 and Oct. 28, 2019 will be considered final and no supplemental information or changes can be made to the application. Programs that plan to apply for funding are encouraged to start gathering the needed information now to ensure they are ready to complete the application by the deadline. While the application itself is not lengthy, it may take some time to collect and prepare the required information. Among the information needed is: • Health professional shortage area (HPSA) score • Structure of residency program, including the number of residency positions overall and the number of positions for which you are requesting funds • ACGME/AOA accreditation letters for both the sponsoring institution and specialty • Information about program graduates, including where they are practicing, in what specialty and in what type of practice from the past three years • Details about your patient population payer mix • Justification of your funding needs Please share this information with colleagues who may benefit from this funding. (If you would like to be added to our distribution list for future updates, please email CalMedForce@phcdocs.org with “subscribe” in the subject line). For more information about CalMedForce, visit phcdocs.org.

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CALENDAR

OCT 12–16: Academy of Integrative Health & Medicine Annual Conference. Learn evidencebased integrative medicine. AMA PRA Category 1 CME accredited program. Sheraton Hotel & Marina, San Diego. OCT 12: 2 p.m. Sixth Annual Champions for Health Solana Beach 5K Sunset Walk/Run. Fletcher Cove, Solana Beach. OCT 26: 23rd Annual Presidential Gala, California Medical Association. Disneyland Hotel, Anaheim. APR 2–5, 2020: California Society of Anesthesiologists Annual Meeting. Paradise Point Resort, San Diego.

MEDI-CAL/PROP. 56

Have You Received Your FY 18–19 Prop 56 Supplemental Payments? THE CALIFORNIA HEALTH CARE, Research and Prevention Tobacco Tax Act of 2016 (Prop 56) created new revenues dedicated to the MediCal program. Physicians receive supplemental payments in both fee-for-service and Medi-Cal managed care when providing Medi-Cal services under certain CPT codes. While the California Department of Health Care Services (DHCS) began disbursing the FY 2018–2019 supplemental payments in fee-forservice Medi-Cal last fall, federal approval of the supplemental Medi-Cal managed care payments was delayed until February. DHCS began dispersing the FY 2018–2019 funds to the managed care plans as part of its capitated payments in March. This includes both the go-forward payments and the retroactive payment for clean claims or accepted encounter data with dates of service between July 1, 2018, and the date the plan received the Prop 56 funds. Per DHCS instructions, for clean claims or accepted encounters received, plans are required to issue supplemental payments to qualifying physicians within 90 days of receipt of the funds from the DHCS. DHCS clarified in these instructions that the 90-day timeframe for distribution of funds also applies to the plan’s delegated groups. Additionally, the DHCS is requiring plans to demonstrate that 95% of the funds were distributed to providers or refund the funds to DHCS. The California Medical Association (CMA) surveyed the plans to determine which entity, plan, or delegated group would be responsible for distributing payments and has created a Prop 56 Payment Source Table. Practices that have not received their supplemental payments

are encouraged to contact the plan or delegated group responsible for distributing payments. Physicians can utilize the payment source information along with the plan contacts table for additional information on who to contact regarding any underpayments. How do I know if I’ve been paid correctly? CMA recently published an updated Prop 56 Payment Monitoring Worksheet to help physicians determine whether they have been paid correctly based on the FY 18–19 supplemental payment amounts (utilize the 2018–2019 worksheet). Is any physician action required to receive the supplemental payments? If you are submitting claims to the managed care plans and are reimbursed on a fee-for-service basis, there is no additional action required. Payments should be automatic. However, physicians who have a capitated contract with either a Medi-Cal managed care plan or one of its delegated entities for eligible services must submit encounter data to the payer in order to receive the supplemental funds. Without the encounter data, the plan or its delegated entity will be unable to determine the services eligible for payment, which will result in nonpayment of the supplemental funds. If you are unsure how to submit encounter data, contact the plan or delegated entity for more information. More information on Prop 56 can be found on the DHCS website. Physicians with questions or concerns can contact CMA’s Reimbursement Helpline at (888) 401-5911 or economicservices@cmadocs.org.

SAN DIEGO PHYSICIAN.ORG

INFECTIOUS DISEASE

ANTIMICROBIAL RESISTANCE IN NEISSERIA GONORRHOEAE: A GROWING THREAT BY MINJI KANG, MD NEISSERIA GONORRHOEAE infection is the second most common communicable disease in the United States with an estimated 820,000 new infections each year.1 It is a major cause of morbidity among sexually active individuals worldwide, as untreated infection can lead to epididymitis in males and pelvic inflammatory disease in females, which can result in infertility and ectopic pregnancy.2 Antimicrobial resistance in Neisseria gonorrhoeae is a growing threat with increasing need for new treatment options, actions by clinicians, laboratories, and public health officials, and continued surveillance for resistance.

sharpest increase in incidence seen among MSM.3,4 History of Antimicrobial Resistance in Neisseria gonorrhoeae With the growing threat of antimicrobial resistance, treatment of gonococcal infection has evolved significantly over the years. Antimicrobial resistance began in the 1940s with sulfonamide resistance.5 Gonococcal infection was subsequently treated with penicillin, but by the 1980s, N. gonorrhoeae

showed increasing resistance to penicillin and tetracycline.5 Thus, fluoroquinolones became the predominant treatment in the 1990s, but with increasing resistance detected in the west coast especially among MSM, fluoroquinolone was no longer recommended. Cephalosporins (injectable ceftriaxone or oral cefixime) subsequently became the backbone of gonococcal treatment. 5 However, by 2012, increasing minimal inhibitory concentration (MIC) was seen with cefixime. 5 To preserve cephalosporins as long as possible, dual therapy with ceftriaxone and azithromycin has become the mainstay for treatment by 2015 (Figure 2, 3).5 Current Treatment Guideline The current preferred regimen for urogenital and pharyngeal infection is dual therapy with ceftriaxone 250mg intramuscular PLUS azithromycin 1 gram orally in a single dose regardless of chlamydial coinfection status.1 In pharyngeal infection, alternative regimens are associated with low rates of eradication and should not be used. If used, a test of cure should be performed. 1 For acute proctitis, ceftriaxone 250mg intramuscular in a single dose PLUS doxycycline 100mg orally twice a day for seven days are recommended.1 To minimize disease transmission, persons treated should abstain from sexual activity for seven days and all sexual partners within 60 days should be

