May/June 2017 - Infectious Diseases Update

May/June 2017

Doctors MetroDoctors T H E J O U R N A L O F T H E T W I N C I TT II EE SS MM EE DD II CC AA LL SS OO CC II EE TT YY

D s u i s o e i t a c s e e f s In

Update In This Issue:

• HIV, VD, and C. diff — Oh My! • The Convenings • Luminary of Twin Cities Medicine

A FAC E O F A M I N N E SOTA DE R M ATOL O GIST Recognized by physicians and nurses as one of the nation’s leading dermatologists, Charles E. Crutchfield III MD has received a significant list of honors including the Karis Humanitarian Award from the Mayo Clinic, 100 Most Influential Health Care Leaders in the State of Minnesota (Minnesota Medicine), and the First a Physician Award from the Minnesota Medical Association, for positively impacting both organized medicine and improving the lives of people in our community. He has a private practice in Eagan and is the team dermatologist for the Minnesota Twins, Wild, Vikings and Timberwolves.

Dr. Crutchfield is a physician, teacher, author, inventor, entrepreneur, and philanthropist. He has several medical patents, has written a children’s book on sun protection, and writes a weekly newspaper health column.

Dr. Crutchfield regularly gives back to the Twin Cities community including sponsoring academic scholarships, camps for children, sponsoring programs for children with dyslexia, mentoring under-represented students from the University of Minnesota, and establishing a Dermatology lectureship at the University of Minnesota. As a professor, he teaches students at both Carleton College and the University of Minnesota Medical School. He lives in Mendota Heights with his wife Laurie, three beautiful children and two hairless cats.

AES

THET I C

L OF APPROVA L SEA

CRU TCHFIELD DERMATOLO GY

CRUTCHFIELD DER MATOLOGY Experience counts. Quality matters.

Mayo Clinic Medical School Graduate | University of Minnesota Dermatology Trained Top Doctor Minneapolis St. Paul Magazine | Best Doctors for Women Minnesota Monthly Magazine Team Dermatologist for the Minnesota Twins, Vikings, Timberwolves and Wild

1185 Town Centre Drive, Suite 101, Eagan | 651.209.3600 | www.CrutchfieldDermatology.com

CONTENTS V O L U M E 1 9 , N O . 3 M AY / J U N E 2 0 1 7

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IN THIS ISSUE

What Infectious Disease Keeps you Awake at Night?

By Charles G. Terzian, M.D.

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PRESIDENT’S MESSAGE

Committing to Physician Health & Wellness

By Matthew A. Hunt, M.D.

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TCMS IN ACTION By Sue Schettle, CEO

INFECTIOUS DISEASES UPDATE 6 • Colleague Interview: Page 32

A Conversation with Frank Rhame, M.D.

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• Update on Sexually Transmitted Infections in Minnesota

By Ashley Beasley, APRN, CNP

12 • Vaccination in 2017: The Good, the Sad and the Challenging.

Updates from the Advisory Committee on Immunization Practices

By Patsy Stinchfield, MS, CPNP, CIC 14

• SPONSORED CONTENT:

Page 30

Adventure Awaits: Travel and Tropical Medicine Clinics Offer Advice to Go

By Mark Sannes, M.D., MS and Cristina Baker, M.D., MPH

16 • Invasive Methicillin Resistant Staphylococcus aureus Infections

By Mackenzie Koeck, MPH, Kathryn Como-Sabetti, MPH, and Ruth Lynfield, M.D. 20

• SPONSORED CONTENT:

The Ongoing Challenge of Clostridium difficile in Healthcare Settings

By Alison Galdys, M.D.

25 • Home Infusion of Anti-infectives: Ensuring Quality of Life While Lowering Costs

By Brenda Wright

Page 6

27 • Environmental Health — Infectious Disease Implications of Climate Change

By Phillip Peterson, M.D. 28

Page 28 MetroDoctors

The Convenings: Real Families. Real Choices. Real Life

By Pamela Palan

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Senior Physicians Association Meeting Held/

In Memoriam

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Career Opportunities

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LUMINARY OF TWIN CITIES MEDICINE

George A. Sarosi, M.D.

The Journal of the Twin Cities Medical Society

May/June 2017

22 • Antibiotic Stewardship Programs: An Idea Whose Time has Come

By Gary R. Kravitz, M.D., FACP, FIDSA, FSHEA

Doctors MetroDoctors T H E J O U R N A L O F T H E T W I N C II TT II EE SS MM EE DD II CC AA LL SS OO CC II EE TT YY

Infe

ctious Diseases

Update I n Th i s I s s u e : • • •

H I V , V D , a n d C . d i ff — O h M y !

Th e C o n v e n i n g s Luminar y of Twin Cities Medicine

How effective are the antibiotics we have available today?

Vigilance in prevention and treatment are key. Articles begin on page 6.

May/June 2017

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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Robert R. Neal, Jr., M.D. Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Stephanie Misono, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Medical Student Co-editor Mac Garrett Managing Editor Nancy K. Bauer TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Erica Nelson Cover Design by Emily Larsen

May/June Index to Advertisers

TCMS Officers

President: Matthew A. Hunt, M.D. President-elect: Thomas E. Kottke, M.D. Secretary: Andrea Hillerud, M.D. Treasurer: Nicholas J. Meyer, M.D. Past President: Carolyn A. McClain, M.D. TCMS Executive Staff

Sue A. Schettle, Chief Executive Officer (612) 362-3799; sschettle@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com Karen Peterson, BSN Executive Director, Honoring Choices Minnesota (612) 362-3704; kpeterson@metrodoctors.com Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com

MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

Grace Higgins, Project Coordinator, Physician Advocacy Network (612) 362-3706; ghiggins@metrodoctors.com

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS.

Pamela Palan, Project Manager, The Convenings (612) 362-3724; ppalan@metrodoctors.com

Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.

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May/June 2017

life is good MetroDoctors

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IN THIS ISSUE...

What Infectious Disease Keeps you Awake at Night?

IN 1982, I FINISHED MY MEDICAL SCHOOL TRAINING and was beginning a surgical internship when we began noticing young healthy patients presenting with unusual, rare conditions.

By 1984 the infectious agent causing HIV was identified as the culprit, peaking my interest in the infectious disease spectrum. I recall one of my early professors and mentors telling me, both in medical school but also in my residency, that in the years to come more medical conditions would be discovered that have an infectious etiology.

In this edition of MetroDoctors, we strive to provide you with up-to-date information on infectious diseases from local experts.

As an editor of this journal, I am continually surprised at how much information the articles submitted not only equip me with informative resources for my patient care activities but also for me personally, and my family and friends. I hope you agree.

Just as my initial exposure to HIV early in my training spurred my interest in infectious disease, Dr. Frank Rhame, our Colleague Interview, relates how HIV “has been his engine of excitement” for three decades. He gives us a concise update on HIV and Hepatitis C with real world experiences from the trenches.

To compliment Dr. Rhame’s interview, we asked a local expert in STDs, Ashely Beasley, APRN, CNP from the Red Door Clinic, to provide a brief update. Unfortunately the trend in STDs is increasing in Minnesota; she offers some preventive strategies.

How many of us actually keep up-to-date on the recommendations for vaccinations — especially, those of us with adolescent children? We present an article from Patsy Stinchfield, an Infectious Diseases CNP at Children’s Hospital, outlining the updated 2017 vaccinations. The information provided includes vaccinations for common entities like influenza and STDs. But don’t think these recommendations apply only to kids — important knowledge is also imparted about some adult vaccinations.

Vaccinations for influenza are considered routine these days.

However, many of us (and our patients) are now taking vacations to somewhat exotic locations and find ourselves exposed to a multitude of infectious agents. An excellent article submitted by the Park Nicollet and HealthPartners travel and tropical medicine clinics points out what we need to know before travel and

By Charles G. Terzian, M.D. Member, MetroDoctors Editorial Board

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the necessary vaccinations and lifestyle management to prevent these illnesses.

In my work as a hospitalist we are vigilant in regard to infection prevention. We are cognizant of what were previously deemed primarily hospital acquired infections such as MRSA and Clostridium difficile; therefore, it is not unusual to see multiple patients with a variety of preventive measures instituted during their inpatient care. That spectrum has somewhat changed. In this edition, we provide an update from the Minnesota Department of Health on the epidemiology of MRSA infections — still a significant challenge for practitioners to identify and manage.

Just as prevalent as MRSA, Clostridium difficile remains a significant challenge in the inpatient setting. An article by Dr. Galdys from the University of Minnesota discusses the hospital economics, epidemiology, and medical management and prevention strategies related to C. diff.

We are all familiar with the emergence of these and other pathogens by our use and over-use of antibiotics. Dr. Kravitz points out in his article that antibiotic resistance has been occurring since the advent of penicillin. Antibiotic stewardship programs were a necessary and important trend in healthcare as recommended by infectious disease experts and now are mandated by the regulatory agencies overseeing hospitals. An in-depth look at how these programs operate and the expected goals is presented.

Many patients need long-term antibiotic management after they leave the hospital. Appropriate referral and education for both providers and patients is essential for this patient population.

Option Care recommends establishing step-by-step protocols to ensure appropriate, quality care is received.

George Sarosi, M.D., the featured Luminary, rounds out this edition underscoring his accomplishments as a highly regarded internist, infectious disease and pulmonary medicine specialist.

We hope you find this valuable and timely information will not only increase your knowledge to better care for your patients and your family, but it might also make for great conversation with colleagues.

May/June 2017

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President’s Message

Committing to Physician Health & Wellness MATTHEW A. HUNT, M.D.

YOU MAY RECALL THE MARCH/APRIL ISSUE of MetroDoctors focused on the topic of addiction. At the beginning of the issue were two key articles about Physicians Serving Physicians (PSP) and Health Professionals Services Program (HPSP). These programs work to help physicians who struggle with addiction and help manage their return to practice if possible. HPSP provides physicians an option to enroll in treatment and monitoring and avoid action by the Board of Medical Practice. PSP works to identify, intervene and support physicians and those around them dealing with addiction. It is an invaluable service for physicians and medical students and meets the reporting requirements of HPSP. One of the pillars of the TCMS strategic plan is that the “Twin Cities is one of the best environments to live and practice in the nation.” It seems to me that an important part of that ‘best environment’ is one that supports physicians at his or her time of greatest need.

According to some, approximately 10% of physicians may face a substance abuse disorder during his or her career. When you add burnout to this list, the prevalence of problems can top 50%. Physicians suffering from addiction, dependency, mental health disorders, or burnout should receive the same nation-leading care that we seek to provide for all of our patients. Our goal to achieve health and well-being for the Twin Cities should not exclude the providers working to make it happen!

With that in mind our organizations, TCMS and TCMS Foundation, have the opportunity to partner with PSP to strengthen and broaden its work. In dealing with physicians recovering from addiction, PSP has recognized that addiction can often be only one part of the problem. Issues beyond addiction, such as co-occurring disorders, or even ‘simple’ burnout compound the problems that physicians face in recovery. For a program that has been sustained on the goodwill of so many and provided its services free of charge for nearly 40 years, growth beyond the main focus on addiction has been a challenge. Joining forces with TCMS brings the opportunity to grow PSP in order to be able to face the breadth of problems that they want to address. This partnership would help TCMS champion support for physicians across the region.

The invitation to grow PSP is before us. TCMS should partner with PSP to provide sustainable, comprehensive care to our members and all physicians in the region when they need help. Our patients and our colleagues deserve this commitment from us.

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May/June 2017

MetroDoctors

The Journal of the Twin Cities Medical Society

TCMS IN ACTION SUE A. SCHETTLE, CEO

Physician Wellness

Supporting T-21

TCMS proactively began conversations with the leaders of Physicians Serving Physician (PSP) as they contemplate what to do next as their long-time executive director, Diane Naas, nears retirement. PSP is a peer program that provides peer support, assessment, consultation and referral to physicians, their families and colleagues who are affected by addiction. Started in 1981, PSP provides assistance to chemically dependent and alcoholic physicians and their families. As I write this update it appears that TCMS is poised to take over the operations of PSP in 2018, if not before.

We really value the services that are offered to physicians and their families through this program and would not want to see it slip away. Hopefully in my next update I can say that it’s a done deal. (See related President’s Message on previous page.)

The TCMS Board of Directors is supporting an ordinance to restrict the sale of tobacco products to persons over the age of 21 in the city of Edina. Board member Caleb Schultz, M.D., serves as a Commissioner on the City of Edina’s Health Commission and leads this effort in that city. To learn more about this issue email, tcms@metrodoctors.com.

Physician Advocacy Network

TCMS tobacco advocacy continues to gain steam. TCMS physicians are currently working in 12 communities throughout Minnesota on tobacco, e-cigarette and culturally-related issues around tobacco. TCMS intern, Yasmin Samatar, is working with Well-Share International focusing in on educating high school youth, providing activities for students and teaching them to be teachers of their classmates. Also, targeted secondhand smoke and e-cigarette efforts are underway in Richfield clinics serving the Latino population and a local Somali school. TCMS intern Symone McClain is working to educate medical and other health sciences students at the University of Minnesota about the harms of menthol tobacco and engage them as advocates for policy change. To date, over a dozen students have volunteered to meet with their city council member.

