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Between 2 million and 4 million people in the U.S. are living with chronic hepatitis C, but most don't know they are infected. Untreated hepatitis C is the leading cause of liver cancer and the most common reason for liver transplantation. The CDC recommends that all baby boomers be screened once for hepatitis C. Photo by Zak Hussein / Press Association via AP Images

Infectious diseases weigh on primary care (ACP annual meeting)

Internists increasingly are managing complex communicable illnesses. The American College of Physicians meeting offered the latest guidance on such diseases.

By — Posted May 13, 2013

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For some infectious disease experts, hepatitis C evokes memories of the early days of HIV/AIDS, when patients were diagnosed in the late stages of the disease and took handfuls of potent drugs every day. Just as in that era, many people with hepatitis C today are unaware they are infected, said San Francisco hepatologist Norah A. Terrault, MD, MPH.

Those who are diagnosed often are in poor health and receive toxic, complicated treatments. Although hepatitis C is curable, it can lead to cirrhosis of the liver, liver cancer and death if left untreated.

“In the last several years, deaths due to hepatitis C have surpassed deaths due to HIV. We expect that to continue,” Dr. Terrault told colleagues during a session of the American College of Physicians annual scientific meeting in San Francisco on April 11-13.

Dr. Terrault's presentation was one of many infectious disease sessions offered at the three-day meeting. The sessions highlighted trends doctors should be aware of, including antibiotic-resistant urinary tract infections and tips on screening for complex communicable diseases. The presentations often were standing room only.

The sessions come as some doctors are becoming more involved than ever in managing complicated infectious diseases, medical experts say. Contributing to that change is the fact that there are too few infectious disease specialists to meet the nation's demand, particularly in rural areas. Another factor is improved treatment that extends the lives of people with diseases such as HIV. As a result, more doctors are treating chronic conditions in patients with complex communicative illnesses.


Dr. Fekete

Physicians face challenges as they take on this expanded role. Those include limited time for office visits and little specialized training in infectious diseases. Complicating matters: growing antibiotic resistance and a lack of new antimicrobials to work against one of the nation's most serious health threats — gram-negative bacteria, which are resistant to all available antibiotics.

But doctors shouldn't have to do this on their own, said infectious disease specialist Daniel P. McQuillen, MD, a senior staff physician at Lahey Hospital and Medical Center in Burlington, Mass. “Infectious diseases experts can work with them and help them manage things and make sure that outcomes are good,” he said.

Collaborating with specialists

One such collaborative effort is Project Echo, launched in 2003 by a New Mexico doctor. The initiative uses real-time videoconferencing to connect primary care physicians with specialists. The specialists train doctors to treat HIV/AIDS and hepatitis C, among other complex conditions.

Data show that the approach is effective. Cure rates of New Mexico adults age 18 to 65 with hepatitis C were 58.2% for people treated by Project ECHO doctors and 57.5% for those cared for at the University of New Mexico's HCV clinic, said a study in the June 9, 2011, issue of The New England Journal of Medicine.

Between 2 million and 4 million Americans are chronically infected with hepatitis C, and 75% are undiagnosed, Dr. Terrault told doctors packed into her ACP session. To put that in perspective, 21% of people with HIV/AIDS are unaware they are infected, said Dr. Terrault, an associate professor in the Dept. of Medicine at the University of California, San Francisco.

Baby boomers are the population most likely to be infected with hepatitis C. They account for 75% of chronic infections among U.S. adults. That high incidence largely is due to risk behaviors baby boomers engaged in during the 1960s and 1970s. A key risk factor for hepatitis C is intravenous drug use.

In recent years, hepatitis C has surpassed HIV as a cause of death.

Dr. Terrault urged her colleagues to follow the Centers for Disease Control and Prevention recommendation that all adults born between 1945 and 1965 be screened once for hepatitis C.

Existing treatment has significant challenges. The combination of injections and pills is expensive and can cause harsh flu-like symptoms. The medications also have limited efficacy in certain populations, including blacks and transplant recipients. By 2014, new drugs are likely to be available that will be more effective, easier to take and have fewer side effects, Dr. Terrault said.

“Alarming” antibiotic resistance

Perhaps more alarming is the increasing antibiotic resistance of bacteria that cause community-acquired UTIs, a condition that frequently is diagnosed in primary care, said Thomas Fekete, MD, who led a packed session on antimicrobials at the ACP meeting.

Patients with minor UTIs who typically would have received a short course of antibiotics might now need the medications through an intravenous line, medical experts say.

“This is really alarming to a lot of people,” said Dr. Fekete, chief of infectious diseases at Temple University School of Medicine in Philadelphia. Antibiotic resistance is occurring for bacteria that cause a common condition in otherwise healthy people, he added.