Figure 1: Gonococcal infection rates by year San Diego County, 1998â&#x20AC;&#x201C;20174 Epidemiology of Gonococcal Infection The epidemiology of gonococcal infection in the United States has changed significantly over time. Incidence rate declined after the 1970s, reaching an all-time low in 2009.3 However, with changes in diagnostic tests, screening and reporting practices, and sexual behaviors especially among men who have sex with men (MSM), gonorrhea incidence rate has steadily increased since 2010.3 Similarly, in San Diego County the overall gonococcal infection rate has been rising as gonorrhea had the highest local increase among all sexually transmitted infections (Figure 1).4 Highest reported rates of gonococcal infections are seen among adolescents and racial minorities, with the

OCTOBER 2019

Figure 2: Overview of antimicrobial resistance in Neisseria gonorrhoeae5

Figure 3: Tetracycline, penicillin, or fluoroquinolone resistance, or elevated cefixime, ceftriaxone, or azithromycin minimum inhibitory concentrations (MIC) by year from 2000–20175

evaluated and treated.1 However, decreased susceptibility to ceftriaxone and increased resistance to azithromycin worldwide suggest that dual therapy with ceftriaxone and azithromycin might not be a long-term solution. In 2011, the first N. gonorrhoeae strain with high-level resistance to ceftriaxone was isolated in Japan. 6 In 2014, a heterosexual male in the United Kingdom failed treatment with dual therapy and was found to be infected with a strain resistant to both ceftriaxone and azithromycin.7 Nevertheless, while higher MIC for ceftriaxone has been reported globally, ceftriaxone still cures approximately 98% to 99% of uncomplicated infections and remains the backbone for treatment.5

Mechanism of Antimicrobial Resistance N. gonorrhoeae has developed resistance to any antimicrobials introduced for treatment within two decades. This is because N. gonorrhoeae is naturally competent for transformation and can change its genome through all types of mutations when exposed to selective pressure. 8 In addition, N. gonorrhoeae has high affinity for horizontal gene transfer so any resistance gene can easily spread across different strains.8 N. gonorrhoeae has acquired or developed resistance mechanisms to all antimicrobials used for treatment through the following four main mechanisms: (1) enzymatic antimicrobial destruction or modification, (2) target modification or protection re-

ducing affinity for the antimicrobials, (3) decreased influx of antimicrobials, and (4) increased efflux of antimicrobials.8 Reducing antimicrobial affinity through target modification is the main mechanism in which N. gonorrhoeae acquires resistance.8 Resistance mechanisms and genes involved are outlined in Table 1. Managing Treatment Failure Treatment failure should be considered in persons with (1) symptoms that do not resolve within 3 to 5 days after treatment with no sexual contact post-treatment; (2) a positive test-of-cure (positive culture > 72 hours or positive NAAT > 7 days) with no sexual contact post-treatment; and (3) positive [Continued on page 20]

SAN DIEGO PHYSICIAN.ORG

INFECTIOUS DISEASE

BIOMEDICAL HIV PREVENTION STRATEGIES San Diego County Medical Society AND GETTING The participates in the Medical Advisory Committee for the County of San TO ZERO Diego’s Getting to Zero initiative to BY MICHAEL L. BUTERA, MD, AND M. WINSTON TILGHMAN, MD

OCTOBER 2019

end the HIV epidemic. Getting to Zero is a comprehensive initiative approved by the San Diego County Board of Supervisors on March 1, 2016, that seeks to eliminate all new HIV infections in San Diego County within 10 years and engage San Diego’s physicians and providers in public and private healthcare systems in the process. Getting to Zero is comprised of three primary strategies to end the epidemic.

Current Situation • There are approximately 14,000 persons in San Diego County living with HIV/AIDS. • One in five individuals newly diagnosed with HIV in San Diego County will receive an AIDS diagnosis within 30 days of their HIV diagnosis, indicating that they were not identified until late in the disease process. • Approximately 1,400 individuals living with HIV in San Diego County are not aware of their HIV status. Around 40% of new HIV infections are attributed to people living with HIV who are unaware of their status. • Approximately 2,800 individuals living with HIV/AIDS are aware of their status but are not receiving HIV primary care. In San Diego County, 90% of patients newly diagnosed with HIV infection get linkage to HIV primary care and treatment, but only 60 percent achieve viral suppression. The CDC estimates that 40–45% of new HIV infections derive from someone who was aware of their status but not in care. • Risk of transmission is greatest in acute HIV infection and in late-stage disease and is related to levels of circulating virus. Primary (i.e., early) infection and late-stage infection are estimated to be 26 and 7 times, respectively, more infectious than chronic asymptomatic infection. [Hollingsworth et al, J Infect Dis 2008; 198:687-93.] STRATEGY I: TEST http://getting2zerosd.com/get-tested/ The Centers for Disease Control and Prevention (CDC) recommended in 2006 that all adults, regardless of risk, be tested for HIV in health care settings. In 2013, the United States Preventive Services Task Force (USPSTF) recommended that all individuals, aged 15 to 65 years, be screened for HIV in healthcare settings, with a recommendation grade of “A.” These recommendations have not been widely adopted by local healthcare providers. STRATEGY II: TREAT http://getting2zerosd.com/get-treatment STRATEGY III: PREVENT https://getting2zerosd.com/get-prevention Initiative Website http://www.getting2zerosd.com

Benefits of HIV Care and Treatment When HIV is suppressed with antiretroviral therapy, the major health benefit is that the progression of HIV disease in that individual is effectively halted and risk of transmission to others eliminated (i.e., Treatment as Prevention, or TasP). Undetectable = Untransmittable (U=U) is evidence-based and true for both serodifferent heterosexual couples and serodifferent male-male couples. Biomedical HIV Prevention Options for HIV-Negative Persons Pre-Exposure Prophylaxis (PrEP) PrEP involves use of an HIV medication, Truvada, by HIV-negative individuals who are vulnerable to HIV infection. Research on the use of Truvada for PrEP demon-

strates that it is up to 96–99% effective in preventing infection when it is taken daily as prescribed. PrEP has been recommended by the CDC for all individuals who are at high risk for HIV infection. The goal is to have protective levels of the drug before exposure to HIV through sexual intercourse or injection drug use. Based on evidence from multiple clinical trials released from 2011 to 2013, the United States Food and Drug Administration (FDA) approved the use of Truvada for PrEP in persons aged 18 years and older and, in 2014, the U.S. Public Health Service issued the first practice guidelines for PrEP. In 2018 the FDA expanded its approval of Truvada as PrEP to include adolescents aged 15 years and older, based on the results of a large clinical trial that demonstrated safety and efficacy of daily Truvada in this population. However, this trial demonstrated a decline in adherence over time, indicating a possible need for increased support for adherence for adolescents who are vulnerable to HIV infection. Based on ongoing evidence of efficacy, safety, and public health benefit, the USPSTF issued a Grade A recommendation for PrEP in June 2019. Despite demonstrated efficacy, uptake of PrEP has been suboptimal. Contributing factors may include: • Lack of awareness among people who are vulnerable to HIV infection of PrEP and post-exposure prophylaxis (PEP, which is discussed below) as effective interventions for preventing HIV infection and how to access them. • Difficulty in obtaining PrEP and PEP without assistance in navigating the healthcare system. • Lack of familiarity with guidelines for the use of PrEP and PEP by primary care and other frontline providers. • Need for support services, such as treatment adherence counseling, which are often unavailable in private and public healthcare systems. For information about PrEP in San Diego County, visit PrEPSanDiego.com. Local physicians and other providers are encouraged to be familiar with indications for PrEP and PEP and guidelines for their use.