MetroDoctors

Physician Leadership

TCMS leaders have literally been working throughout the country to empower physicians to become public health advocates. Thanks to a grant received from the Physicians Foundation, TCMS physician leaders are sharing with other county and state medical associations what they have learned as physician champions for public health. We have been to Iowa and Michigan and plan to visit Colorado, Florida, Connecticut and Montana in the coming months.

Transitions Clinic Model

The TCMS board recently heard from leaders behind a movement called the “transitions clinic model” that works to help prisoners transition from incarceration to community life, utilizing community health workers that have a

shared life experience around incarceration. The TCMS board voted to support a grant application that would help bring this model to Minnesota.

Twin Cities Physicians’ Social — May 23, 2017

Twin Cities physicians and physiciansin-training are invited to attend a free social event on Tuesday, May 23 from 5:30 to 8 p.m. at Lake Monster Brewing in St. Paul. The event is a celebration of medicine, a thank you to members, and a welcome to new and prospective members. Food and beverages will be provided. In conjunction with the event, tours of LeafLine Labs, a registered Minnesota medical cannabis provider, will be available. Visit their state-of-the-art St. Paul patient care center (adjacent to Lake Monster Brewing) and learn more about how our medically-focused law differs from common misconceptions.

Mark your calendars and watch your email for more information!

TCMS Intern and Respiratory Therapy student Yasmin Samatar talks to Karen students at LEAP High School about the impact of smoking on lung health.

The Journal of the Twin Cities Medical Society

May/June 2017

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Infectious Diseases Update

Colleague Interview: A Conversation with Frank Rhame, M.D.

F

rank Rhame, M.D. currently serves as the Infectious Diseases Research Director at Abbott Northwestern Hospital; Adjunct Professor, Division of Epidemiology, Department of Medicine, University of Minnesota; and Adjunct Associate Professor, Epidemiology, School of Public Health, University of Minnesota. Dr. Rhame received his medical degree from Columbia University College of Physicians and Surgeons. He completed a medical internship at Harlem Hospital Center, Columbia Service and medical residencies at the University of Michigan Hospital and Stanford Hospital, where he also completed an Infectious Disease fellowship.

Please provide a (brief) historical overview of HIV. Human Immunodeficiency Virus (HIV) is a zoonosis of chimpanzees, specifically the Pan troglodytes subspecies troglodytes that made an all too successful species jump to humans in extreme southeastern Cameroon in about 1920. (The extraordinary power of DNA sequencing permits this reconstruction).

For the next 50 years, just down the Congo River in the new metropolis of Kinshasa, the virus amplified and adapted to humans. Beginning about 1960 it began its lethal spread around the globe.

This is just the latest in a long series of assaults on the Order Primates by retroviruses. In fact, we have evolved at least three specific proteins designed to thwart retroviruses.

HIV has evolved separate accessory proteins to counteract each of these defenses. Our genes that code for these defensive proteins are among those that have been most heavily affected by evolutionary pressure. More than 5% of our genome is the detritus of past retroviral attacks.

The resultant virus, HIV, takes advantage of profound human proclivities (sex and drug use). It has challenged human societies to deal with biological realities that force recognition 6

May/June 2017

and response to uncomfortable aspects of human sexuality, sexual orientation and injecting drug use. We have only been variably and incompletely successful.

HIV can grow in most human cells but needs the presence of a surface protein, CD4 (recognized by the 4th in a series of monoclonal antibodies), that enables certain lymphocytes to perform the “helper” function (hence, the two names). Untreated, the infection produces progressive immunodeficiency over 5-15 years, the last of which is the disease we recognized in 1981 as AIDS. CD4 cell depletion eventually lays the infected person open to an odd set of “opportunistic” infections, wasting and death.

The virus was discovered by Luc Montagnier in France in 1983. Robert Gallo securely linked the virus that became HIV with the clinical condition AIDS in 1984 and made the key contributions to the development of the antibody test, which became available in 1985. Zidovudine, a nucleoside reverse transcriptase inhibitor (NRTI), entered clinical trials in 1987 and several more NRTIs followed. But it was not until late in 1995 that the first protease inhibitor (PI), saquinavir, demonstrated that, with NRTIs, full control of HIV replication could be achieved. By that time, about 5,000 Americans a year were MetroDoctors

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dying of AIDS and many more around the globe, mostly in Africa. HIV has spread to every human subpopulation. The cumulative death toll is now over 130,000 in the USA and 40,000,000 globally.

What public health improvement measures related to HIV have been instituted and how effective have they become? Has human preventive behavior in susceptible HIV populations changed in such a way as to affect the incidence of disease?

Very sensitive blood tests, somewhat augmented by donor deferral, have brought the transfusion transmission rate to well under 1 per 1,000,000 blood component exposures. Lower rates of new infection will be needed to bring this rate lower because the virus is hard to detect in the first week of infection.

Mother-to-child transmission rates are below 1% from mothers with fully controlled virus. Minnesota has a highly effective HIV Perinatal Program directed by Laura Hoyt, M.D. and carried out by Cheri Booth, RN, MSN, MPH that is dedicated to doing what it takes to be sure Minnesota pregnant women take antiretrovirals well and are properly managed at delivery. Minnesota has not had a transmission in 20 years from a mother who took her medications as prescribed.

Unfortunately, not all states have such a strong program and globally full suppression rates are often inadequately achieved.

Pregnant women who do not take their meds well pose one of the most difficult ethical challenges I have encountered.

Occupational HIV transmission has virtually disappeared since the 1980s. Recognition of the hazard of blood to health care workers and the expenditure of large sums to purchase equipment with a lower chance of percutaneous exposure is largely responsible but post-exposure prophylaxis (PEP) has probably helped.

The incidence of HIV transmission by needle sharing is much less common now than what it was in the 1980s. It is perhaps surprising that the rate is still as high as it is today since little effort is required to obtain clean needles and syringes and there is no downside to using clean works. But an instinct for long-term health preservation can be lacking in substance abusers.

In spite of enormous effort and expenditure, we have hardly affected rates of unprotected sexual intercourse. This is perhaps unsurprising given the human impulse to sexual activity. It is undoubtedly unwise to have unprotected sex with a person of uncertain repute. But the per act rate of HIV transmission with a known HIV positive person off medications is of the order of 1 in 100 and if the HIV status of the partner is unknown HIV status, the odds are longer. This often is not enough to deter a sexually aroused person. That’s how MetroDoctors

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N gonorrhea and C trachomatis make a living. Condoms do reduce sexual pleasure and performance to varying degrees.

Fortunately, sexual transmission from persons with undetectable HIV in the blood is exceedingly rare. Many, probably most, HIV positive persons are motivated to avoid passing on the virus. Some do it by condom use or abstinence. Most do it by taking antiretrovirals. Sexual transmission rates are declining because an increasing fraction of HIV positive persons are taking antiretrovirals well and because HIV negative persons can largely protect themselves by taking pre-exposure prophylaxis (PrEP) well.

How have the morbidity and mortality rates in HIV/AIDS changed since the inception of effective antiviral (“triple cocktail”) therapy? Please also address any unwanted anti-infective drug resistance development for this condition.

Since 1996, persons whose HIV has no resistance and who take combination antiretrovirals well have been able to fully suppress their virus. What has changed since then is that the regimens have become easier to take (most are one or two pills once a day), better tolerated (usually we can find a regimen that produces no symptoms), more compatible with other drugs (drug-drug interactions remain an ongoing issue, as in most of medicine; but we can usually find a solution) and with very little long-term toxicity (we now have two regimens with a reasonable claim to have no long-term toxicity). In the late 1990s, I was pretty happy with our therapeutic choices. After watching >1,000 people die, they seemed too good to be true.

But I was wrong: there has been a sequence of successively improved medications and there are probably several more to come. Say what you want about “big pharma” in this arena, which I know well, it has developed remarkable compounds.

Resistance is another matter. In the developed world, where viral load monitoring permits us to promptly switch from failing regimens, resistance is declining. Initial resistance arises in the middle of the adherence spectrum. If you take your antiretrovirals infrequently there isn’t enough drug to select the resistant mutations from the background of wildtype viruses. If you take your antiretrovirals well, there’s no replication to permit the occasional resistant mutation to arise. It’s when there’s replication in the presence of drug that resistance arises. Once it does, if the regimen is continued, a succession of additional mutations accrues producing denser resistance. In resource poor areas this ongoing use of failing regimens allows highly resistant viruses to evolve. Evolution is a tough opponent. We have to save lives in the third world

(Continued on page 8) May/June 2017

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Infectious Diseases Update Colleague Interview (Continued from page 7)

by providing antiretrovirals. But we are building a legacy of very resistant viruses.

In the U.S., HIV resistance is a problem in persons who initiated antiretroviral treatment before fully suppressive regimens became available in 1996, in persons with erratic adherence who started treatment since, or in persons unlucky enough to have become infected with an already resistant virus. Some of these viruses have become extraordinarily resistant. Nevertheless, we can usually find a fully suppressive regimen. But the regimens are more complex to take and produce more side effects.

What other diseases are associated with HIV? There are 22 different infections, cancers (all due to infectious agents) or other conditions that meet the AIDS epidemiologic definition. There are another ~20 pathogens arising at an increased rate in persons with HIV-caused immunodeficiency.

Most interestingly, attesting to the value of immune surveillance, there’s an increase in all cause cancers even in high CD4 count patients with fully suppressed HIV. Coinfection with hepatitis B and/or hepatitis C is common. HIV/HCV coinfected persons respond to the wonderful new hepatitis C drugs just like HCV monoinfected persons.

But HIV does make hepatitis C progress more rapidly. Drugdrug interaction problems are common and modification of the antiretrovirals regimen may be needed.

Hepatitis B and HIV interact in a more complex manner because several antiretrovirals, notably tenofovir, have antihepatitis B activity. The principal subtlety is that clinicians often focus on the HIV even in coinfected patients. If the HIV regimen is interrupted for adverse events, coverage difficulties or unilateral patient cessation, the hepatitis B reactivates and can produce symptomatic illness. The clinician must be aware that an alternate hepatitis B treatment, e.g., entecavir, should be instituted.

Finally, it is now clear that HIV, even in patients with fully suppressed virus, produces accelerated progression of ASCVD. It may also be that even fully controlled HIV aggravates the progression of other features associated with aging, e.g., mentation decline, decreased renal and pulmonary capacity, frailty. It’s difficult to be sure on these matters because a perfect control population can’t be found (we don’t get to randomize HIV infection). But it is clear for ASCVD. The most potent ASCVD risk factors are advancing age or bad genes. After these factors come uncontrolled hypertension, tobacco and poorly controlled diabetes — all of which are modifiable. Then 8

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comes obesity, sedentary lifestyle, HIV and other conditions that produce chronic immune stimulation (e.g., hepatitis C, rheumatoid arthritis and many others). In the case of HIV, the chronic immune stimulation is at least partly due to the severe and irreversible damage the virus produces in gut lymphocytes. This permits translocation of bacterial debris. This, in turn, serves the interests of HIV because it replicates better in activated lymphocytes. There is active investigation of ways to mitigate immune activation in persons with controlled HIV infection.

What’s on the horizon for the treatment of HIV? Vaccination status report?

I’d be content to take one pill once a day with no drug interactions, no meal imperative and no side effects in return for full control of an illness. But patients have a variety of attitudes toward medications and there’s great patient interest in longduration regimens — even injectable regimens. I’d be more eager to take one pill a day than come to a clinic for a monthly, painful injection. But there may be a special appeal in the HIV arena for long duration regimens. The need for obsession about perfect adherence is eliminated. And one doesn’t have to deal with a daily reminder of a lifelong, potentially fatal illness, about which it’s difficult to totally escape some sense of shame. Accordingly, there is active investigation of oral and injectable regimens that can be taken monthly or at even longer intervals.

Vaccination remains a bleak prospect, in spite of substantial effort. If one thinks about how vaccines work it may be that there never will be a sufficiently protective HIV vaccine. If a measles vaccinated person is exposed to measles virus, several rounds of replication follow. But the amnestic response is prompt enough that the exposed person demonstrates nothing more than a titer boost. But HIV may need nothing more than a few rounds of replication to become established. Our immune systems don’t seem able to stop it. Hopefully, this pessimistic view will prove to be incorrect. Some of the best minds in virology are working on the matter. They have provided great strides in understanding although not yet a successful vaccine.

