As our next speaker.

Here is Dr. Prudish Tasch,

excellent infectious disease

specialist. He's an associate

professor of medicine at the Mayo

College of Medicine.

One, a handful of education

awards, one of Mayo's best

dressed consultants, year in

and year out.

He's always got the three piece suit

on. He's on CNN.

He's helping out celebrities left

and right.

This guy's, you know, as good as

they come.

But

all joking aside, he is a great

speaker.

He's been on our course a bunch of

times and he's an expert in

infectious disease.

And whether he's on service or not,

if I give him a page, he's always

helping me out with everything.

So happy to have him here.

Please welcome Dr. Tache.

Well, good, I'm glad to see the room

is full. This is awesome, and it's

Thursday. It's been going on for a

couple of days now.

Everyone's still showing up.

Sweet.

So, Ed, it's tough to follow

Rob, because he

first of all, I think actually

cares.

Which is awesome.

And he's interested in people

learning and stuff.

So I got to do my best to

follow.

Rob,

by the way, just show of hands.

How many guys are within the Mayo

system.

OK.

And

most of you guys are O.J.

Mayo system and another his

hospital beds. But how many of you

guys within the Mayo system do

outpatient stuff?

OK. Just a handful, so most of I get

this, this is a whole impatient

thing, right?

I just want to get it a little bit

of a sense, because some of this

they're gonna be talking about.

So we talk about influenza,

then prophylaxis, immunocompromised

host and then asymptomatic bacteria.

You try to focus on hospital

medicine. But some of this is gonna

be touching on on outpatient

stuff as well.

So a lot of my focus in my life

now, what I do is a lot of a risk

management stuff. And then there's

one bug that every year just sort of

halts your

outpatients or your hospital

system.

It's influenza. You know, it's going

to happen every year.

And we act surprised every time.

Yeah.

Yeah.

It's it's like every time my son

decides he doesn't want to go to

bed, like, ha, I didn't

know this was going to happen, but I

did.

So there's sort of influenza.

So I want to get

some guys quick

question up front.

So which of these patients

presenting with influenza like

illness during a period of

widespread influenza activity in

your community should be given

antiviral treatment for influenza?

So A a previously healthy

45 year old guy hospitalized

now with influenza who presented

four days after the start of

symptoms, a 55

year old guy with hypertension, with

mild illness, presenting 24

hours after onset,

let's say, to an urgent care,

a three year old boy with mild to

moderate illness presenting 36

hours after onset,

or a 25 year old with a BMI

of 35 who has mild illness

presenting 24 hours after

onset.

And so you don't even know how many

you owe. Look at all this.

Wow. Six, sir.

Two thirds of you.

So it turns out that's actually not

what's recommended.

Nine percent of you.

Which is why I'm glad, because now

I'm talking.

And hopefully I'll I'll convince you

why it should be that first guy.

Even though it's 48 out.

Even though it's four days later.

OK.

So a little bit of background.

If you have never seen influenza,

you're probably in the wrong room.

But influenza A..

So we have influenza An, influenza

B, influenza C infects

humans and seals.

So we're gonna to sort of cast that

aside from now.

So influenza A cause of seasonal

epidemics, of respiratory illness

in the temperate climates, in

topical areas is year round.

And so you in

there are two major flu fluids,

a subtype.

So there's H three N2,

which has been circulating since the

1968 Hong Kong flu.

And then H1N1,

which started circulating co

circulating at the same time is a

three and two since the 1977 Russian

flu. And then in 2009, there

was a new H1N1

that sort of took its place after

the pandemic.

So usually it's just

one of them will predominate.

It's either an H3 and two strain or

an H1N1 one strain.

Now, every time there's a new

pandemic, basically one of these

strain types gets replaced, would

it, by whatever the new

pandemic strain. So we had an H1N1

before and then 2009

came and basically that old H1N1

subtype came

out and went away.

And then we have this new one that

sort of took its place and

alternating in one year can H1N1

year and the year to predominates

three eight two year.

Now, influenza B also circulates

in the winter, but that doesn't

causes a big spike in epidemics.

And every year is responsible for

tens of thousands of deaths

in the United States.

And the vast majority of these

are result of exacerbations of

existing medical comorbidities,

especially in older people.