SAN DIEGO PHYSICIAN.ORG

INFECTIOUS DISEASE RECOMMENDED INDICATIONS FOR PREP USE BY MSM • Adult man without acute/established HIV infection • Any male sex partners in past 6 months • Not in a monogamous partnership with a recently tested, HIV-negative man AND at least one of the following: • anal sex without condoms (receptive or insertive) in past 6 months • any STI diagnosed or reported in past 6 months • ongoing sexual relationship with an HIV-positive male partner RECOMMENDED INDICATIONS FOR PREP USE BY HETEROSEXUALLY ACTIVE MEN AND WOMEN • Adult person without acute or established HIV infection • Any sex with opposite-sex partners in past 6 months • Not in a monogamous partnership with a recently tested HIV-negative partner AND at least one of the following: • is a man who has sex with both women and men (behaviorally bisexual) • infrequently uses condoms during sex with one or more partners of unknown HIV status who are known to be at substantial risk of HIV infection (IDU or bisexual male partner) • is in an ongoing sexual relationship with an HIV-positive partner RECOMMENDED INDICATIONS FOR PREP USE BY INJECTION DRUG USERS • Adult person without acute or established HIV infection • Any injection of drugs not prescribed by a clinician in past 6 months AND at least one of the following: • any sharing of injection or drug preparation equipment in past 6 months • been in a methadone, buprenorphine, or suboxone treatment program in past 6 months • risk of sexual acquisition In patients with the above risk factors screen for clinical eligibility • Documented negative HIV test result before prescribing PrEP • No signs/symptoms of acute HIV infection

OCTOBER 2019

• Normal renal function; no contraindicated medications • Documented hepatitis B virus infection and vaccination status • Three-month supply of truvada may be given with q three-month follow-up. • HIV test, medication adherence counseling, behavioral risk reduction support, side effect assessment, STI symptom assessment • At 3 months and every 6 months thereafter, assess renal function • Every 6 months, test for bacterial STIs • Do oral/rectal STI testing assess pregnancy intent/pregnancy test every three months • Access to clean needles/syringes and drug treatment services Post-Exposure Prophylaxis PEP is the use of combination antiretroviral therapy for 28 days by HIV-negative persons to prevent infection following a significant exposure to HIV in the 72 hours before treatment initiation. Recommended regimens are similar to first-line regimens for treatment of established HIV infection. The following are key recommendations for PEP as per the 2016 CDC guidelines for non-occupational PEP (nPEP). More information is available at https://www.cdc. gov/hiv/pdf/programresources/cdc-hivnpep-guidelines.pdf. • Healthcare providers should evaluate persons rapidly for nPEP when care is sought ≤72 hours after a potential exposure that presents a substantial risk for HIV acquisition. • The patient’s baseline HIV infection status should be determined through HIV testing, preferably by using rapid combined antigen/antibody, or antibody blood tests. In addition, testing for sexually transmitted infections (STIs), hepatitis B and C, and pregnancy and blood chemistries are recommended. • If HIV blood test results are not immediately available, and nPEP is otherwise indicated, it should be initiated without delay. • nPEP is recommended when the source of the body fluids is known to be HIVpositive and the reported exposure presents a substantial risk for trans-

• •

•

mission. Body fluids considered infectious include blood, semen, vaginal or rectal secretions, breast milk, and any fluid visibly contaminated with blood. Transmission risk from urine, sweat, nasal secretions, and saliva are considered negligible. nPEP is not recommended when care is sought >72 hours after potential exposure. A case-by-case determination about the need for nPEP is recommended when the HIV status of the source of the body fluids is unknown and the reported exposure presents a substantial risk for transmission if the source did have HIV infection. A 28-day course of a three-drug antiretroviral regimen should be prescribed. For patients who do not have health insurance, patient assistance programs are available for all of the recommended first-line medications through their respective manufacturers. The preferred regimen for otherwise healthy adults and adolescents with normal renal function is a fixed-dose combination of tenofovir disoproxil fumarate (tenofovir DF or TDF) (300 mg) with emtricitabine (200 mg) (i.e., Truvada) once daily plus either raltegravir (RAL) 400 mg twice daily or dolutegravir (DTG) 50 mg daily. The preferred alternative regimen for otherwise healthy adults and adolescents is a fixed-dose combination of tenofovir DF (300 mg) with emtricitabine (FTC) (200 mg) once daily (i.e., Truvada) plus darunavir (DRV) (800 mg) and ritonavir (RTV) (100 mg) once daily. Regimens are also provided for children, persons with decreased renal function, and pregnant women. All persons evaluated for nPEP should be provided any indicated prevention, treatment, or supportive care for other exposure-associated health risks and conditions (e.g., bacterial STIs, traumatic injuries, hepatitis B virus and hepatitis C virus infection, pregnancy). All persons who report risk factors for recurring HIV exposures (e.g., injection drug use, or sex without condoms) or who report receipt of ≥1 course of nPEP in the past year should

receive risk-reduction counseling and education about PrEP. • In May 2019, the FDA alerted the public and healthcare providers of a possible association of dolutegravir use in pregnancy and neural tube defects. A raltegravir-containing regimen is preferred for women who are not using an effective birth control method or are in the early stages of pregnancy. For interim guidance regarding nPEP for women of childbearing potential, see https:// www.cdc.gov/hiv/pdf/basics/cdchiv-dolutegravir-alert.pdf. For detailed recommendations regarding efficacy data, concomitant testing and prophylaxis for STIs, other blood-borne illnesses, and pregnancy, lab testing and monitoring for medication adverse reactions, and follow-up testing, please see the 2016 CDC nPEP Guidelines Update.