Do you foresee a time where there is a definitive treatment for HIV similar to the new developments for hepatitis C? Hepatitis C and HIV have vastly different replication cycles, making the former easier to cure. HIV produces a DNA version of itself that gets integrated into the host genome. Cure of an individual cell would require specific excision of this “provirus.” Getting rid of the last infected cell seems more plausible but still a daunting prospect. On the other hand, MetroDoctors

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hepatitis C is an RNA virus with no DNA intermediate that replicates entirely in the cytoplasm. It has no latent state. If replication is suppressed long enough for all the HCV particles to be cleared (it seems to be close to 8 weeks — more potent anti-HCV drugs don’t much shorten the needed treatment interval), cure is achieved.

To what degree is (or should) the management of HIV be incorporated into primary care training?

The pendulum on this issue has swung several times. Initially, HIV care was a specialty activity: mostly infectious diseases physicians or gay physicians whose patient populations created the need. By the early 1990s there was a push to broaden the caregiver population. Mostly we were assisting patients in getting to their demise as gracefully as possible. But when good treatment started in the late 1990s a large succession of medications made it difficult to dabble. In addition, AIDSspecific funding for supportive services (dieticians, pharmacists, case managers, social workers, and mental health professionals) augmented the push to specialty clinics. Today, at least in urban areas, most HIV care is provided in these clinics.

Nevertheless, I would argue that HIV care should be part of all medical training. Our patients have a broad array of complications and, as they age, they acquire the same maladies that afflict us all. I need the help of other specialties every day.

Their familiarity with HIV enables them to be better consultants. As medical complexity increases, I don’t see these trends decreasing.

wholesale acquisition cost (WAC), a list price. The actual prices are secretly negotiated between the payers and “big pharma” and kept secret. In Minnesota, few patients are unable to get medications. But the copays can be formidable. And insurance interruptions can thwart the desired adherence with patient harm resulting.

The pricing of pharmaceuticals is an exceedingly complex issue. In addition to the above unfortunate lack of transparency, there is a fairly impenetrable array of rebates and “market basket” discounts. Global disparities add more complexity.

Pharma asserts that the cost of bringing drugs to market is high, which is undoubtedly correct. But the segment is more profitable than most and they don’t open their books.

Has this pricing affected care for individuals only in the U.S. or has it also affected patients in other countries and especially those in third world countries?

However difficult funding for medications can be in the U.S., it is worse in resource poor countries. One of the ironies of antiretroviral access is its randomness. Sometimes poorer people have better access. Geography can play an arbitrary role. Some countries have guaranteed coverage to all and actually provided it. In others people still die for want of pills.

In countries with less well developed health care infrastructure, what are the current barriers to HIV/AIDS treatment?

Describe your ideal system or process for working with primary care practitioners as relates to HIV management.

The principle barriers are insufficient money and stigma. These two problems interact. People are more willing to be tested and enter care if they know medications will be provided.

HIV specialists vary from doing primary care for HIV infected persons to supplementing the primary clinician with occasional visits. Most of us are comfortable anywhere along this range that the patient and the primary care practitioners prefer. The only exception is the patient with a serious ongoing illness other than HIV (e.g., cystic fibrosis, spinal cord injury, congestive heart failure). In these cases, the primary care should be provided by the clinician specializing in the more important illness.

Anything else you would like to say?

Have you seen some pharmaceutical companies changing their pricing on meds used for HIV and has this been prohibitive for patients who need access to these medications?

HIV has been my engine of excitement for over three decades.

I have met, worked with and helped so many wonderful people I could hardly count them. While HIV brought out the worst in some, it brought out the best in many others.

The science of it has been thrilling. We now know more about HIV than any other virus. It is a formidable opponent with remarkably intricate capabilities. It takes advantage of at least 200 human modalities, many of which were unknown when it surfaced. What we have learned about HIV and how to study it has illuminated many other pathogens.

Finally, it has taught us a great deal about ourselves.

The price of antiretroviral seems to be rising over time. Of course, none of us knows the actual price. We know the MetroDoctors

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9

Infectious Diseases Update

Update on Sexually Transmitted Infections in Minnesota Recent Trends

The number of sexually transmitted infections (STIs) reported in Minnesota continues to increase. The latest numbers available from the Minnesota Department of Health (MDH) are staggering.

Chlamydia is the most commonly reported STD in Minnesota, with 21,238 cases reported in 2015. This represents a four-fold increase since 1996. While there are fewer cases of gonorrhea (4,097 cases in 2015), rates of this STI also increased in recent years, with rates higher in men compared to women. Numbers for chlamydia and gonorrhea were highest among adolescents and young adults (ages 15-24), accounting for 64% of the cases of chlamydia and 47% of cases of gonorrhea.

Syphilis numbers have also increased in recent years. In 2015, Minnesota had 246 cases of primary and secondary syphilis, which are the infectious stages of syphilis. Men who have sex with men (MSM) accounted for 65% of cases of early syphilis (primary, secondary, and early latent stages) in men. Of the MSM population with early syphilis, 56% were co-infected with HIV. Rates among females have been increasing dramatically, and in 2015 there were three cases of congenital syphilis.

This has led MDH to advise more testing in women of child-bearing age and to increase syphilis screening in pregnancy, with screening encouraged for all women at their first prenatal visit, 28 weeks’ gestation, and delivery.

Rates of all these STIs reflect health disparities, with an increased incidence

By Ashley Beasley, APRN, CNP

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May/June 2017

among persons of color. The incidence rate of chlamydia was 9 times higher among black patients compared to white patients, while the incidence rate for gonorrhea was 16 times higher for blacks.

What Should Be Our Response to This?

Sexual History. Be matter-of-fact in your questioning of patients. Ask patients how many people they’ve had sex with in the previous year, gender of partners (male, female, transgender), and how they are sexual with these partners (oral, vaginal, anal sex). MSM should be asked if they are the insertive partner for anal sex (often referred to as “top”) and/or receptive partner (“bottom”). Ask about condom use.

Screening. All of these STIs can occur without symptoms. Patients who give oral sex to male partners should have pharyngeal testing for gonorrhea and chlamydia.

Patients who have anal sex as receptive partner should have rectal testing for gonorrhea and chlamydia. This is especially

important for MSM, as rectal STIs increase the risk of HIV acquisition. Ask your lab if they are able to do these site-specific tests for you. The Centers for Disease Control and Prevention (CDC) recommends the following screening frequency: Gonorrhea and Chlamydia. Annual screening is recommended for all females under age 25 and for those 26 and older who are at increased risk (new sex partner, more than one sex partner, a sex partner with concurrent sex partners, sex partner with an STI). Screening for males is not universally recommended outside of adolescent clinics and STI clinics, but annual screening of those at higher risk is prudent.

MSM should get site-specific screening (pharyngeal and rectal swabs as indicated in addition to urine sample) every 3-6 months. Patients can self-collect swabs for vaginal, rectal, and pharyngeal specimens; this has been shown to be as accurate as samples collected by clinicians.

Syphilis. Screening is recommended at least annually for MSM and those living with HIV, but more frequent testing every 3-6 months should be done for those at increased risk (see list above). Pregnant women should be tested at their first prenatal visit, 28 weeks’ gestation, and delivery. Patients at higher risk (see list above, in addition to those that use IV drugs and trade drugs/money for sex) should be screened annually.

Vaccination as Prevention. While hepatitis B vaccination is a part of routine childhood immunizations in Minnesota, hepatitis A and HPV vaccines are underutilized tools for STI prevention. Hepatitis A vaccine is recommended for all MSM as well

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as patients who use illegal drugs (whether IV or not). HPV vaccine is recommended for all patients ages 12-26. New guidelines recommend two doses if patient starts the series before age 15; otherwise three doses are needed to complete the series.

Expedited Partner Therapy (EPT). Minnesota law was amended in 2008 to allow health care providers to prescribe medications to partners of infected patients with gonorrhea and chlamydia who are unlikely to come in to a clinic for evaluation and treatment. Providers can give medications to patients for their partners or give a prescription to a patient to give to their partners. Unfortunately, current guidelines for gonorrhea therapy include an injection of ceftriaxone, making EPT more challenging. Although Suprax can be prescribed for gonorrhea, it does not treat pharyngeal gonorrhea and requires a recheck at site of infection to ensure resolution of infection.

Other Prevention Tools. Condoms do prevent many STIs, but they must be used

consistently, and patients rarely use condoms for oral sex. Additionally, condoms work less well for the STIs that are transmitted through skin-to-skin contact: HPV, herpes, and syphilis. For HIV prevention, the FDA approved use of Truvada in 2012 for PrEP, pre-exposure prophylaxis. This is a well-tolerated medication with few contraindications; its use decreases HIV acquisition by greater than 90% if taken consistently. The CDC published revised nPEP (non-occupational post exposure prophylaxis) guidelines in 2016. Use of Truvada plus another medication (Tivicay or Isentress) taken for 28 days beginning within 72 hours of risky condomless sex greatly reduces the risk of HIV acquisition.

References: 1. CDC Adult Immunization Schedules. https:// www.cdc.gov/vaccines/schedules/.

2. CDC Sexually Transmitted Diseases Treatment Guidelines, 2015. https://www.cdc.gov/std/ tg2015/.

3. CDC STD Screening Guidelines. https://www. cdc.gov/std/tg2015/screening-recommendations.htm.

4.

CDC PEP and PrEP Guidelines. https://www.cdc. gov/hiv/guidelines/preventing.html.

5. MDH STDs. https://www.health.state.mn.us/ std.

6.

MDH Syphilis Testing of ALL Pregnant Women. http://www.health.state.mn.us/han/2016/ jan14syph.pdf.

Ashley Beasley, APRN, CNP, is a nurse practitioner at Hennepin County Public Health Clinic, Red Door Services, the largest HIV and STD clinic in Minnesota. She can be reached at Ashley.Beasley@hennepin.us or (612) 596-8437.

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11

Infectious Diseases Update

Vaccination in 2017: The Good, the Sad and the Challenging.

Updates from the Advisory Committee on Immunization Practices

A

s an Infectious Disease/Immunology Nurse Practitioner at Children’s Minnesota, I have had the honor and pleasure of being part of the Advisory Committee on Immunization Practices (ACIP), our CDC vaccine policymaking group, since 2004 when I started my four-year term as a voting member.

Additionally, I have been a liaison member representing the National Association of Pediatric Nurse Practitioners since 2008.

I bring the clinician’s view to our deliberations. This past year, there were many changes that affected both the adult and childhood immunization schedule. Some changes were good, some sad and some continue to be challenging.

The Good News:

1. HPV vaccine is now just two doses.

Favorable to clinicians was the excellent data showing two doses of HPV vaccine were effective (non-inferior) in preventing HPV-related cancers and genital warts compared to three doses. The vaccine is licensed to begin with patients as young as 9 years of age and data from that younger, 9-11, age group shows they have a more robust immune response to the vaccine compared to older individuals.

It is not too early to vaccinate against cancer in 9 year olds. The second dose should be given 6-12 months after the first. Immunocompromised males and females (T cell and B cell deficiencies, HIV, autoimmune disease or suppressive therapies) should still receive three doses. There are a few

By Patsy Stinchfield, MS, CPNP, CIC

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details for implementing the 9-valent HPV vaccine in this interim period which are: a. FDA licensed 9vHPV vaccine in 9-26 year olds b. Better responses occur when we vaccinate younger ages than older c. Recommended age is 11-12 , but can start as early as 9 years d. Two doses are needed if started before 15th birthday e. Three doses are needed if started at 15 years and older f. If started at 14 and 6 months has passed, can give just one additional dose g. Think of two-dose series as dropping the middle dose from the previous three dose series.1 2. Vaccinating pregnant women of any age with Tdap against pertussis at each pregnancy is safe to the woman and developing baby and effective in preventing whooping cough in the household. Tdap vaccine has been well-studied in over 50,000 women and showed no increased risk for adverse maternal or infant health outcomes.2 The ideal time to vaccinate is between 27 and 36 weeks gestation, but certainly vaccinate anytime before delivery or soon thereafter if not already accomplished (studies showed an accelerated uptake at ~34 weeks gestation). Tdap with each pregnancy shows efficient placental transfer of vaccine-induced antibodies. Importantly, Tdap may be given at any time during pregnancy. Vaccinate pregnant women against pertussis!

3. We now have a second option for

Meningococcal B prevention that is in two doses. A new two-dose schedule was approved for Trumenba® (Pfizer) in addition to previously approved MenB-4C (Bexsero®, GSK). The details of MenB recommendations are: a. Category A: The following should receive MenB vaccine: i. Persons 10+ years of age at increased risk ii. Persistent complement component deficiencies iii. Anatomic or functional asplenia iv. Microbiologists who may be exposed to isolates v. Those at increased risk because of an outbreak

b. Category B: MenB vaccine may be administered: i. To adolescents and young adults 16-23 years of age

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ii. Consequent to a patientprovider discussion 3 At Children’s Minnesota, we have elected not to wait for parents or teens to ask about MenB, but instead offer it to all 16-year-olds at that visit.