Gonorrhea is another infection affected by antibiotic resistance, said infectious disease specialist Lisa L. Maragakis, MD, MPH, who led an ACP session on drug resistance. Neisseria gonorrhoeae has been developing resistance to the oral antibiotics used to treat it for decades. Fluoroquinolones, which have been prescribed for the infection in recent years, no longer are effective, Dr. Fekete said. In Canada, there have been at least nine gonorrhea infections resistant to cefixime, which is the last effective oral antibiotic for the illness, said a study in the Jan. 9 issue of The Journal of the American Medical Association.

In August 2012, the CDC revised its gonorrhea treatment guidance and said cefixime no longer should be a first-line treatment for the disease.

“Now we're stuck with injectables,” Dr. Fekete said. “Gonorrhea is going to be a big problem, because we don't have another backstop.”

One of the few bright spots at the infectious diseases sessions concerned Clostridium difficile. While C. diff rates are expected to increase in the near future due to new requirements that U.S. hospitals report such rates, cases of the disease probably will decrease in the long run, said Dale Gerding, MD, who led a session on the infection. Contributing to the decreased rates will be a C. diff vaccine that is in development and new short-term prevention methods that aren't widely used yet, said Dr. Gerding, professor of medicine at Loyola University Chicago Stritch School of Medicine in Maywood, Ill.

“Even though there's a lot of community-associated C. diff, the majority of those patients have had exposure to health care, if not in the hospital, then in office visits,” Dr. Gerding said. “Properly prescribing antibiotics is the biggest thing primary care doctors can do” to prevent the infection.

Furthermore, Dr. Maragakis encourages physicians to order a culture when they prescribe an antibiotic. A culture offers more information about the infection, including drug resistance, and thus enables doctors to modify treatment if a patient is not getting better, she said.

A recent report shows that although seven antimicrobials are in the pipeline, none would be effective against gram-negative bacteria. And there's no certainty the antibiotics in development will be approved by the Food and Drug Administration, said the report posted online April 17 in Clinical Infectious Diseases.

“There are patients out there right now who we don't have antibiotics for,” said Barbara E. Murray, MD, a report author and president-elect of the Infectious Diseases Society of America. “It is very scary.”

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Doctors told: Don't “friend” patients on social media

As the public's use of digital communication and social media continues to expand, physicians and medical students need to be cautious about what they post on the Internet and should avoid “friending” patients online, according to new policy by two organizations.

The policy about online medical professionalism was issued April 11 by the American College of Physicians and the Federation of State Medical Boards. The guidance was presented at the ACP annual scientific meeting in San Francisco on April 11-13 and published in the April 16 issue of Annals of Internal Medicine.

“It is important for physicians to be aware of the implications for confidentiality and how the use of online media for nonclinical purposes impacts trust in the medical profession,” said Humayun Chaudhry, DO, president and CEO of the FSMB.

The guidance comes at a time when nearly 90% of physicians report using at least one social networking site for personal reasons, said an August 2011 survey by the online physician learning collaborative QuantiaMD. Facebook was the most common site doctors visited for personal reasons (61%), followed by YouTube (31%) and LinkedIn (19%), the survey said.

Misuse of social media has led to disciplinary action by medical boards. Ninety-two percent of U.S. medical and osteopathic boards have received at least one report of an online professionalism violation, and 56% issued a serious disciplinary action, including license suspension, said a study of 48 state medical boards in the March 21, 2012, issue of The Journal of the American Medical Association.

To help prevent such incidents, the ACP and FSMB issued recommendations that “provide needed guidance on best practices to inform standards for the professional conduct of physicians online,” said Phyllis A. Guze, MD, immediate past chair of the ACP Board of Regents.

Key recommendations for physicians and medical students include:

  • Keep professional and personal online personas separate by creating a site exclusively for community outreach and networking.
  • Don't “friend” patients or contact them through social media.
  • Before posting information online, consider how the public might perceive the content.
  • Don't vent about work issues on the Web.
  • Only email and text message patients who have agreed to such communication methods and with whom you have an established relationship.
  • Regularly search for your name online and correct inaccurate information when possible.

The policy encourages medical institutions to issue policies on the use of digital media. It also recommends that educational programs be developed to inform students and physicians about the potential repercussions of posting content online.

The American Medical Association recommends that physicians consider separating personal and professional content online. When doctors see content posted by a colleague that appears unprofessional, they have a responsibility to bring that content to the individual's attention so it can be removed or other actions can be taken, the AMA said.

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Treatment tips

Here are some patient treatment recommendations and meeting notes from the American College of Physicians annual scientific meeting.

Watch out for these drug interactions. Interactions with the drug warfarin are among the leading reasons people are hospitalized for a drug interaction in the United States, said Seattle internist Douglas Paauw, MD.

The most severe interaction occurs with the antibiotic combination trimethoprim/sulfamethoxazole, which often is used to treat methicillin-resistant Staphylococcus aureus and urinary tract infections, said Dr. Paauw, who led a session on medication errors.