Dr. Butera is an Infectious Disease specialist and Dr. Tilghman is Medical Director/STD Controller HIV, STD & Hepatitis Branch of Public Health Services, County of San Diego Health & Human Services Agency. References: Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363(27):2587-2599. doi: 10.1056/NEJMoa1011205 Baeten JM, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367(5):399-410. doi: 10.1056/ NEJMoa1108524 Thigpen MC, Kebaabetswe PM, Paxton LA, et al. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission

in Botswana. N Engl J Med. 2012; 367(5):423434. doi: 10.1056/NEJMoa1110711 Choopanya K, Martin M, Suntharasamai P, et al. Antiretroviral prophylaxis for HIV infection among people who inject drugs in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomised, double-blind, placebocontrolled phase 3 trial. Lancet. 2013;381(9883):2083-90. doi: 10.1016/ S0140-6736(13)61127-7 https://www.cdc.gov/hiv/pdf/prepguidelines2014.pdf PEP Guideline Document Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV—United States, 2016 from the Centers for Disease Control and Prevention, U.S. Department of Health and Human Services

Time to Clean Up Your HR Practices!

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SAN DIEGO PHYSICIAN.ORG

INFECTIOUS DISEASE

DEVELOPMENT OF A PROGRAM FOR HEALTH SCREENING OF ASYLUM SEEKERS IN SAN DIEGO BY LUCY E. HORTON, MD, MPH, AND CHRISTINE THORNE, MD, MPH

OCTOBER 2019

Background/Overview Individuals seeking asylum in the United States have presented to Customs and Border Protection (CBP) for decades in accordance with US federal law. Starting in 2009, the Department of Homeland Securityâ&#x20AC;&#x2122;s Immigration and Customs Enforcement (ICE) instituted the Safe Release Program, helping asylum seekers get to their destinations across the U.S. through phone calls with and transportation to sponsors, 90% of which were located outside of San Diego County. Beginning in October 2018, ICE ceased this program and instead began to drop off asylum seekers in San Ysidro at parks, bus stops, fast food restaurants, and other public spaces without the means to travel to their sponsors. The San Diego Rapid Response Network (SDRRN), a group of nonprofit organizations with a joint mission to help

immigrants, refugees, and asylees, started collecting asylum seekers from the public areas and bringing them to safe locations, initially homes, and subsequently, a shelter, under the management of Jewish Family Service of San Diego (JFS). Families housed at the shelter include an average of one to two young children, with average stays of 12 to 48 hours. Nearly all asylum seekers have a US sponsor, often a family member, and travel to reunite with them as soon as travel can be arranged. JFS helps connect asylum seekers with their sponsors and arrange for travel to their final destination across the U.S. In late December 2018, the County of San Diego expanded efforts to protect the health of the public, including asylumseeking families, by conducting health screening assessments in the setting of the shelter with the goal of identifying and

preventing the spread of communicable diseases. The County of San Diego Health and Human Services Agency (HHSA) set up a contract with UC San Diego Health (UCSD) under the leadership of Drs. Linda Hill and Kathleen Fischer, who have more than a decade of experience directing the Refugee Health Assessment Program. The mission of HHSA/UCSD Asylum-Seekers Health Assessment Program was to provide daily services at the shelter including: screening and evaluating asylum seekers for diseases of public health concern, treating and/or referring conditions to outside medical care, and transferring newly arriving families to the general shelter population or isolation if appropriate. Physicians were recruited from across San Diego to staff daily screening clinics running from 3 to 11 p.m. From December through June, nursing and support staff from HHSA completed a questionnaire with each patient, took vitals, and provided lice and scabies screening and treatment. Physicians provided physical examinations and evaluation for acute, emergent, and infectious diseases of public health significance. In order to coordinate and standardize the screening procedure and ensure timely, accurate, and coordinated treatment of asylum seekers, shelter-specific protocols for a variety of communicable diseases were developed. While typical management of conditions such as lice, scabies, and varicella are straightforward, management of these illnesses in a congregate setting, where guests sleep in large rooms holding more than 160 people, requires a different level of care and consideration of public health variables. Shelter protocols incorporated recommendations for appropriate isolation and treatment, given the constraints and challenges of the shelter setting. For example, guests with lice were treated before entering the shelter, whereas those with scabies were isolated in smaller sleeping rooms at the shelter for treatment. Asylum seekers with influenza-like illness required off-site respiratory isolation, and patients with varicella required off-site respiratory isolation, and travel clearance after all lesions had scabbed. Additionally, the difficulty of using creams for scabies treatment in a facility with limited shower

access led to the use of oral ivermectin for management of scabies in the majority of cases. For all situations where individuals required isolation, family members were allowed to remain with them in isolation rooms or off-site locations were arranged to accommodate the entire family unit. From December 2018 to March 2019, the SDRRN shelter was located at a facility in the South Bay donated by Catholic Charities. Every evening, one or more large groups of asylum seekers were brought by bus to the shelter by ICE or CBP upon their release into the U.S. The shelter held more than 150 people in a congregate room and had showers, on-site kitchen serving hot meals prepared by volunteers, and a playroom for children. However, due to space limitations and for infection control purposes, health screening on arrival took place outside, prior to entry into the shelter. Nurse intake, lice screenings, and some physician screenings took place in outdoor tents. While accommodations were attempted for weather conditions, this was not always feasible. When possible, physician screening was conducted in an entryway and inside an extra mobile clinic van parked on-site. Mobile on-site clinics from local federally qualified health clinics (FQHCs) were available in the parking lot for further evaluation of patients who required non-emergent acute care or prescription medication beyond the standard intake screening. On Jan. 29, the San Diego County Board of Supervisors voted to use a countyowned facility as a temporary migrant shelter to house asylum-seeking families being released into San Diego. In April the shelter moved to the current location in downtown San Diego. The new space allowed for a large, well-ventilated indoor screening area prior to shelter entry and more permanent clinical resource setup for provision of on-site acute care to new arrivals and those staying in the shelter. Between Dec. 30, 2018, and Aug. 18, 2019, a total of 14,420 asylum seekers were screened at the shelter. The most commonly observed conditions were lice, scabies, influenza, varicella, and pregnancy complications. There have been zero cases of measles, mumps, hepatitis A, or tuberculosis, despite public concerns that this