The Sad News:

1. Intranasal influenza vaccine was not available in the U.S. this season due to very low efficacy in the past season.

This quick, easy-to-deliver vaccine hasn’t appeared to impact flu vaccine rates among children, adults or health care professionals due to an excellent supply of injectable options, but intranasal is missed. Studies are ongoing as to the disparity in efficacy results from different data in the U.S. and abroad but resolution is not likely by the fall of 2017 influenza vaccination season.

There is good news, though. Allergy to eggs is no longer a contraindication to influenza vaccination due to the lack of actual anaphylaxis after vaccination in egg-allergic individuals with the amount of egg albumin in the flu vaccine being so low.4

a vaccine visit and discuss the undeniable merits and safety of vaccines to patients in a clear, confident, presumptive manner, such as “you are due for your influenza vaccine and a tetanus booster, which we will do today.” Follow this by briefly reviewing the vaccine information sheet (VIS) with parents/guardians as required by federal law. There are many myths about vaccines. To find facts to share with your patients/parents/guardians, go to: a. CDC: https://www.cdc.gov/vaccines/index.html b. MDH: http://www.health.state. mn.us/divs/idepc/immunize/index.html c. Immunization Action Coalition: http://www.immunize.org/ d. Vaccine Education Center: http:// www.chop.edu/centers-programs/ vaccine-education-center The ACIP meeting is open to the public and can be watched via live streaming.

The meeting data slides, full meeting transcripts and recommendations can be found on the CDC website at www.cdc.gov/acip.

In addition, to stay up-to-date, be sure to get the The Morbidity and Mortality Weekly Report (MMWR) to your inbox which is where the new recommendations are first published. https://www.cdc.gov/ mmwr/index.html.

Thank you for all you do to reduce and eliminate vaccine-preventable diseases.

Patsy Stinchfield, MS, CPNP, CIC, Infectious Disease/Immunology Nurse Practitioner; Senior Director, Infection Prevention and Control, Children’s Minnesota.

References: See the ACIP website at www.cdc.gov for detailed information on: 1. HPV dosing 2. Tdap vaccine safety in pregnant women 3. MenB 4. Influenza and egg allergy 5. Hepatitis B in newborns

The Challenging News:

1. Hepatitis B dose number one is to be delivered within 24 hours of birth.

New language was recently adopted: “…the first dose of vaccine should be administered within 24 hours of birth.” This language also would apply to the approximately 35,000 births that occur out-of-hospital annually. The change is based on need — there were 952 perinatal Hep B cases reported to CDC last year; 90% develop chronic HBV infection in infants. These severe cases could be prevented if Hep B vaccine is provided within the first 24 hours of life.

This will be a challenge for hospitals, birth centers, etc. requiring staff to determine flow and communication protocols.5 2. The anti-vaccine movement has found new energy since the 2016 election.

As scientists and clinicians, we will need to continue to make every visit MetroDoctors

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13

Sponsored Content

Adventure Awaits: Travel and Tropical Medicine Clinics Offer Advice to Go Contributed by Mark Sannes, M.D., MS and Cristina Baker, M.D., MPH

We live in a global world with the ability to reach the far corners of the Earth with increasing ease. According to the National Travel and Tourism Office, more than 60 million Americans traveled internationally in 2016. Over half of these travelers did not seek medical advice before departure.1 Travelers returning to their country of origin after visiting friends and relatives were even less likely to seek pre-travel counseling and are at markedly increased risk for travel-related illnesses.2 Pre-travel counseling, preventive vaccines and prophylactic medications are the cornerstone of minimizing these risks.

The travel and tropical medicine clinics at Park Nicollet and HealthPartners have more than 30 years of experience in providing expert advice for persons traveling abroad. Combined, they saw more than17,500 travelers last year. The dedicated staff at our clinics is composed of highly specialized physicians and nurse clinicians with a collective volume of knowledge about travel and tropical medicine that is second to none in Minnesota. At HealthPartners, we also have the expertise of Patricia Walker, M.D., and William Stauffer, M.D., worldrenowned authorities in tropical medicine, for guidance in treating patients who acquire rare tropical illnesses while traveling abroad.

In addition, we are part of an international network of clinics called GeoSentinel which reports diseases in international travelers to the Centers for Disease Control and Prevention. Faculty teach tropical and travel medicine at the University of Minnesota and have published more than 100 articles in the field of migration medicine.

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May/June 2017

Patients often ask their primary care providers questions such as, “I am going to Mexico — do I need any shots?” A travel medicine consultation involves much more than vaccines, as we focus on true reasons for morbidity and mortality during international travel. We recommend that providers avoid administering live virus vaccines if they are referring patients to a travel medicine clinic within 30 days. Being seen at least 4-6 weeks before travel is best to allow required vaccines to take effect.

Components of Pre-travel Consultation Review of the Medical History The travel consultation begins with a review of the traveler’s health history. Certain medical conditions merit special consideration and may alter the medications and immunizations that can be safely administered. Immunocompromised individuals (e.g., organ-recipients, those with HIV, those taking immunomodulatory medications for conditions such as rheumatoid arthritis) are traveling in increasing numbers. Advances in medical therapy allow these patients to feel well enough to travel, but their treatment

puts them at increased risk for more severe disease from travel-related illnesses. Also, some may not be able to receive live recommended vaccines.

Pregnancy and drug and food allergies also require the expertise of a travel medicine specialist. Advising pregnant women about international travel requires in-depth knowledge of the safety of vaccines and medications in pregnancy as well as the risk that different infectious diseases pose to the mother and baby. Finally, some travelers’ allergies to eggs, gelatin or certain antimicrobial agents may limit their ability to safely receive certain vaccines or prophylactic medications. Travel medicine specialists know the components of each vaccine and can identify alternative agents if travelers have allergies or intolerances to medications used for malaria prevention or traveler’s diarrhea.

Immunizations At their appointment, travelers are asked for a detailed travel itinerary and the reason for traveling (e.g., tourism, business, visiting friends and relatives, volunteer or aid work).

Our travel medicine specialists review the traveler’s destinations and planned activities, determine the immunizations needed, review the traveler’s vaccination history and provide vaccines needed for general health.

Sometimes our providers encounter young travelers who are behind on their childhood vaccines or adults who need routine vaccinations. Immunizations often recommended for international travelers include hepatitis A, typhoid and yellow fever.

In the United States, yellow fever vaccine is distributed only through approved vaccinating centers, including Park Nicollet and HealthPartners.

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Review Need for Medications to Prevent Conditions Such as Malaria and Traveler’s Diarrhea Another important aspect of pre-travel counseling is education about non-vaccine preventable diseases. Malaria is the most common cause of febrile illness in the returning traveler, and the use of malaria chemoprophylaxis among travelers remains inadequate.3 Our travel medicine specialists determine if there is risk of malaria, discuss personal protective measures (e.g., mosquito netting, insect repellant), review the risks and benefits of chemoprophylaxis and recommend appropriate medications based on the itinerary.

The most common medical condition that travelers experience while abroad is gastrointestinal illness. During the pre-travel consultation, travelers are educated about traveler’s diarrhea, including prevention strategies such as food and water precautions, non-antimicrobial drugs for prophylaxis (e.g., bismuth subsalicylate) and the importance of oral rehydration therapy.

Travelers are also educated about the judicious use of antibiotics for self-treatment and are evaluated for potential drug interactions between routine medications and antibiotics (e.g., ciprofloxacin, azithromycin) used for traveler’s diarrhea.

Education About How to Avoid and Manage High-Risk Conditions During Travel In many parts of the world, access to medical care is limited. Educating travelers about how to avoid certain risks is an essential part of the pre-travel consultation. Each trip is unique, and the risks that may be encountered vary significantly depending on the destination. Travelers are informed about environmental hazards and prevention strategies such as wearing shoes to avoid parasites that can enter through the skin, avoiding swimming in fresh water where there is a risk of leptospirosis and schistosomiasis and avoiding contact with animals to reduce the potential for bites and rabies.

Travelers are counseled about avoiding activities that can lead to sexually transmitted infections and unwanted pregnancy. Parents are educated about ways to prevent illness in young children, and travelers to high altitudes are counseled about prevention and treatment of altitude illness.

Many illnesses that travelers encounter MetroDoctors

can be avoided by limiting exposure to insects. Vector-borne illnesses transmitted by mosquitos (e.g., malaria, dengue fever, yellow fever, Japanese-encephalitis, Zika, chikungunya), as well as those acquired from ticks and sandflies, are some of the most common causes of travel-related illness.

During a travel medicine consultation, our providers emphasize prevention strategies such as staying indoors during mosquito feeding time, using long-acting insect repellant, treating fabrics with insecticides and wearing appropriate clothing to reduce exposed skin.

Reviewing the Latest International Health Alerts and Providing Necessary Travel Documents The world is constantly changing, and disease outbreaks and international events such as natural disasters may affect a traveler’s health and impede travel. Our providers know where to obtain the most detailed and up-to-date information on evolving situations. They review the latest international health alerts and educate travelers so that they can protect themselves or choose to avoid certain destinations.

Many countries require proof of vaccination of yellow fever for entry. For travelers with itineraries that include multiple countries, the order of travel may change such requirements. Our staff are experts in these requirements and give travelers the documents needed for proof of vaccination. In addition, we provide a Hajj clinic every year for those traveling to Mecca and Medina.

Making Travel Comfortable and Safe Travelers use many modes of transport. Our providers can help travelers manage motion sickness and minimize the effects of jet lag.

They also discuss precautions that travelers can take to optimize their personal safety in unfamiliar surroundings. In addition, patients can be counseled on specialty issues such as high altitude illness, scuba diving and wilderness travel.

Arriving Home If, for any reason, pre-travel counseling and prevention efforts fail, the Park Nicollet and HealthPartners infectious disease travel and tropical medicine clinics are also uniquely positioned to manage illnesses such as fever,

The Journal of the Twin Cities Medical Society

traveler’s diarrhea and other travel-related illnesses. We are a resource to other physicians in the community and should be consulted to evaluate returning travelers who are ill.

Post-travel screening and treatment for exposure to tuberculosis, strongyloides and schistosomiasis, is recommended for certain long-term travelers and expatriates and these services are available at our travel clinics.

Park Nicollet and HealthPartners travel clinics are committed to keeping travelers safe. The next time you see a patient who is traveling abroad to a high-risk area or a traveler with a complicated medical condition, please consider referring them to a Park Nicollet or HealthPartners travel clinic for a comprehensive pre-travel visit. A travel clinic consultation will help your patient improve his or her chances of remaining healthy and enjoying the trip.

Cristina Baker, M.D., MPH, is an infectious disease specialist and current Department Chair of the Infectious Disease and Travel Clinic at Park Nicollet. She completed her Infectious Disease fellowship and obtained a Masters in Public Health from the University of Minnesota. Prior to working at Park Nicollet, she practiced at Hennepin County Medical Center.

Mark Sannes, M.D., MS, began his career at Park Nicollet in 2006, working in the Infectious Disease and Travel Clinic. He served as ID Department Chair and Medical Director of the Travel Clinic from 2011 – 2015. From 2013 – 2016, he served as Clinical Quality Lead for Specialty Services, and as Co-Director of the Quality Improvement Advanced Training Program (ATP). Dr. Sannes assumed the role of Senior Medical Director of Specialty Services at Park Nicollet in December 2015. He received his medical degree from the University of Minnesota Medical School and M.S. from the University of Minnesota School of Public Health/Graduate School.

References 1. Freedman DO, Chen LH, Kozarsky PE. Medical considerations before travel. N Engl J Med. 2016;375(3):247-260.

2.

Leder K, Tong S, Weld L, et al. Illness in travelers visiting friends and relatives: a review of the GeoSentinel Surveillance Network. Clin Infect Dis. 2006;43(9):1185-1193.

3. Freedman DO, Weld LH, Kozarsky PE, et al.

Spectrum of disease and relation to place of exposure among ill returned travelers. N Engl J Med. 2006;354(2):119-130.

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Infectious Diseases Update

Invasive Methicillin Resistant Staphylococcus aureus Infections Introduction

Staphylococcus aureus (SA) infections have been recognized as a burden to health since the bacterium was identified in 1880.1-3 Strains of SA that are resistant to methicillin and other similar beta lactam antibiotics are referred to as methicillin-resistant (MR)SA. These strains first appeared in the 1960s and became common among infections acquired in the hospital during the 1980s.4,5 Community-associated strains appeared in the mid-1990s and became common during the mid-2000s.6-10 Known risk factors for MRSA infections include recent hospitalization, surgery, chronic or current dialysis, presence of a central venous catheter, residence in long-term care facilities and prisons, intravenous drug use, and exposure to broad spectrum antibiotics.8,11-13 For epidemiological purposes, MRSA infections are classified as hospital onset (MRSA isolated >3 days after inpatient admission), healthcare-associated, community onset (if there are healthcareassociated risk factors such as presence of an indwelling device, history of MRSA colonization or infection, surgery, hospitalization, dialysis or residence in a long-term care facility 12 months preceding culture) and community-associated.14 Infections caused by MRSA span a broad spectrum of illnesses: skin and soft-tissue infections, necrotizing fasciitis, osteomyelitis, septic arthritis, pneumonia, endocarditis, organ abscess, bacteremia and other infections causing severe morbidity and mortality.13,15

By Mackenzie Koeck, MPH, Kathryn Como-Sabetti, MPH, and Ruth Lynfield, M.D.