But infants, especially those

less than six months, are also at

risk of severe illness and death.

So the transmission is a problem

predominately by a large right.

So it's predominantly by large

droplets.

If you're going to see a patient,

please wear a

surgical mask.

If you don't wear glasses, make sure

there's some sort of face shield

and respiratory etiquette and

hand hygiene to prevent community

spread.

So, you know, coughing

into your the crook of your elbow,

washing your hands.

So clinical features

is not new for anybody, but

incubation period between one and

four days.

However, this influenza tends to be

actually be contagious a day before

symptoms start

and can be on know ongoing

for a good week.

Most infectivity is during the

height of symptoms.

I often is an abrupt onset

of fevers, myalgia and a

non-productive cough tends to

get better soon within a week.

I remember a couple of years ago I

came down with influenza.

At first I was afraid I was going to

die.

And then I was afraid that I wasn't

going to die.

It was awful.

But I got better and

I only say broke our protocols

and things like that. And I knew

I'm a healthy at that time.

Thirty nine year old guy

I should not get also Tanvir.

And sure enough, I did not give

myself Oseltamivir and

I did better and I'm alive and I'm

here today.

Eat Skittles and and

it's okay but it feels pretty

terrible at the time.

So what would super weird about this

season and I fall for

those are the few seven of you

raise your hand. You do. Our

patients have an email.

I write a weekly influenza

summary of our entire enterprise,

looking at what the trends

are, what we're going to expect and

things like that.

And

this was like a crazy story this

year for nerds

because it never happens like this,

where initially you just sort of

came in with H1N1

predominant across the country.

And in general, H1N1

epidemic year are less severe than

age three and two years.

And that's just generally speaking.

And then

in the southeast,

we started seeing a new they can age

three and two strain come in.

So after they had a H1N1

epidemic, then there comes

another one of an age

three N2 epidemic

that only, you know,

ended up being about half of them

were actually well-matched, the

vaccine strain.

So a lot of the country

ended up seeing basically two flu

seasons like right next to each

other. I don't raise your hands.

Did you guys see this where you

were?

Yeah.

Awful.

And, you know, I'm looking at Iowa,

your northeast Iowa.

Southwest Wisconsin.

And they both, like, went from H1N1.

And a story and Mike.

It is how is this not coming?

Like we're in either hurricane

here in Rochester, Minnesota.

And sure enough,

we got super lucky.

Like, once again, the floodwaters

just rose enough to hit the feet

of the Mayo brothers and then came

right back down.

And basically we avoided in Manila

and southeast Minnesota, we avoided

two flu season traced back to back.

But yeah, initially it was all H1N1.

But towards the end, it became

mostly age three and two.

And so if you thought this was a

longer flu season than usual.

Yeah, wise.

And this is unusual.

And for me, it was just this crazy,

strange story unfolding.

I'm writing my weekly reports.

And some people were just like just

telling what I'm supposed to poop my

pants like Woody.

Why are you telling the saga?

Other people like this is really

exciting.

So depending which camp you're on,

I thought it was really exciting,

but scary at the same time.

OK, so we'll talk about prevention

because this can be confusing.

There's so many different vaccines

available.

Which one do you use?

Goodbye. Before he accepted frisee

or in the sound a neighbor way

or in holidays and all throughout

May.

And you'll never get it right no

matter what you say.

So I sort of

try to clear this up a little bit.

So there's inactivated vaccines

and there's live attenuated vaccines

and there's only one live attenuated

vaccine, but most of the rest of

them are inactivated.

We don't generally use, say,

straight straightup influenza except

for the life time we get to.

And basically, they're just

containing, we hear H1N1.

It is the haemagglutinin

neuraminidase antigens that

you're expecting to come in the next

year.

And these are her purified antigens

of an H3 and two strain

H1N1 strain.

A couple of B strains of it's A

quadrivalent or one B string

and pretty much everyone is

recommended, get this, over eight,

six months. The protection lasts

between six and eight months.

And because of that, you need to get

vaccinated every year.

Vaccine efficacy.

I'll talk a little bit more about

sort of how our view of this has

changed over time.

But 60 percent

effective in preventing

influenza in healthy adults, 60

percent.