SANâ&#x20AC;&#x2C6;DIEGOâ&#x20AC;&#x2C6;PHYSICIAN.ORG

INFECTIOUS DISEASE population would be at increased risk for vaccine-preventable childhood illnesses and tuberculosis based on their countries of origin. Influenza at the Shelter In mid-May, DHS began sending flights of detained asylum seekers from Texas to facilities in San Diego. Several days after this started, an outbreak of influenza was reported in the McAllen facility in Texas. In San Diego, several cases of influenza were identified during routine health screenings at the shelter, and an outbreak of influenza was declared. During this time, all guests at the shelter were rescreened daily for influenza-like illness (ILI) using a standardized protocol that included screening questions and vital signs. All guests screening negative for ILI were given oseltamivir chemoprophylaxis and were rescreened daily to monitor for any new ILI symptoms. All new arrivals and existing guests screening positive were immediately placed in respiratory isolation off-site, started on oseltamivir treatment, reassessed daily, and kept in isolation until 24 hours after the last reported or recorded fever. During this period, over 100 cases of ILI were identified and treated. In midJune, the outbreak was declared over, daily ILI screening among the shelter population ceased and oseltamivir prophylaxis was discontinued due to elimination of influenza from the shelter population. Routine ILI screening remains for all asylum seekers on arrival to the shelter with influenza rapid diagnostic testing present on-site for any who screen positive. Educational Component In order to staff the daily clinic, a large and diverse group of clinicians were recruited and trained, with a focus on clinicians with prior experience in international health, underserved medicine, infectious disease, and public health. As of July 2019, the program included 61 physicians, five nurse practitioners, and 92 residents representing training programs across San Diego County. Additionally, NP and RN students from USD and medical students from UC San Diego were su-

OCTOBER 2019

pervised at the clinic as a part of their clinical rotations. For each clinic shift, a lead physician was assigned in order to oversee and organize the clinical staff, coordinate care with the shelter manager, and assign supervision of students and trainees. Participating training programs who sent their residents and students to work at the shelter include: Scripps-Mercy Family Medicine Residency Program; UC San Diego residents and fellows from Preventive Medicine, Family Medicine, Internal Medicine, Pediatrics, and Emergency Medicine Programs; Scripps Green Internal Medicine Residency Program; and Kaiser Family Medicine Residency program. Broad participation of training programs in San Diego allowed for physicians, NPs, and RNs to gain experience providing population and public healthcare in a resource-limited setting, expand knowledge of outbreak prevention and management, and deliver healthcare to a diverse patient population. While the majority of the asylum seekers are from Central America, they have traveled from numerous different locations. Spanish language interpreters were present

on-site for clinicians not fluent in Spanish. A phone interpretation service was used for all other languages. Asylum seekers’ countries of origin and native languages have been diverse and included: Russian, Vietnamese, Haitian Creole, Punjabi, and Mayan languages (e.g., Mam, K’iche’, Q’eqchi’). Additionally, asylum seekers had often traveled through numerous countries in order to reach the U.S.-Mexico border, with some guests listing countries extending from Chile north through Central America and others having traveled through Europe and Asia prior to arrival in Mexico. Due to this diversity of travel experience and possible exposures, clinicians had to remain aware of the potential for infectious and tropical diseases not typically seen within the United States. Current Status and Conclusion Starting in June 2019, numbers of new arrivals released by ICE and brought to the shelter have markedly decreased. This is due in part to the implementation of new U.S. policies, including the Migrant Protection Protocols (MPP), which forces asylum seekers to return to and remain in

Mexico to await their immigration court date in the U.S., as well as seasonal drops in new arrivals at the U.S.-Mexico border typically observed during the hot summer months. With the downturn in new arrivals, the resolution of the influenza outbreak, and the conclusion of the six-month contract with UC San Diego, the County of San Diego extended a contract with UC San Diego to provide new arrival shelter screening including screening previously conducted by HHSA nurses, but also to include acute care for those staying in the shelter, follow-up care for guests isolated off-site in hotels, and transition of care for long-term guests. Over the past year, changes in asylumseekers presenting at the border, including a large number of families with young children, has presented a challenging and dynamic situation in San Diego. During

this time, the coalition of public and private organizations including the County of San Diego Health and Human Services Agency, UC San Diego Health, the County Board of Supervisors, participating community health centers (La Maestra and San Ysidro Health Center), and the San Diego Rapid Response Network have collaborated to address the health of recently released asylum seekers and maintain broader public health of San Diego. While international affairs and evolving federal regulations regarding asylum seekers make it difficult to predict future needs and a timeline for ongoing use of the shelter and health screenings, participating entities and clinicians remain committed to meeting needs as they arise. Further information about helping these efforts: • Funds are desperately needed to main-

tain daily operation of the shelter and to support cross-country travel expenses of the migrant families. Donations can be made at GoFundMe.com/ MigrantReliefSD or at rapidresponsesd.org. • Donations can also be made via the Amazon Wish List to supply clothing, personal hygiene items and more. Or visit rapidresponsesd.org for donation drop-off locations. Dr. Horton is an infectious diseases specialist and Dr. Thorne is a preventive medicine physician, both at UC San Diego. Dr. Horton serves as site director of the Health Assessment Program for asylum-seekers at the shelter run by Jewish Family Services/ Rapid Response Network in San Diego and Dr. Thorne serves as one of the shelter’s lead physicians.

Tracy Zweig Associates INC.

REGISTRY

PLACEMENT

FIRM

Physicians

Nurse Practitioners Physician Assistants

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

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SAN DIEGO PHYSICIAN.ORG

INFECTIOUS DISEASE

PRESCRIBING ANTIBIOTICS TO PREVENT INFECTION A Reassessment of the Risks and Benefits of Surgical Antibiotic Prophylaxis BY SHIRA ABELES, MD PEOPLE WITH SERIOUS bacterial infections need antibiotics. The rest of the time, particularly when we use them to prevent infections, the benefits of antibiotics are less clear while the potential harms remain significant. In this age of antibiotic resistance, we have to seriously consider the use of antimicrobials and the individual and communal risks and benefits of each use. In this context, we have been reexamining how and why antibiotics should be used for clean and cleancontaminated surgeries. The literature has shown across the surgical spectrum