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May/June 2017

Mackenzie Koeck, MPH

Kathryn Como-Sabetti, MPH

The National Perspective

The rate of invasive illness caused by MRSA in the United States in 2005, based on surveillance conducted in the Centers for Disease Control and Prevention’s Emerging Infections Program sites, including Minnesota, was estimated at 31 cases per 100,000 persons.16 Of these infections, 58% were healthcare-associated, community onset, 27% were hospital onset and 14% were community-associated.

The Emerging Infections Program documented a 31% decrease from 2005 to 2011 in invasive MRSA disease with a rate of 25.8 cases per 100,000. Of these infections, 60% (rate of 15.5/100,000) were healthcare-associated, community onset, 18% (rate of 4.5/100,000) were hospital onset and 20% (rate of 5.2/100,000) were community-associated. The most significant decrease was in hospital onset infections (54%); however, there were decreases in healthcare-associated, community onset (28%) infections and a slight decrease in community-associated (5%) infections.

Overall, in 2005, 18% of invasive MRSA

Ruth Lynfield, M.D.

cases died during the hospitalization, compared to 13% in 2011. The adjusted allcause in-hospital mortality rate decreased from 7.1 per 100,000 in 2005 to 3.6 per 100,000 in 2011.

A More Recent Minnesota Perspective (2010-2015)

The Minnesota Department of Health conducts surveillance for invasive MRSA in the two most populous counties in Minnesota: Hennepin and Ramsey Counties.

Inclusion in surveillance requires that MRSA is isolated from a normally sterile site such as blood, cerebrospinal fluid, pleural fluid, bone or other internal body site, and the person is a resident of Hennepin or Ramsey County. Demographic information, medical history, and clinical course of infection are collected for each case through a medical record review, and cases are classified epidemiologically.

During 2010 to 2015, the incidence rates for invasive MRSA decreased from a high of 18.2 cases per 100,000 population in 2011 to a low of 11.2 cases per

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100,000 population in 2015 (p=<0.001).

The incidence of healthcare-associated, community onset invasive MRSA infections followed the same trend as observed for invasive MRSA overall; incidence was the highest in 2011 with 13.2 cases per 100,000 population and lowest in 2015 with 7.9 cases per 100,000 population in 2015. The decreasing incidence of healthcare-associated, community onset invasive MRSA was statistically significant from 2010 to 2015 (p<0.001). Incidence of hospital onset cases was highest in 2011 with 2.4 cases per 100,000 population and lowest in 2015 with an incidence of 1.1 cases per 100,000 population in 2015; there was no decrease in incidence of hospital onset cases over time. The overall rate of community-associated invasive MRSA for this period was 2.8 cases per 100,000 population and there was a significant increase in the incidence of communityassociated cases (p=0.003). The trends of invasive MRSA infections can be seen in Figure 1.

The overall median age of invasive MRSA cases between 2010 and 2015 was 61 years with a range of 0-103 years, 67.4% of cases were white and 41.2% were female. Gender and race did not vary by epidemiologic case classification, however hospital onset, (median age 60 years) and healthcare-associated, community onset, (median age 64 years) cases were older than community-associated cases, (median age 47.5 years) (p<0.001). Residence in a long-term care facility did not change over the time period of 2010-2015 for healthcare-associated, community onset and hospital onset cases. The proportion of cases receiving chronic dialysis was consistent for hospital onset cases for all years but decreased among healthcare-associated, community onset cases (p=0.032).

Comorbidities were present in 71.6%, 79.5% and 69.4% of hospital onset, healthcare-associated, community onset, and community-associated MRSA cases, respectively. The most common comorbidities were kidney disease, diabetes, and cardiovascular disease. These three comorbidities were more common in healthcareassociated, community onset cases when MetroDoctors

Figure 1

compared to hospital onset and community-associated cases (p<0.001 for all). Common infection types included bacteremia (70.6%); septic arthritis (15.4%); and osteomyelitis (15.0%). Bacteremia was the most common infection type reported among all invasive MRSA cases from 2010 through 2015 and did not demonstrate variability by year. Although bacteremia was the most common infection type, healthcare-associated, community onset MRSA cases were more likely to have bacteremia than community-associated cases and hospital onset cases (p<0.001).

Community-associated cases were more likely to have septic arthritis than hospital onset or healthcare-associated, community onset cases (p<0.001).

Overall, 11.5% of invasive MRSA cases were fatal while hospitalized. Hospital onset cases had the highest mortality (18.4%), followed by healthcare-associated, community onset cases (11.9%), and community-associated (3.9%). Hospital onset cases were not more likely to die during hospitalization than healthcare-associated, community onset cases; however, both hospital onset and healthcare-associated, community onset cases were more likely to die during hospitalization than community-associated cases (p<0.001 for each). The proportion of cases who died as an inpatient among all epidemiologic

The Journal of the Twin Cities Medical Society

case classifications did not change over the time period.

Conclusions

Over the past 10 years the rates of invasive MRSA have decreased substantially. Initial decreases, documented in hospital onset cases were likely due to improvements in infection control in the acute care setting, such as bundles and checklists to prevent central line associated infections. Notably, in Minnesota we have documented significant decreases in healthcare-associated, community onset infections. This epidemiological group includes patients who tend to be older and have comorbidities, most commonly diabetes, kidney disease, and cardiovascular disease. This group is also predominantly male and compared to hospital onset and community-associated MRSA cases, this group is more likely to receive dialysis and reside in long-term care facilities within the year prior to invasive infection. Healthcare-associated, community onset cases are also more likely to have bacteremia than the other two groups.

Enhancing infection prevention measures during dialysis and understanding where interventions may be useful for long-term care residents, may further decrease rates of invasive MRSA. (Continued on page 19)

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Changing the world one traveler at a time More than 60 million Americans traveled internationally in 2016.

Clinicians at Park Nicollet Travel Clinic and researchers at HealthPartners Institute are partnering to keep patients safe before, during and after international travel.

HealthPartners Institute is one of the largest medical research and education centers in the Midwest.

As part of an integrated health care organization that includes hospitals, clinics and a health plan, our teams are helping transform health care across the nation.

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Invasive Methicillin Resistant Staphylococcus aureus Infections (Continued from page 17)

We have not observed significant decreases in community-associated infections. Other prevention approaches, such as development of an effective S. aureus vaccine, may be needed to impact rates in this group, and further decrease rates of infection in hospital-onset and in healthcare-associated, community onset infections. In addition, more fastidious practice of antibiotic stewardship across the continuum of health care is important to reduce the antibiotic pressure that favors development of antibiotic resistant infections.

Invasive MRSA is severe and the case fatality rate remains high for in–hospital deaths. Patients with invasive MRSA, particularly those with hospital onset and healthcare-associated, community onset have comorbidities. In addition to infection prevention and control measures, further investments in maintaining optimal primary care and decreasing the severity of comorbidities such as diabetes, kidney and cardiovascular disease, may also have an impact on rates of invasive MRSA. Mackenzie Koeck, MPH, is an epidemiologist at the Minnesota Department of Health.

She graduated from Concordia College in Moorhead, MN with a major in Biology and concentrations in Chemistry, Dietetics, and Sociology. Ms. Koeck attended the University of Minnesota, School of Public Health where she earned her MPH in Epidemiology. She is currently the Surveillance Coordinator for Staphylococcal disease at the Minnesota Department of Health.

Kathryn Como-Sabetti, MPH, is the Epidemiology Supervisor of the Emerging Infections Unit at the Minnesota Department of Health. Ms. Como-Sabetti received her Bachelor of Science degree in Nutrition Science from North Dakota State University and a Master of Public Health degree in Epidemiology from the University of Minnesota. During her 18 years at the Minnesota Department of Health she has worked in a number of different project areas including

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vaccine-preventable disease surveillance, community-associated methicillin resistant Staphylococcus aureus, and pandemic influenza planning in the areas of isolation and quarantine and community mitigation during a pandemic. As part of her position at MDH Ms. Como-Sabetti supervises surveillance activities for Staphylococcus aureus.

Ms. Como-Sabetti has also worked as an epidemiologist in the Infection Control Department of Children’s Hospitals and Clinics of Minnesota.

Ruth Lynfield, M.D., received her medical degree from Cornell University Medical College and did postgraduate training in Pediatrics and in Pediatric Infectious Diseases at Massachusetts General Hospital (MGH). She attended in Pediatric Infectious Disease at MGH and was Assistant Director of the New England Regional Newborn Screening Program at the Massachusetts State Laboratory from 1992-1997.Dr. Lynfield then joined the Minnesota Department of Health as a medical epidemiologist, and was appointed State Epidemiologist in 2007 and Medical Director of the Department in 2010. Dr. Lynfield is the Co-Principal Investigator for the Minnesota Emerging Infections Program.

Her research focuses on emerging infections, antimicrobial resistance and prevention of infectious diseases.

References 1. Licitra G. Etymologia: Staphylococcus. Emerg Infect Dis. 2013;19(9):1553.

2. Myles IA, Datta SK. Staphylococcus aureus: an introduction. Semin Immunopathol.

2012;34(2): 181-4.

3. Ogston A. Classics in Infectious Diseases. “On Abscesses.” Rev Infect Dis. 1984;6(1):122-8.

4.

Barrett FF, McGehee RF, Finland M. Methicillinresistant Staphylococcus aureus at Boston City Hospital. Bacteriologic and epidemiologic observations. N Engl J Med. 1968;279(6):286-9.

5. Panlilio AL, Culver DH, Gaynes RP, et al.

Methicillin-resistant Staphylococcus aureus in U.S. Hospitals, 1975-1991. Infect Control Hosp Epidemiol. 1992;13:582-6.

6. Four pediatric deaths from communityacquired methicillin-resistant Staphylococcus aureus—Minnesota and North Dakota, 19971999. Morb Mortal Wkly Rep. 1999;48(32):70710.

7.

Herold BC, Immergluck LC, Maranan MC, et al.

Community-acquired Staphylococcus aureus in children with no identified predisposing risk.

JAMA. 1998;279(8):593-8.

8. David DZ, Daum RS. Community-acquired methicillin-resistant Staphylococcus aureus: epidemiology and clinical consequences of an emerging epidemic. Clin Microbiol Rev. 2010;23(6):616-87.

The Journal of the Twin Cities Medical Society

9.

10.

11.

12.

13.

14.

15.

16.

Fridkin SK, Hageman JC, Morrison M, et al.

Methicillin-resistant Staphylococcus aureus disease in three communities. N Engl J Med. 2005;352(14):1436-44.

Como-Sabetti K, Harriman KH, Buck JM, et al.

Community-associated methicillin-resistant Staphylococcus aureus: trends in case and isolate characteristics from six years of prospective surveillance. Public Health Rep. 2009;124(3):427-35.

Boyce JM. Methicillin-resistant Staphylococcus aureus in hospitals and long-term care facilities: microbiology, epidemiology, and preventive measures. Infect Control Hosp Epidemiol.

1992;13(12):725-37.

Como-Sabetti KJ, Harriman KH, Fridkin SK, et al. Risk factors for community-associated Staphylococcus aureus: results from parallel studies including methicillin-resistant and methicillin-sensitive S. aureus compared to uninfected controls. Epidemiol Infect.

2011;139(3):419-29.

Malcolm B. The rise of methicillin-resistant Staphylococcus aureus in U.S. correctional populations. J Correct Health Care. 2011;17(3):25465.

Dantes R, Mu Y, Belflower R, et al. National burden of invasive methicillin-resistant Staphylococcus aureus infections, United States, 2011.

JAMA Intern Med. 2013 Nov 25;173(21):1970-8.

Miller LG, Kaplan SL. Staphylococcus aureus: a community pathogen. Infect Dis Clin North Am. 2009 Mar;23(1):35-52.

Klevens RM, Morrison MA, Nadle J, et al.

Invasive methicillin-resistant Staphylococcus aureus infections in the United States. JAMA. 2007;298(15):1763-71.

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May/June 2017

19

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The Ongoing Challenge of Clostridium difficile in Healthcare Settings Contributed by Alison Galdys, M.D. Clostridium difficile (CD) is the leading cause of healthcare-associated diarrhea.