He urged physicians to avoid that antibiotic combination for patients who are taking warfarin. Acetaminophen can be used occasionally by patients on the anticoagulant, said Dr. Paauw, professor of medicine and director of the Medicine Student Program at the University of Washington School of Medicine.

Physicians can minimize negative side effects from statins by avoiding, when possible, simvastatin, which tends to have the most drug interactions, he said. Those least likely to react with other medications are pravastatin, which is a weak form of the drug, and rosuvastatin, a potent statin with the fewest reactions, Dr. Paauw said.

To help prevent serious medication side effects, he encouraged physicians to avoid prescribing quinolones. Use of that family of antibacterial drugs has been linked to arrhythmias and tendon ruptures, Dr. Paauw said.

Manage smoking like a chronic disease. Physicians should treat patients' tobacco use like a chronic disease, because it needs long-term management similar to diabetes and hypertension, said Nancy A. Rigotti, MD, director of the Tobacco Research and Treatment Center at Massachusetts General Hospital in Boston.

Although helping patients to quit smoking can be challenging, treating tobacco use is important, because cessation reduces mortality, said Dr. Rigotti, who led a session on smoking cessation. She said 69% of smokers want to quit and 52% of people who light up try to kick the habit each year.

The most effective smoking-cessation methods feature a combination of medications and counseling, which can be done one-on-one with the patient, in a group setting or by telephone, Dr. Rigotti said. Drugs that have been shown to help smokers quit include bupropion SR and varenicline, marketed as Chantix.

She encouraged physicians to refer patients to the “quitline” (1-800-QUIT-NOW), which helps patients give up tobacco.

Consider home visits part of primary care. House calls can be a viable option for clinical practice, particularly when the patient has difficulty accessing medical care due to physical or psychiatric problems, said internist and geriatrician Rebecca Conant, MD. She is the founding director of the University of California, San Francisco, Housecalls Program, which has provided in-home primary care to more than 300 homebound seniors since 2001.

During her session on home visits, she said a 2005 report found a 43% increase in home medical visits for Medicare patients between 1998 and 2004. Many of those visits were made by primary care physicians.

When making house calls, doctors should bring a map for directions, the proper paperwork and a way to access electronic health records wirelessly, Dr. Conant said. She recommended that doctors include in their bag a blood pressure cuff, stethoscope, oximeter, otoscope, tape measure, gauze and tape, and blood-draw supplies.

To ensure the safety of physicians and other staff conducting home visits, she said routine visits should be conducted during the daytime. Dr. Conant also recommended that office staff be aware of doctors' schedules and that physicians check in with their offices throughout the day.

Balance work and life. Doctors also were given guidance on caring for themselves. Many have moderate to high levels of emotional exhaustion, and some have low to moderate levels of personal achievement, said the doctors who led a session on managing work/life balance.

One key to physicians achieving that balance is to take care of their health, said Monica Harris-Broome, MD, who led the session with two physician colleagues.

“We talk to patients about everything they have to do to heal themselves. But do we do” any of those things, asked Dr. Harris-Broome, director of the Communication Skills Program at the University of Miami Miller School of Medicine.

Self-care includes eating a balanced diet, exercising regularly and making time for reflection and spirituality. Beyond self-care, there are steps physicians can take to help achieve a better work-life balance, the doctors said. Those steps include:

Identifying your ideal work schedule and then trying to achieve it.

Seeking out people who can help you balance your schedule, such as family, peers and mentors.

Learning how to say no to requests for your time and not feeling guilty about it.

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External links

American College of Physicians 2013 Internal Medicine annual scientific meeting (link)

“Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers,” The New England Journal of Medicine, June 9, 2011 (link)

Information on hepatitis C for health professionals, Centers for Disease Control and Prevention (link)

“Chronic Hepatitis C: Why Baby Boomers Should Get Tested,” CDC, August 2012 (link)

Neisseria gonorrhoeae Treatment Failure and Susceptibility to Cefixime in Toronto, Canada,” The Journal of the American Medical Association, Jan. 9 (link)

Information on antibiotic-resistant gonorrhea, CDC (link)

Clostridium difficile: Development of a Novel Candidate Vaccine,” Vaccine, June 19, 2012 (link)

“10 x '20 Progress — Development of New Drugs Active Against Gram-Negative Bacilli: An Update from the Infectious Diseases Society of America,” Clinical Infectious Diseases, April 17 (link)

“Online Medical Professionalism: Patient and Public Relationships: Policy Statement from the American College of Physicians and the Federation of State Medical Boards,” Annals of Internal Medicine, April 16 (link)

“Physician Violations of Online Professionalism and Disciplinary Actions: A National Survey of State Medical Boards,” The Journal of the American Medical Association, March 21, 2012 (link)

“Trends in House Calls to Medicare Beneficiaries,” The Journal of the American Medical Association, Nov. 16, 2005 (link)

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