OCTOBER 2019

that antibiotics given after surgeries for prophylaxis do measurable harm without benefit, and therefore optimizing the potential benefits while minimizing harm is the best approach for our patients. What role do prophylactic antibiotics play in SSI prevention? Not only must an operation achieve its goal, but it must avoid complications from the surgery itself, including surgical site infections (SSIs). There have been many advances in preventing SSIs over the last two centuries, starting with the basic concepts

of handwashing in the 1800s with Ignaz Semmelweis, the concept of germ theory by Louis Pasteur in the mid-1800s, and the practice of sterilization starting with Joseph Lister in the 1860s with carbolic acid. Over time, we have developed numerous sophisticated pre-, peri- and post-operative practices to avoid SSIs; from the highly controlled environment of the operating room to advanced sterilization practices, cutting edge surgical techniques, preparation of the surgical site, optimization of underlying patient factors such as obesity, diabetes control, and nutritional status, enhanced recovery after surgery protocols (ERAS), and finally to advances in post-operative wound care. These efforts are incorporated in the everyday prevention of SSIs and they are highly effective; all in the absence of antibiotics. Some clean surgeries and procedures do not warrant antibiotic prophylaxis (such as some clean thyroid and parathyroid surgeries, for example,1) but in other clean and clean-contaminated surgeries, antibiotics may provide some protection against SSIs.2 The goal of prophylactic antibiotics is to be active in the surgical field at the time of surgery when normally sterile tissues are exposed and have a surface in common with non-sterile body sites or the air. It is widely understood that if antibiotics are started significantly after incision time, they lose their potency, and have virtually no effect when started after surgery.3, 4 Based on this research that clearly demonstrates that antibiotics lose their protective potency if started late into or after a surgery, it should not be surprising that continuing antibiotics after the surgery also does not add any benefit in preventing SSIs. Â Why donâ&#x20AC;&#x2122;t longer courses of prophylactic antibiotics prevent bacterial infection? When antibiotics are used to treat an infection, their target is clear: They target specific bacteria that have grown out of control in a site within the body. Once these bacteria are adequately killed, the antibiotics can and should be stopped. When antibiotics are used for surgical antibiotic prophylaxis, their target is a location, not an overgrowth of a specific bacteria. Antibiotics cannot sterilize the skin or mucosal surfaces, but a dose of antibiotics pre-operatively that targets the main pathogenic

bacteria in the pertinent body surfaces involved in the surgery (and re-dosing during surgery if appropriate) can reduce the burden of bacteria in the surgical field. When the surgery is complete and the surfaces of the body are intact again, there is no further benefit to ongoing prophylactic antibiotics.5 Instead, resistant organisms grow and colonize the patient including at the site of surgery, and the patient will also be at further risk for C difficile infection, and antibiotic side effects.6 If bacteria invade the surgical site during an operation, there would not be enough time for the bacteria to establish large robust colonies, so killing these bacteria with antimicrobials would not require sustained antibiotic pressure. After an operation is complete, clean tissues are no longer in communication with sites colonized with microbes. In addition, the surgical site would be well-perfused and the antibiotics during surgery would presumably get to the surgical site and sterilize it. After the surgical wound is closed, there is no added benefit for the patient to receive antibiotics, but there are added risks. This has been shown in an increasing number of studies across all surgical specialties.7-12 Surgical guidelines are therefore now firmly recommending stopping prophylactic antibiotics at time of wound closure for clean (wound class I) and clean contaminated (wound class II) surgeries.7,8 Providers perceive that prolonging prophylactic antibiotics after clean and clean-contaminated surgeries will protect the patient, but this unfortunately is not the case. Instead, the myriad of other initiatives aimed at SSI prevention should be emphasized. Oftentimes enforcing strict hand hygiene, sterile technique, and wound care are more powerful and safer than the addition of extra antibiotics which unintentionally only introduce unnecessary risks and often side effects such as nausea, diarrhea, and potentially more serious adverse drug events. How about antibiotics when drains have been placed? Prolonging prophylaxis due to the presence of surgical drains is not recommended for the same reasons above.9,10 It makes more sense to keep the area of the drain clean, rather than to place selective pres-

sure on the skin microbiota with systemic antibiotics. Prolonging antibiotics in these situations does not prevent infections, but when infections do occur, they harbor more resistant bacteria.13 For clean and clean-contaminated surgeries, surgical antibiotic prophylaxis should stop at the time of wound closure. Across the surgical spectrum, the evidence does not support improved benefit with post-operative antibiotics; rather, it can cause potential harm. Dr. Abeles is medical director of Antimicrobial Stewardship and an Infectious Diseases specialist with UC San Diego Health’s Jacobs Medical Center. References 1. Uruno T, Masaki C, Suzuki A, Ohkuwa K, Shibuya H, Kitagawa W, Nagahama M, Sugino K, Ito K. Antimicrobial prophylaxis for the prevention of surgical site infection after thyroid and parathyroid surgery: a prospective randomized trial. World J Surg. 2015 May;39(5):1282-7. doi: 10.1007/ s00268-014-2932-1. 2. Bowater RJ1, Stirling SA, Lilford RJ. Is antibiotic prophylaxis in surgery a generally effective intervention? Testing a generic hypothesis over a set of meta-analyses. Ann Surg. 2009 Apr;249(4):551-6. 3. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgicalwound infection. N Engl J Med. 1992 Jan 30;326(5):281-6. 4. de Jonge SW, Gans SL, Atema JJ, Solomkin JS, Dellinger PE, Boermeester MA. Timing of preoperative antibiotic prophylaxis in 54,552 patients and the risk of surgical site infection: A systematic review and meta-analysis. Medicine (Baltimore). 2017 Jul;96(29):e6903. doi: 10.1097/ MD.0000000000006903. 5. McDonald M, Grabsch E, Marshall C, Forbes A. Single- versus multipledose antimicrobial prophylaxis for major surgery: a systematic review. Aust N Z J Surg. 1998;68(6):388-396. doi:10.1111/j.1445-2197.1998.tb04785.x 6. Branch-Elliman W, O’Brien W,

Strymish J, Itani K, Wyatt C, Gupta K. Association of duration and type of surgical prophylaxis with antimicrobial-associated adverse events. JAMA Surg. 2019 Jul 1;154(7):590-598. doi: 10.1001/jamasurg.2019.0569. 7. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 2017; 152:784. 8. Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. Journal of the American College of Surgeons Volume 224, Issue 1, January 2017, Pages 59-74 https://doi. org/10.1016/j.jamcollsurg.2016.10.029 9. Murphy RK, Liu B, Srinath A et al. No additional protection against ventriculitis with prolonged systemic antibiotic prophylaxis for patients treated with antibiotic-coated external ventricular drains. J Neurosurg . 2015;122(5):1120–1126. 10. Lewis A, Lin J, James H, Krok AC, Zeoli N, Healy J, Lewis T, Pacione D. A single-center intervention to discontinue postoperative antibiotics after spinal fusion, British Journal of Neurosurgery. 2018: 32:2, 177-181. 11. Orlando G, Manzia TM, Sorge R, Iaria G, Angelico R, Sforza D, Toti L, Peloso A, Patel T, Katari R, Zambon JP, Maida A, Salerno MP, Clemente K, Di Cocco P, De Luca L, Tariciotti L, Famulari A, Citterio F, Tisone G, Pisani F, Romagnoli J. One-shot versus multidose perioperative antibiotic prophylaxis after kidney transplantation: a randomized, controlled clinical trial. Surgery. 2015 Jan;157(1):104-10. 12. Harbarth S, Samore MH, Lichtenberg D, Carmeli Y. Prolonged antibiotic prophylaxis after cardiovascular surgery and its effect on surgical site infections and antimicrobial resistance. Circulation. 2000;101(25):2916. 13. Lewis A, Sen R, Hill TC, James H, Lin J, Bhamra H, Martirosyan N, Pacione D. Antibiotic prophylaxis for subdural and subgaleal drains. J Neurosurg. 2017 Mar;126(3):908-912. doi: 10.3171/2016.4.JNS16275.