Hospital spending on CD infection (CDI) in the United States is estimated to be a staggering $3 billion a year.1 Despite intense efforts, morbidity and mortality due to CDI remain unacceptably high, and the Centers for Disease Control and Prevention classifies CD as an urgent threat requiring aggressive action on the part of healthcare professionals.

assisted by diarrhea, irrespective of whether or not diarrhea is attributable to CDI. CD spores are extremely resistant to heat, desiccation, and alcohol-based disinfection and can reside on surfaces for months.

detecting CD toxins or the glutamate dehydrogenase (GDH) antigen, and nucleic acid amplification testing (NAAT) for toxin genes. CCNA and EIA for the detection of CD toxins exhibit inadequate sensitivity for use as stand-alone tests for CDI. GDH immunoassay is more sensitive, but its specificity is limited by the fact that GDH is produced by toxigenic and nontoxigenic strains. Stool tests that detect toxin genes via NAAT demonstrate better sensitivity than toxin EIA and CCNA and do not detect nontoxigenic strains, but these do not differentiate toxigenic CD colonization from CDI. The best way to overcome suboptimal CD test specificity is to avoid testing patients whose probability for CDI is low, especially patients who lack abdominal pain or cramping or whose loose stool pattern is unaltered from a prior baseline or is attributable to pharmacotherapy or alternate GI pathology.

CDI Diagnosis

CDI Treatment

The definition of clinical CDI requires diarrhea accompanied by either a stool test positive for toxigenic CD or colonoscopic or histopathologic findings demonstrating pseudomembranous colitis. Resolution of gastrointestinal (GI) symptoms following specific therapy for CDI lends additional support for the diagnosis, and alternate causes for diarrhea should be sought in patients whose symptoms are only modestly impacted by CDI-specific therapy.

The gold standard for detection of fecal CD is toxigenic culture, but this method is largely limited to research settings because it is laborious and resource-intensive.

Stool tests for CD detection commonly employed in clinical laboratory settings include cell cytotoxicity neutralization assays (CCNA), enzyme immunoassays (EIA)

Until recently, targeted CD pharmacotherapy combined with cessation of unnecessary broad-spectrum antimicrobials was the mainstay treatment for CDI. Metronidazole, vancomycin, and fidaxomicin appear in U.S. and European CDI treatment guidelines. Oral metronidazole or enteral vancomycin is recommended for treatment of an initial or recurrent CDI episode that is mild in severity. Vancomycin is preferred for multiple recurrent or severe CDI. Fidaxomicin demonstrated non-inferiority to vancomycin for cure of CDI and has been associated with reduced CDI recurrence among patients infected with non-North American pulsed-field type 1 (NAP1) CD strains, but its role in therapy remains controversial due to its extremely high cost.3 For severe, complicated

CDI Pathophysiology and Epidemiology

CD is spread via fecal-oral transmission and is inherently resistant to most classes of antibacterial agents. Only toxigenic CD is associated with CDI. CD toxins disrupt the structural integrity and growth cycle of intestinal cells. Acquisition of toxigenic CD can result in either asymptomatic colonization or clinically apparent CDI. Host factors that promote intestinal dysbiosis, such as increased age, immune suppression, antimicrobial receipt, and inflammatory bowel disease, are associated with loss of CD colonization tolerance and progression to CDI. Symptoms of CDI can range from mild diarrhea and abdominal cramping to fulminant colitis and toxic megacolon. Factors influencing CDI severity are incompletely understood, but two characteristics appear to play a prominent role: 1) toxin quantity, which is influenced by bacterial promoter and regulator genes, and 2) circulation of host immunoglobulins.

The clear majority (â&#x2030;Ľ80%) of incident CDI is linked to contact with ambulatory, acute, or long-term care settings.2 CD is enriched in healthcare settings because its growth is selected for by antimicrobial use and its spread to the environment is 20

May/June 2017

MetroDoctors

The Journal of the Twin Cities Medical Society

CDI that presents with toxic megacolon or perforation, colectomy can be a lifesaving intervention. Diverting loop ileostomy permits ante grade instillation of vancomycin and may prevent colectomy.

CDI can recur in 40% of patients who receive conventional antibiotic regimens, so secondary prevention is a key endpoint for therapeutic interventions. Oral vancomycin administered in a tapering or pulsed fashion is indicated for patients with a history of recurrent CDI. A newer strategy employs passive immunization with bezlotoxumab, a monoclonal antibody capable of neutralizing CD toxin B (TcdB). In a recent clinical trial, bezlotoxumab combined with standard antibiotic therapy was associated with reduced CDI recurrence (absolute rate reduction 11%, p<0.001), although not with increased rates of clinical cure.4 In October 2016, the Federal Drug Administration (FDA) approved its use in the prevention of recurrent CDI. The ways in which bezlotoxumab should be incorporated into CDI treatment strategies require further study, including costeffectiveness analyses.

Among the sentinel events in CDI is intestinal dysbiosis, and novel therapies for CDI aim to restore the heterogeneity of gut microbiota — a strategy thought to have originated during ancient times with the use of human feces to treat human enteric illness. Experimental use of fecal microbiota transplantation (FMT) for CDI began nearly four decades ago, and in 2013 results were published on the first randomized controlled trial demonstrating that FMT, when compared to 14 days of vancomycin, reduced risk for recurrent CDI in a study population of 29 patients.5 While the FDA deems it an investigational practice, many medical centers have adopted FMT for the treatment of CDI and report varying degrees of efficacy, although it should be noted that significant heterogeneity exists in the practices of donor selection and the dose and delivery route of donor feces. Metagenomic investigations aim to elucidate donor feces characteristics associated with desired outcomes and to identify effective alternate biotherapeutics that do not require costly donor screening or the risk of unintentionally instilling pathogenic or potentially oncogenic microorganisms. Investigation of active

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immunization for CDI prevention is another expanding area of research. Data from a phase III CD toxoid-based vaccine are expected in the coming year.

Prevention

Amidst advances in CDI therapeutics, stubbornly high incidence rates persist.

Stewardship initiatives to curb unnecessarily broad or not clinically indicated antibiotic use have been successful in reducing CDI rates. Sporicidal environmental disinfection, isolation precautions for patients with CDI, and emphasis on hand washing instead of alcohol-based disinfectants are additional key elements of a CDI prevention program. However, CDI rates remain high despite these interventions, and novel approaches for CDI prevention are needed. Adjunctive “no touch” technologies are now being tested for surface disinfection.

Among these are ultraviolet light-emitting devices, (UVDs) of which there are several commercially-available models that vary in UV wavelength, bulb size, and energy output. In several small prospective cohort studies, UVDs have been associated with reduced CDI, but when tested in a recent randomized control trial, their use did not offer any advantage over universal bleach disinfection for CDI prevention.6 Further studies are needed to determine optimal methods of UV delivery for microbicidal purposes and how UVDs might best complement manual cleaning and disinfection.

As clinical research increasingly recognizes, isolation and disinfection strategies that focus solely on patients with known CDI may be overly simplistic. The prevalence of asymptomatic CD colonization among inpatients and residents of longterm care facilities ranges from 10-40%, and epidemiologic studies provide direct molecular evidence that CD-colonized patients can be reservoirs for CDI transmission. A recent investigation identified increased risk for CDI among inpatients inhabiting rooms whose former occupants received antibiotics, and this effect persisted even when the former occupant did not have clinical CDI. Reduced rates of healthcare-associated CDI were demonstrated in a separate investigation when surveillance was performed to detect CD colonization and enhanced precautions and environmental disinfection were enforced CD-colonized patients.7 Additional

The Journal of the Twin Cities Medical Society

studies are needed to further clarify how to manage the risk of CDI transmission via CD-colonized individuals.

Curbing CDI will require novel approaches to complement existing practices.

Innovative strategies to reduce CD in the healthcare environment combined with ongoing stewardship practices and promising CDI therapeutic options together will comprise a defense against the ongoing challenge posed by this formidable pathogen.

Alison Galdys, M.D., serves as Assistant Medical Director for Infection Prevention, University of Minnesota Health, a role that involves multidisciplinary collaboration in the development of strategies to reduce healthcare-associated infections. Dr. Galdys graduated from the University of Minnesota School of Medicine. She completed her residency in Internal Medicine-Pediatrics and fellowship in Infectious Diseases at the University of Pittsburgh Medical Center.

After her fellowship, Dr. Galdys joined the University of Pittsburgh Infectious Diseases faculty where her areas of focus were hospital epidemiology and infection prevention. In 2016, she joined the Division of Infectious Diseases and International Medicine at the University of Minnesota.

References 1. Dubberke ER, and Olsen, MA. Burden of Clostridium difficile on the healthcare system. Clin Infect Dis. 2012;55(Suppl 2):S88-92.

2. Lessa FC, Yi M, Bamberg WM, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med. 2015;372:2369-2370.

3.

Crook DW, Walker AS, Kean Y, et al. Fidaxomicin versus vancomycin for Clostridium difficile infection: meta-analysis of pivotal randomized controlled trials. Clin Infect Dis. 2012;55(Suppl 2):S93-103.

4. Wilcox MH, Gerding DN, Poxton IR, et al.

Bezlotoxumab for prevention of recurrent Clostridium difficile infection. New Engl J Med. 2017;376:305-317.

5. van Nood E, Vrieze A, Nieuwdorp M, et al.

Duodenal infusion of donor feces for recurrent Clostridium difficile. New Engl J Med. 2013;368:407-15.

6. Anderson DJ, Chen LF, Weber DJ, et al.

Enhanced terminal room disinfection and acquisition and infection caused by multidrugresistant organisms and Clostridium difficile (the Benefits of Enhanced Terminal Room Disinfection study): a cluster-randomised multicenter, crossover study. Lancet. Forthcoming 2017.

7. Longtin Y, Paquet-Bolduc B, Gilca R, et al.

Effect of detecting and isolating Clostridium difficile carriers at hospital admission on the incidence of C. difficile infections: a quasiexperimental controlled study. JAMA Intern Med. 2016;176(6):796-804.

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Infectious Diseases Update

Antibiotic Stewardship Programs: An Idea Whose Time has Come

A

ntibiotic resistance has been emerging since shortly after the advent of penicillin; however, in recent years the problem has worsened. You can hardly peruse a news site or medical journal without encountering yet another article on emerging antibiotic resistance. A recent headline grabber was a lady in Reno, Nevada who died of Klebsiella pneumonia sepsis after having received prior surgery in India to repair a fractured femur. The microbe was confirmed by the CDC to be the New Dehli Metallo-beta lactamase (NDM), and it was fully resistant to 26 antibiotic agents! (ref: MMWR) Surveillance cultures were performed on the other patients hospitalized on her unit. Fortunately, no other patients tested positive for the NDM bacteria.1 However, this case shows how perilously close we now are to the so-called “end of the antibiotic era.”

“Hospitals are a centerpiece for resistance, reflecting the clustering of highly vulnerable patients, extensive use of invasive procedures, and high rates of antibiotic use.”2 The CDC has called for a national response to prevent the emergence of antibiotic resistant microbes. One of the key elements is hospital Antibiotic Stewardship Programs (ASPs). About 3040% of antibiotic use in humans is unnecessary. ASPs aim is to curtail excessive use of antibiotics through a variety of interventions.3 ASPs have shown the ability to reduce hospital antibiotic consumption by 11-38%.2 Evidence shows that curbing overuse of antibiotics is among the

By Gary R. Kravitz, M.D., FACP, FIDSA, FSHEA

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May/June 2017

best ways to prevent Clostridium difficile infections and to slow the emergence of multi-drug resistant infections. Thus ASPs have been gradually initiated at an expanding number of hospitals with nearly 40% of hospitals now having some type of ASP. 2016 was an “annus mirabilis” (wonderful year) for Antibiotic Stewardship Programs. In this single year there emerged the new Infectious Disease Society of America (IDSA) Antibiotic Stewardship Guidelines, the CDC Core Elements for Hospital Antibiotic Stewardship Programs, and the Center for Medicare and Medicaid Services (CMS) requirement of ASPs as a condition of participation.4 Lastly, the Joint Commission (JC) issued a new Antibiotic Stewardship Quality Standard.5 ASPs have moved front and center in every hospital’s quality management programs and are no longer optional. They are required in every hospital and long-term care facility. Antibiotic Stewardship Programs are an idea whose time has come.

How do ASPs work? The 2016 IDSA Antibiotic stewardship guidelines focus on six strategies: • Prospective audit and feedback to clinicians (PAF) • Prior authorization of restricted agents • Hospital specific treatment guidelines for common infectious conditions • Cascading sensitivity panels • Rapid diagnostic testing • Antibiotic “time-outs” 48-72 hours after starting antibiotics to verify that antibiotics are still needed and that antibiotic coverage is winnowed to the narrowest spectrum agent for the shortest duration necessary.

Of the elements above, studies show that prospective audit and feedback to the prescribing clinician is by far the most effective way to control antibiotic usage followed by hospital-specific guidelines for the treatment of common infections.

Some ASPs are more effective than others. The CDC recommends that the following elements are needed to have an effective ASP program: CDC Element 4: Action includes

CDC’s 7 core elements of antimicrobial stewardship Element 1

Leadership commitment

Element 2

Accountability

Element 3

Drug expertise

Element 4

Action

Element 5

Tracking

Element 6

Reporting

Element 7

Education

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The Journal of the Twin Cities Medical Society

the six strategies listed above in the IDSA guidelines.

Sadly many of these elements have yet to be fully implemented. A CDC survey of 4,000 hospitals found that only 40% of hospitals met all seven of the core elements.

With this in mind, the JC took the CDC core elements and made them an antimicrobial stewardship quality standard effective as of January 1, 2017. This new standard has eight elements and applies to all hospitals and long-term care facilities (LTCFs). The elements are: Element #1: Leadership establishes antimicrobial stewardship as an organizational priority.

Element #2: The hospital educates medical staff about antimicrobial resistance and antimicrobial stewardship.

Element #3: The hospital educates patients, and their families as needed, regarding the appropriate use of antibiotics.

Element #4: The hospital has an antimicrobial stewardship multidisciplinary team that includes the following: • Infectious disease physicians • Infection preventionist(s) • Pharmacist(s) (ID-trained preferred) • Practitioner(s) (usually Hospitalists) Element #5: Reiterates the CDC’s seven core elements (listed above).

Element #6: Establish treatment guidelines for common infections, implement them and use them as a standard for prospective audit and feedback (PAF).

Element #7: The hospital collects, analyzes data on antibiotic use and antibiotic resistance and reports it to the hospital quality committee and the CEO. Element #8: The hospital takes action on improvement opportunities identified by its antimicrobial stewardship program.

Hospital administrators are keenly aware of the new JC Antibiotic Stewardship Standards and are scrambling to put programs into place that meet the new Standard.

Can these recommendations be implemented? Yes, they can! Ascension hospital system has already established facilitybased ASPs based on CDC core elements at all 141 of its hospitals, including: MetroDoctors

• system-based guidelines • physician and pharmacist leader at each site • Chief Medical Officer (CMO) also involved at each site • Fully compliant with JC 2017 Antibiotic Stewardship standards.6 (ref: Ascension) Barriers to starting an ASP are considerable. Many smaller hospitals and LTCFs do not have an infectious disease specialist on staff. The number of PharmDs with advanced training in Infectious Disease is woefully inadequate in view of the dramatically increased level of demand. There has been a lack of practical recommendations about staffing levels needed to carry out a successful program, especially in smaller community hospitals, critical access hospitals, and LTCFs. Key administrative support, financial support, and specialized IT resources needed for electronic monitoring of antibiotic usage are also often lacking.

A survey done by the IDSA found the following results as outlined in the chart below: Perceived Barriers to full implementation of ASPs:

Element

Percent reported

Lack of time

66

Lack of financial resources

63

IT support issues

61

Resistance from providers

20

No barriers

7

Conclusions:

Antibiotic stewardship programs have evolved rapidly over the past decade and have been shown to be the most effective way to curtail overuse on antibiotics in the hospital and LTCFs. This, combined with eliminating the use of antibiotics in animal husbandry, are the most important weapons in preserving “the miracle of antibiotics.”2 Starting this year, ASPs are now mandated as a quality standard by the JC. The immediate task is to build effective ASPs at all hospitals, large and small, as well as in LTCFs. Gary R. Kravitz, M.D., FACP, FIDSA, FSHEA, attended Northwestern University Medical School and completed an Infectious Disease fellowship at the University of Chicago. He is a founder of St. Paul Infectious Disease Associates and serves as the Director of Infection Control at United Hospital in St. Paul, MN where he founded the Antibiotic Stewardship Program in 2002. He is engaged in Antibiotic Stewardship Programs at seven different hospitals and has more than 30 research publications.

References: 1.

Chen Lei Todd R, Kiehlbauch J, et al. Notes from the Field.; Pan-resistant NDM-betal-lactamase in Washoe County, Nevada, 2016. MMWR/ Jan13, 2017/66;33.

2. Bartlett JG, Gilbert DN, Spellberg, B: Seven Ways to Preserve the Miracle of Antibiotics.

Clin Infect Dis 2013;56:1445-60.

3. CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. http://www.cdc.gov/getsmart/healthcare/ implementation/core-elements.html.

4. CMS. CMS Promotes Antibiotic Stewardship in Hospitals. https://www.cms.gov/Newsroom/ MediaReleaseDatabase/Fact-sheets/2016-Factsheets-items/2016-06-13.html.

5. JC. New Antibiotic Stewardship Standard. https://www.jointcommission.org/assets/1/6/ New_Antimicrobial_Stewardship_Standard. pdf.

6. http://ascension.org/news/social-media-hub/ social-hub-articles/2016/12/09/16/56/ascensionhospitals-get-smart-about-antibiotics.

7.

IDSA/SHEA/PIDS Joint Taskforce Survey on Antibiotic Stewardship (summited for publication).

This same IDSA survey is seeking to determine optimal staffing levels for running successful ASPs across the spectrum of inpatient care facilities.7 Results should soon be available as a guide.

The Journal of the Twin Cities Medical Society

May/June 2017

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Bariatric Education Days will be held May 25 and 26, 2017 at the Radisson Blu Mall of America in Bloomington, MN. This conference has been approved for AMA PRA Category 1 Credits, ANCC Credits, and Minnesota Board of Psychology Credits.

Infectious Diseases Update

Home Infusion of Anti-infectives: Ensuring Quality of Life While Lowering Costs

A

n increasing number of patients require ongoing infusion of antiinfectives — including antibiotics, antifungals and antivirals. Given the choice, few would opt to be hospitalized or reside in a skilled nursing facility to receive this life-saving care when they could have it more comfortably at home.

Indeed, home infusion therapy has grown substantially during the past 20 years, and anti-infectives are the most common medication so utilized.1 The benefits of home infusion are many. Patients can leave the hospital sooner — or avoid admission altogether — and receive treatment at home where they have more control, independence and freedom.

Home infusion is not only significantly less costly than hospital- or skilled nursing facility-based therapy,1,2 it also reduces exposure of these vulnerable patients to virulent and increasingly antibiotic-resistant healthcare-associated infections (HAIs).3 Anti-infective infusion is indicated for a variety of conditions, including respiratory infections, cellulitis, osteomyelitis, urinary tract infections, diabetic foot ulcers, endocarditis and pneumonia. Today’s delivery devices simplify administration of anti-infective infusion, which typically is given once or twice a day for two to six weeks, depending on diagnosis. When administered by a high-quality home infusion provider offering extensive education, robust clinical management and ongoing support throughout the continuum of care, most patients can safely and effectively self-infuse through the appropriate vascular access delivery device, such as a peripherally inserted central catheter (PICC) or midline catheter.

Referring a Patient for Home Infusion

Because infections can quickly become life-threatening, a high-quality home infusion provider will respond to referral requests within two hours of the receipt of documentation. Patients seen at the physician’s office or emergency department can begin targeted therapy at home within 24 hours, avoiding hospital admission altogether. Ensuring a smooth transition from diagnosis to safe and successful home infusion therapy requires high-quality, high-touch home infusion that puts the patient at the center of care and employs established step-by-step protocols.

• Assess appropriateness. Determining whether the patient is an appropriate candidate for home infusion is key.

The home infusion team works with the patient’s physician and other hospital staff to assess the patient’s ability to understand and follow instructions related to care. Is the patient independent and if not, does he or she have adequate support? Does the patient have other comorbidities that might complicate therapy?

• Verify coverage. The home provider verifies insurance and connects the patient to financial assistance resources, if needed. Recognizing the cost benefits, most private insurers cover home infusion, as do Medicare Advantage plans. While the home infusion industry has been advocating for expanded coverage, Medicare Part B and D do not currently cover supplies and home infusion service, so verification of coverage before proceeding with home infusion plans is important.

By Brenda Wright MetroDoctors

The Journal of the Twin Cities Medical Society

• Develop an individualized plan. A multidisciplinary team — including the physician and home infusion nurse, pharmacist and clinical liaison — collaborates to create a customized approach for the patient following the doctor’s care plan, whether the patient is suffering from a relatively simple bacterial respiratory infection or a complex diabetic foot ulcer. The pharmacist conducts a full case review to confirm the antiinfective choice and suggest treatment adjustments if warranted, including dosing changes that may reduce the number of infusions, easing patient self-care. Topics of discussion include the treatment plan, the risk of side effects, comorbidities and goals of therapy.

• Educate the patient. Prior to discharge, the home infusion nurse meets with the patient (and caregiver, if appropriate) to facilitate hands-on learning focusing on: caring for vascular access, administering medication, using and maintaining the equipment, properly storing medications, looking for early warning signs of side effects and the importance of adhering to therapy. After the patient is discharged home, the nurse will visit the patient to reinforce the training and assess the situation to verify the patient is capable, comfortable and has access to necessary services such as running water and refrigeration. The goal is to teach patients how to take an active role in their own health and empower them to provide good self-care.

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Infectious Diseases Update Home Infusion of Anti-infectives (Continued from page 25)

• Provide ongoing support. Nurses, pharmacists and other staff provide ongoing support according to the care plan and patient’s daily needs. The wide range of patient circumstances demonstrates why a customized care plan is vital. At a minimum, the patient receives a weekly check-in call to inquire about health status, response to therapy, side effects and other issues and has 24/7 phone access to the home infusion provider to address questions or concerns. Conversely, some patients require a nurse to administer each infusion. The home infusion team also provides the physician with regular status updates.

Following these protocols ensures patients receive clinically appropriate, high-quality care that results in significant benefits and cost savings.

Patient Benefits

While home infusion patients enjoy improved quality of life, the benefits extend much further. Therapy compliance (adherence) is vital to successful treatment and individualized, high-touch care reinforces this goal by providing education and support. When problems arise, they typically are related to financial coverage or side effects. To ameliorate these potential problems, a high-quality infusion provider following the previously noted protocols not only ensures adequate coverage prior to the start of therapy, but employs procedures to reduce or quickly address side effects.

The individualized care plan, monitoring and interventions by the pharmacist and nurses reduce the infusion-related incidences such as allergic reactions, resulting in a 98% rate of incidence-free infusion encounters, according to an Option Care analysis.4 Further, patients are taught to contact the home infusion nurse at the first sign of side effects. The home infusion nurse will then discuss the issue with the patient’s physician and devise a plan to address the problem in a timely manner.

Patients clearly appreciate receiving high quality well-coordinated care at home, as well as accommodation of 26

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their schedules. For example, Option Care surveyed their patients, finding: 96% expressed overall satisfaction with the anti-infective therapy program, 95% were satisfied with the provider’s ability to solve problems, 95% were satisfied with the knowledge of the patient’s health condition and 97% were satisfied with the provider’s skill in administering therapy.5,6 Cost Effectiveness

While high quality care and patient satisfaction are of topmost importance, cost remains a key driver of the provision of care. Home infusion offers significant cost savings for the payer and often for the patient. The per-day hospital cost for infusion is about $1,500, while home or alternative site infusion is about $200, an approximately 90% decrease in costs, according to one analysis.1 Another study found infusion care provided at alternate sites of care, including the home, resulted in savings of up to 60% for health plans and patients.2 The indirect cost savings — or cost avoidance — are potentially even more significant. High-touch home infusion reduces 30-day hospital readmission rates compared to the national average for patients discharged from the hospital.

For example, an Option Care study determined that readmission rates were up to five times lower in the home infusion population compared to the national average of discharged patients.7,8 During a one year period, about 4% of home infusion patients were readmitted within 30 days for pneumonia, compared to more than 15% of discharged patients overall. 7,8 About 4% of home infusion patients were readmitted for septicemia, compared to more than 20% of discharged patients overall. 7,8 Another study by the same provider showed a .44% rate of unplanned antibiotic-related hospital readmissions.9 Further, decreasing or avoiding time spent in the hospital or skilled nursing facilities reduces exposure to Hospital Acquired Infections (HAIs), a costly and significant problem. In 2011, about 721,800 infections occurred in 648,000 hospital patients and 75,000 patients died.10 Increasingly, many infections are caused by resistant pathogens such as Klebsiella and

E. coli. These HAIs cost hospitals $28 to $34 billion a year.11 The aging population and growing incidence of chronic conditions promises to increase the need for anti-infective infusion therapy. Home infusion administered by a quality provider that provides patient-centered comprehensive clinical management across the continuum of care improves outcomes and reduces costs, while allowing patients to work, attend school, continue activities and enjoy life.

Brenda Wright is Vice President, Clinical Services at Option Care. She brings more than 20 years of home infusion and specialty pharmacy experience to Option Care, where she leads quality initiatives and supports new product introductions. www.optioncare.com.

References 1. Home Infusion Industry Overview, June 2014.

HarrisWilliams&Co. Accessed Feb. 13, 2017 at: http://www.harriswilliams.com/system/files/ industry_update/2014.6.24_home_infusion_industry_overview.pdf.

2. Einodshofer, M. A plan for medical specialty medications–increase member access, affordability and outcomes while decreasing plan costs. Presented at: 2012 Pharmacy Benefit Management Institute Annual Drug Benefit Conference; 2012 Feb. 22-24; Scottsdale, Ariz.