SAN DIEGO PHYSICIAN.ORG

CLASSIFIEDS PHYSICIAN OPPORTUNITIES SAN DIEGO COUNTY EMPLOYMENT OPPORTUNITY: The County of San Diego has a current employment opportunity for M.D.Chief, TB Control & Refugee Health (Public Health Medical Officer). Please see the link for more information: M.D.-Chief, TB Control & Refugee Health (Public Health Medical Officer19412807UTB INTERNAL MEDICINE PHYSICIAN: Solvang, California – Established private internal medicine practice in the heart of wine country in the beautiful Santa Ynez Valley within Santa Barbara County seeks a BC/BE internist to join a busy practice within the lovely Danish town of Solvang. Competitive salary and benefits while living and working in a small community with excellent schools, short commutes, fine restaurants, entertainment and Mediterranean climate with no smog or traffic. Enjoy excellent quality of life while practicing medicine in a small clinic affiliated with the Cottage Health System. For more information please contact Office Administrator Amy Comer at 805/688-2600. FAMILY PRACTICE MD/DO: Family Practice MD/DO wanted for urgent care and family practice office in Carlsbad, CA. Flexible weekday and weekend shifts available for family practice physician at busy, wellestablished office. FAX or email CV to (760) 603-7719 or gcwakeman@sbcglobal.net. PART-TIME/FULL-TIIME RADIOLOGIST POSITION OPEN - IMPERIAL RADIOLOGY: MEDICAL DIRECTOR, CALIFORNIA CHILDREN’S SERVICES: The Our company is an outpatient diagnostic radiology facility in search of a part-time/full time radiologist. All candidates must have an active California Medical License. Please contact us via e-mail at info@carlsbadimaging.com with your resume if this positiion is of interest to you. Thank you. Job Type: Part-Time/Full Time. Pay: TBD. 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 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

OCTOBER 2019

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.

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

PHYSICIAN POSITIONS WANTED RESEARCH PHYSICIAN (NO CLINICAL PRACTICE) PHYSICIAN Provides medical leadership, oversight, and management of human clinical trials while ensuring the integrity of the studies and the safety and well-being of human subjects. Performs duties in accordance with company’s values, policies, and procedures. On call responsibilities: shares in rotation of weekly call schedule. Please email resumes to tabitha. alvarado@prosciento.com PRACTICE FOR SALE CLINICAL RESEARCH SITE/MULTI-SITE SPECIALTY PHYSICIAN PRACTICE COMBO FOR SALE: Great opportunity for a Group Practice. Clinical Research offers a way for physicians to continue to practice medicine the way they like and provide an additional source of income that is compatible with their goal of providing great care and options for their patients. Patients will have the opportunity to participate in the research of new treatments. Current site has staff and facilities for research, physician suites, and X-Ray. Use as a primary location or as a satellite office with research site. Current physicians and staff willing to train and work alongside physicians new to research. Contact E-Mail: CL9636750@gmail.com

NEW OFFICE SPACE IN VISTA

500-4000 sq. ft. office units available for lease in brand new high-quality building, in second story with elevator above a thriving primary care clinic and urgent care attracting 100 patients per day of foot traffic. Street-facing and located in Vista along the growing redevelopment zone. Please contact Richard Alvarez at Prime Investors Corp. ralvarez2@verizon.net or 760-224-9283. 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.

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. OFFICE SPACE / REAL ESTATE AVAILABLE 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.

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 usage. Contact Jo Turner (619) 7334068 or jo@siosd.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) 2918930 or cell (619) 840-0624. 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. NON-PHYSICIAN POSITIONS AVAILABLE

OUTPATIENT PRIMARY CARE PHYSICIAN Located in Vista/Oceanside, Vista Community Clinic is a private, nonprofit outpatient community clinic with 5 locations in North San Diego County, serving people who experience social, cultural or economic barriers to health care. Position: Full-time, Part-time and Per Diem FM/IM Physicians. Responsibilities: Provide outpatient care. No hospital call. Malpractice coverage provided. Requirements: California license, DEA LICENSE, CPR CERTIFICATION AND BOARD CERTIFICATION. Visit us at www.vistacommunityclinic.org Forward resume to hr@vistacommunityclinic.org EEO/AA/M/F/Vet/Disabled

FINANCE DIRECTOR: San Diego Sports Medicine and Family Health Center is hiring a full-time Financial Director to manage financial operations. Primary responsibilities include

monitoring of income, expenses and cash flow, reconciling bank statements, supervision of accounts payable, oversee billing department, oversee accounts receivables, payments and adjustments, prepare contracts, analyze data, prepare financial reports, prepare budgets, advise on economic risks and provide input on decision making. MBA/Master’s and 5+ years relevant work experience preferred. Excellent references and background check required. Salary commensurate with skills and experience. To apply, please send resume to Jo Baxter, Director of Operations jobaxter@ sdsm.com PHYSICIAN ASSISTANT/NURSE PRACTITIONER: Our growing Neurosurgery office in Chula Vista is looking for a part-time Nurse Practitioner/Physician Assistant. The job requires running clinic two days per week and possible hospital rounds/surgical assist in the future. We are looking for an efficient, hardworking team player with communication skills, caring and ability to adequately document is expected. Must have a current CA (PA or NP) license. We are willing to train the right candidate. For more information, fax resume to (619) 476-7963 Attn: Office Manager. NON-PHYSICIAN POSITIONS WANTED 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 process-related outcomes and establish benchmarks, and the production of automated reporting. (619) 913-7568 | 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) 3002780. [559]

PLACE YOUR AD HERE Contact Dari Pebdani at 858-231-1231 or DPebdani@SDCMS.org

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INFECTIOUS DISEASE [Continued from page 7] culture on test-of-cure if there is evidence of decreased susceptibility to cephalosporins, regardless of whether sexual contact post-treatment is reported.1 If persistent or recurrent symptoms occur 3 to 5 days after completing treatment, patients should be evaluated for reinfection or for other sexually transmitted infections.1 If reinfection is unlikely, culture and NAAT for N. gonorrhoeae should be submitted.1 All suspected treatment failure should be reported to the local public health authorities and Centers for Disease Control and Prevention at (404) 718-5447.1 Overall, the management of suspected treatment failure is uncertain. The same initial regimen with ceftriaxone 250mg intramuscular and azithromycin 1 gram orally as a single dose can be given as reinfection is more likely than resistance.1 If symptoms persist or recur despite repeated treatment, higher doses with ceftriaxone 1 gram intramuscular and azithromycin 2 grams orally as a single dose can be considered to overcome the elevated MIC.1 Other alternative regimens to consider are gentamicin 240mg intramuscular with azithromycin 1 gram orally or ertapenem for 3 days.1 Treatment may require individualized use of nontraditional antimicrobial regimen. Conclusion While promising results have been shown with new regimens (gepotidacin, and zoliflodacin)9,10, action is needed by clinicians, laboratories, public health officials, and all those at risk. Continued surveillance for gonococcal resistance along with ongoing research and development of new treatment regimens are crucial as antimicrobial resistance threatens the treatment and prevention of gonococcal infection. Bibliography 1. Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64:1-137 2. McCormack WM, Stumacher RJ, Johnson K, et al. Clinical spectrum of gonococcal infection in women. Lancet 1977; 1:1182-5

OCTOBER 2019

Table 1: Antimicrobial resistance responsible for the different resistance mechanisms in Neisseria gonorrhoeae8

Enzymatic antimicrobial destruction or modification

Target modification or protection reducing antimicrobial affinity

Antimicrobial Agent

Genes

Mechanism

Penicillin

Penicillinase

Hydrolyze and inactivate β-lactam ring

Sulfonamide

folP

Alteration in target DHPS

Penicillin

penA

Decrease PBP2 acetylation rate

Penicillin

ponA

Reduces penicillin acylation of PBP1

Tetracycline

rpsJ

Reduces affinity for 30S ribosomal target

Tetracycline

tetM

Blocks target binding

Spectinomycin

rpsE

Disrupts binding to the ribosomal target

Fluoroquinolone

gyrA

Reduces binding to DNA gyrase

Fluoroquinolone

parC

Reduces binding to topoisomerase IV

Macrolide

erm

Block binding to 23S rRNA

porB1b

Produce alteration in porin

pilQ

Produce alteration in porin

Penicillin

mtrR

Overexpression of MtrCDE efflux pump

Macrolide

mef

Encodes efflux pumps

Decreased influx of antimicrobials

Increased efflux of antimicrobials

3. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2017. Atlanta, GA: US Department of Health and Human Services; September 2018 4. Sexually Transmitted Diseases in San Diego County 2018. County of San Diego, Health and Human Services Agency 5. Centers for Disease Control and Prevention. Antibiotic-resistant gonorrhea. Atlanta, GA: US Department of Health and Human Services; 2018 6. Ohnishi M, Saika T, Hoshina S, et al. Ceftriaxone-resistant Neisseria gonorrhoeae, Japan. Emerg Infect Dis. 2011 Jan;17(1):148-9 7. Fifer H, Natarajan U, Jones L, et al. Failure of Dual Antimicrobial Therapy in Treatment of Gonorrhea. N Engl J

Med. 2016 Jun 23;374(25):2504-6 8. Suay-García B, Pérez-Gracia MT. Drugresistant Neisseria gonorrhoeae: latest developments. Eur J Clin Microbiol Infect Dis. 2017 Jul;36(7):1065-1071 9. Taylor SN, Marrazzo J, Batteiger BE, et al. Single-Dose Zoliflodacin (ETX0914) for Treatment of Urogenital Gonorrhea. N Engl J Med. 2018 Nov 8;379(19):1835-1845 10. Taylor SN, Morris DH, Avery AK, et al. Gepotidacin for the Treatment of Uncomplicated Urogenital Gonorrhea: A Phase 2, Randomized, Dose-Ranging, Single-Oral Dose Evaluation. Clin Infect Dis. 2018 Aug 1;67(4):504-512 Dr. Kang is an infectious diseases fellow at UC San Diego with a primary focus on antimicrobial stewardship/hospital epidemiology.

Dr Tania Rivera and her staff at Rheumatology Center of San Diego

C H A M P I O N S F O R H E A LT H

Daniel G, Project Access patient

Reconnecting With Life By Adama Dyoniziak

“SHE NEVER ABANDONED ME… and she wanted to help me” is how Daniel describes Dr. Tania Rivera, his physician at Rheumatology Center of San Diego. Daniel had psoriasis with arthritis, which greatly affected his entire life. “People would look at me with disgust. I had to wear long sleeves so that my skin could not be seen. I was embarrassed, and became depressed so much that I didn’t want to leave my home to [avoid people’s looks]. But thank God there are people who helped me through Project Access like Dr. Rivera.” Daniel is a husband with four children and one grandchild. “I was feeling despair due to my sickness,” he says, and he was

worried he would not be able to provide for his family as a dishwasher. “The truth is, [psoriasis] gave me a lot of shame. [Co-workers] asked me ‘what do you have there?’ And I would say ‘nothing’ and I would roll down my long sleeves. “But when the supervisor saw me ... I quit work. Even with my own wife I was embarrassed. I wondered: ‘What reaction will she have?’ ‘Will she treat me differently?’ but she said, ‘I know your illness and I know it is not contagious.’” Dr. Rivera says that helping patients and seeing their happiness as their condition improves is her reward for volunteering. “Patients need physicians help because

they have no other means, and a doctor needs to go back to his/her roots as to why they joined the profession to know that they can help [by volunteering] as well,” she says. Dr. Rivera believes volunteering is an important part of life. “I have done volunteer work all my life. I volunteered  at my church as a teen, in medical school I worked with end-stage cancer patients as a support person,” she says. “Along with Project Access, I also volunteer at the UCSD Student Run Free Clinic.” In her spare time, Dr. Rivera enjoys hiking and spending time outdoors with her husband and children. She is an avid runner and has run in the New York City Marathon. The good news is that Daniel is now able to reconnect with people and has his life back. “Whenever I go see Dr. Rivera, she is very generous and very kind,” he says. “She is a very good person. I am very grateful to her. I have no words to describe what Project Access has done for me. Right now I am working part-time. It’s not much, but little by little I am climbing, as they say.” Climbing back into life, one day at a time! If you would like to volunteer to provide pro bono specialty care for Project Access, please contact Adama Dyoniziak at (858) 300-2780 or adama.dyoniziak@ championsfh.org. Ms. Dyoniziak is executive director of Champions for Health.

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