3. Wisplinghoff, H., Bischoff, T., Tallent, S. M., et al. Nosocomial bloodstream infections in U.S. hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study. Clinical Infectious Disease, 2004; 39(3), 309-317.

4. Option Care data on file. Review of October 2009-February 2011 patient data, based on an average of 39,978 patients per month.

5.

Option Care data on file. September 2013-August 2014 patient satisfaction data. Survey of 211 patients.

6.

Option Care data on file. September 2013-August 2014 patient satisfaction data. Survey of 174 patients.

7. Option Care data on file. Review of September 2012-August 2013 patient data, based on 45,917 anti-infective patients.

8. Elixhauser A. Steiner C. Readmissions to U.S. hospitals by diagnosis 2010. Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, Statistical Brief #153.

Accessed Feb. 13, 2017 at http://www.hcup-us. ahrq.gov/reports/statbriefs/sb153.jsp.

9. Option Care data on file. Review of February 2014 patient data, based on 48,750 antiinfective patients.

10. Magill SS. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014 Mar 27;370(13):1198-208.

11. Scott, R. D. The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Centers for Disease Control and Prevention. March, 2009. Accessed Feb. 13, 2017 at https://www.cdc.gov/HAI/pdfs/ hai/Scott_CostPaper.pdf.

MetroDoctors

The Journal of the Twin Cities Medical Society

Environmental Health — Infectious Disease Implications of Climate Change

F

rom the beginning of life almost four billion years ago there have been winners and losers. And the fate of both has been heavily influenced by microbes. During the course of the past 450 million years, five Mass Extinctions have occurred. One — dubbed the “Great Dying” — was caused by an archaea (Methanosarcina) that released enough methane to trigger a lethal climate change. In what geologists are calling a new Anthropocene Epoch, climate change is again contributing to an alarming number of extinctions.

But this time one mammalian species (Homo sapiens) is playing a critical role.

Fueled by global warming-related increases of atmospheric carbon dioxide and methane generated by fossil fuels, the breeding season and habitat of ticks and mosquitoes have expanded. More frequent extreme weather events (e.g. flooding and heat) favor mosquitoes and other insect vectors as well as certain aquatic microbes.

One tick species, Ixodes scapularis, is particularly nasty. It transmits both bacteria — Borrelia burgdorferi (the cause of Lyme disease) and Anaplasma phagocytophilum (the cause of human anaplasmosis) — and a parasite — Babesia microti (the cause of babesiosis). Minnesotans are in the midst of expanding epidemics caused by these pathogens. Of the pandemics caused by mosquito-borne viruses, West Nile Virus infection is common in Minnesota. Travel to more temperate areas of the world, however, exposes us to the risk of other mosquito-borne pandemics, e.g., dengue, chikungunya, and Zika, transmitted by Aedes mosquitoes; and malaria carried by Anopheles mosquitoes. Ocean

warming encourages the growth of Vibrio species in coastal waters raising the risk of cholera.

Of the 140 emerging or reemerging infections of humans in the past half century, most are byproducts of human technology — most importantly fossil fuelrelated climate change and air travel which rapidly disseminate vectors and infectious agents. The good news is that technological solutions are rapidly developing that help curb global warming, such as solar and wind power. But if such solutions aren’t promoted, you can bet that microbes will be winners. In the words of Louis

Pasteur, “It is the microbes who will have the last word.”

Phillip Peterson, M.D., Professor of Medicine Emeritus, University of Minnesota Medical School. He can be reached at: peter137@ umn.edu.

References: • Flahault A, R. de Castaneda, I Bolon. Climate change and infectious diseases. Public Health Reviews 37:21-23 (2016).

• Altizer, S, RS Ostfeld, PTJ Johnson, S Kutz, C, D Harvell. Climate change and infectious diseases: from evidence to a predictive framework. Science 341: 514-519 (2016).

• Wu X, Y Lu, S Zhou, L Chen, B Xu. Impact of climate change on human infectious diseases: Empirical evidence and human adaptation.

Environment International 86:14-23 (2016).

By Phillip Peterson, M.D. MetroDoctors

The Journal of the Twin Cities Medical Society

May/June 2017

27

n exciting new event is sweeping Minnesota. It’s called The Convenings — a series of three community affairs orchestrated by MPR Morning Edition host, Cathy Wurzer.

The inspiration came from conversations Cathy had with Bruce Kramer who, at the time was dean of the School of Education at the University of St. Thomas, and was diagnosed with Amyotropic Lateral Sclerosis (ALS) in December of 2010.

These conversations about his experiences were turned into podcasts and a book they co-authored titled: We Know How This Ends: Living while Dying.

Before Bruce passed away in March of 2015, he instructed Cathy to continue their work allowing the ideas they shared about continuing to live a purposeful, meaningful life even while facing death to ripple through to the greater community. Bruce found that his limited timeline let him strip away superficial nonsense and concentrate on building deeper relationships with his family and friends.

A

ailing and rapidly aging population. Studies show the majority of people don’t want their families to be burdened by end-of-life decisions, yet less than one-third of people have communicated their preferences to their families. Ultimately, disagreements among family members can cause anger, resentment, and pull

The goals of The Convenings are to: • Inspire people to think about and discuss their choices for living and dying well • Evoke a sense of urgency for such conversations • Build/spark communities of care throughout the state • Empower community leaders with skills and resources to stimulate conversation and increase public awareness of living and dying well • Share stories about and ideas from what other communities are doing These goals reflect a growing need for authentic discussion and thoughtful decision making as society grapples with an

Cathy Wurzer and Brenda Winter, writer, The Convenings – Luverne, MN.

Cathy Wurzer engages audience members at The Convenings – Northwest Metro.

By Pamela Palan Project Manager, The Convenings

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May/June 2017

MetroDoctors

The Journal of the Twin Cities Medical Society

families apart when they should be pulling together. Futile attempts to extend life can also bankrupt families.

The Convenings are three unique, community-focused events developed with a team from each community and designed to be sustainable well into the future: • A kick-off luncheon where business, health and faith leaders learn about the concepts, and are given tools they can use to reach out to others in their community.

• Deemed the “main event,” an evening of music, storytelling, and sharing led by Cathy. The community shares inspirational personal stories, medical experts share their experiences, and the community team shares resources the community can use to learn more. There is also live music.

Six to nine months after the Convening, Cathy returns for a Re-Convening. This event has music, too, but the focus here is to have the community report back on all the work that has been done so all can see the ripples of engagement throughout the community.

Honoring Choices Minnesota is a partner with The Convenings.

Top: Audience at The Convenings – Northwest Metro at Faith Lutheran Church, Coon Rapids, MN. Upper Left: Renee Crichlow, M.D., Family Medicine, North Memorial Health; speaker, The Convenings – Northwest Metro.

Left: Audience at The Convenings – Ely, MN. Above: Cathy Wurzer interviewing Mike Rouse at The Convenings – Ely, MN.

MetroDoctors

The Journal of the Twin Cities Medical Society

May/June 2017

29

Senior Physicians Association Meeting Held

Rebecca Thoman, M.D., Campaign Manager for Doctors for Dignity, Compassion & Choices MN, kicked off the 2017 Senior Physicians Association events with a presentation on “Understanding Medical Aid in Dying.” Attendees learned about programs currently in existence, primarily the Oregon experiences, noting that aid in dying is a component of, not an alternative to, hospice care and physicians

have a responsibility to relieve suffering.

Twenty-two bills have been introduced in legislatures throughout the country this year.

Join your colleagues for the next SPA program on Tuesday, May 2 at 12 noon, “Climate is Changing the Face of Disease”

by Bruce Snyder, M.D. Register now at metrodoctors.com.

Rebecca Thoman, M.D., Campaign Manager for Doctors for Dignity, addressed the SPA audience.

All physicians age 62 and older are invited to attend. Contact Nancy Bauer for more information: nbauer@metrodoctors. com; (612) 623-2893.

SPA President Eugene Ollila, M.D. welcomed guest speaker Rebecca Thoman, M.D.

In Memoriam JAMES E. BROWN, M.D., passed away on December 18, 2016. He was the Assistant Chief Medical Officer for the Northern Pacific and Burlington Northern railroad. Dr. Brown joined the medical society in 1988.

RICHARD L. ENGWALL, M.D., an anesthesiologist, passed away on February 5, 2017. Dr. Engwall joined the medical society in 1959.

GREGORY GEPNER, M.D., passed away on March 12, 2017. He was a family physician and Medical Director at Smiley’s Clinic Fairview Riverside.

Dr. Gepner joined the medical society in 1984.

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May/June 2017

DONALD M. LARSON, M.D., passed away on March 2, 2017 at the age of 94.

Dr. Larson practiced OB/GYN alongside his brother, Roger, for 33 years. Dr. Larson joined the medical society in 1953.

JOHN W. LAWROW, M.D., passed away in February 2017. He was a founding member of Northeast Internists, PA. Dr. Lawrow joined the medical society in 1963.

FREDREKIA LEWIS, M.D., passed away on February 24, 2017 at the age of 64. Dr. Lewis practiced Internal Medicine at Open Cities Health Center.

PAUL C. OLFELT, M.D., a radiologist, passed away in January 2017. Dr. Olfelt joined the medical society in 1956.

HAROLD RAVITS, M.D., passed away in March 2017. Dr. Ravits practiced Dermatology at the University of MN. He joined the medical society in 1950 and served as President of Ramsey County Medical Society in 1971.

JEAN H. SMELKER, M.D., a pediatrician and fiber artist, passed away on September 15, 2016. Dr. Smelker joined the Senior Physician Association in 1988.

MetroDoctors

The Journal of the Twin Cities Medical Society

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31

LUMINARY of Twin Cities Medicine

By Marvin S. Segal, M.D.

GEORGE A. SAROSI, M.D. It has been a long and circuitous path for our Luminary — from the turmoil of Hungary in the ’50s to the relative calm of an academic medical life in Minnesota over 60 years later. Let’s review some of the touchstones he has experienced along the way.

George Sarosi spent most of his youth in Budapest, raised by his mother, a Ph.D. chemist, after his OB/GYN specialist father who served in the army, perished at Auschwitz during WW II. The Nazi occupation of Hungary as an Axis member, was followed post war by Soviet occupation and a cruelly repressive government. In 1956, Hungarian social unrest led to the development of a resistance initiative by the proud Hungarian people, of which a University Brigade militia played a prominent role. George, then a medical student and a militia member, eventually interrupted his studies and emigrated to the U.S. along with hundreds of thousands of other refugees — hopefully leaving tyranny and religious discrimination behind.

That bright, young immigrant student knew no English, but quickly learned it via a crash 12-week course — enough to qualify for University of North Dakota entrance, first as a biochemical major leading to acceptance to their two year medical school, followed by completion of his final two years and an M.D. degree from Harvard University.

Dr. Sarosi then traveled back west, following his North Dakota wife’s scholarly nursing pursuits, for an Internal Medicine residency at our U of M. During that time he actually published 16 papers and served as Chief Resident under the tutorage of Dr. Richard Ebert, whom he describes as “mentor extraordinaire.” Within 10 years from residency completion, he attained full Professorship and soon after was named the C.J. Watson Professor of Medicine.

George is best known for his infectious disease and pulmonary expertise, though his overall knowledge has been described by colleagues as “astonishing” in essentially all areas of Internal Medicine. This is evidenced by scores of publications on a wide range of topics including virtually all important mycoses and their treatments. The knowledge gained from his study and experience with HIV/AIDS has had a profound career effect on the expansion of his general knowledge in the behavior of pathogenic microorganisms.

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May/June 2017

Dr. Sarosi’s leadership capabilities have been expressed in departmental chairmanship positions at the Universities of Minnesota, Texas, Arizona, Stanford and Indiana — the latter being an important professional hallmark where he was able to complement the great scientists of that institution with his remarkable clinical expertise. Dr. George has earned fellowships in Pulmonary and Infectious Disease organizations and his teaching talents have been recognized multiple times in virtually every institution with which he’s been associated — as “Outstanding Teacher/ Attending of the Year,” and numerous national distinguished service awards and editorial positions have continued through recent years. It’s little wonder why he states that his favorite professional activity has been “interactions with the learners.”

This energetic and engaging chap with a charmingly wry sense of humor was a sought-after soccer star in his youth and a Senior Olympic fencing champion in the 80s. He is a voracious reader and is an accurate and gently opinionated source of information on world and American history, current events, the splendors of paprika and the future direction of medicine.

What a treat it is to listen to and absorb some of his honest and introspective philosophical approaches to life — e.g. “internists are the core of medicine;” “life can be a series of accommodations to stress;” “medicine has changed — it’s humbling to think back on some of the crud I once told my students;” “we mainly talk with people we like and agree with — it’s like living in an echo-chamber, sometimes too painful to leave our bubble.”

How fortunate for many of us that that young Hungarian lad decided to head our way so many years ago!

This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine.

Please forward names of physicians you would like considered for this recognition to Nancy Bauer, Managing Editor, nbauer@metrodoctors.com.

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The Journal of the Twin Cities Medical Society

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