If we look at, you know, two doses

of MMR is like 98 percent,

99 percent.

Why is 60 percent something we're

still using?

We'll get to that.

But it's a sure you know

better than nothing.

But we also sort look at well, you

were not really try to prevent

influenza. We're trying to prevent

influenza death.

Right. And so it is 50

50 percent, 50 to 60 percent

effective in preventing

hospitalization in the elderly

and 80 percent effective in

preventing death in the elderly.

That's why we give this vaccine

right to prevent death.

And yet they may still get

influenza, but there are far

less likely to die from it.

That includes kids, too.

Most of the kids who died.

Are the ones around vaccinated?

So just a discussion

about what, though, with a different

vaccines are. So try Valen.

So H1N1 age three and

two antigens plus one

B or quadruple, which has two

different bees.

And these are it's an intramuscular

injection. This is the standard

vaccine.

And I put the the trade needs in

here in case you need to refer to

them later, figure out what you have

in your clinic.

Then there's the high dose,

Tri-Valley. So there's three of

them.

And it's using hired higher doses

of the antigens.

And so we tend to use these in age

over 65.

Then there is an anti adjuvanted

try Valen.

So this is you have these anti

adjuvants that help the immune

system sort of boost the response to

these antigens.

And we also tend to recommend

this in those over age 65.

And this there's a few that are

known. So all the most of for

longtime influenza vaccines were

only made in eggs.

Macoute, inject them, grow them,

wait and then take them from the

from the fluid and

then cook the eggs.

I'd use like salmon.

And I like

goat cheese.

You wouldn't use you don't eat the

eggs. OK.

Anyway, so there's a few of them

that are not made an egg.

So there's a cell culture

quadrivalent that is not

made an egg. So if someone has a

civet now the severe egg allergy.

So the CDC says ignore.

If somebody says it's severe egg

allergy, you can still safely get

the vaccine.

But if somebody is adamant, like,

look, I'm not going to take this,

saying, well, there's one that's

made in cell culture, that there's

never been an egg involved.

And if if they're more likely to get

it and take it, then give them this.

There's one that's recombinant sort

of not made in cell culture, but

just, I think created in yeast

really, anyway, but

also not made in eggs.

Then there's a live attenuated

quadrivalent vaccine

trade name is FluMist.

And for a long time, it looked

like it was much better for kids and

it was adults. But you can give it

to adults who are afraid of needles.

But this is a saga like, wait,

what's going on with FluMist?

So the initial studies show

that it was actually better than

inactivated vaccine for kids.

So this is like it's basically the

reason it's an influenza vaccine

that's been

over created.

So that only replicates in your nose

or colder temperatures.

It doesn't cause disease and you

just swap out the agent and

genes that

give the antigens.

And so it sure looks like

influenza but doesn't

cause disease like influenza.

And so was actually a preferred

vaccine in kids in 2014.

But then, you know, in

2013, 2014,

there there's some U.S. data show

there is less efficacy

against H1N1.

And it was

that we started seeing this

in the H1N1 that came in

from the pandemic.

And so the thought was this.

The attenuated seed strain that

was used to carry the H1N1 antigens

was likely not ideal.

When you're trying to prevent this

sort of new H1N1 that came in 2009.

So ASCAP removed

this as a recommended vaccine,

not just for kids, which is across

the board.

Then they put in a new H1N1 site

and one seed strain and initial

data show that it's worked again.

And so the ACA, a piece of the

Advisory Council on Immunization

Practices, which advises the CDC,

restored it as a recommended

vaccine.

But the American Academy of

Pediatrics really.

Whoa, whoa, whoa, whoa.

You just told us this stuff doesn't

work. And so

their recommendation is that they

would not recommend this vaccine to

more clinical data is available.

So there's your if you see some

people saying, well, know

this vaccine is recommended again

and other people are saying it's

not. Well, there are.

Those are both true.

The pediatricians.

I think there's one.

The academy wants to see a little

bit more data before this is a

first line. And I know

a lot about influenza and

influenza vaccines.

And I just asked my pediatrician,

what do you recommend?

And she said, I would give you the

shot to your kids.

And that's what I did.

There is a guideline that came out

on influenza.

So what I won't talk about next is

sort of the approach to a patient

showing up either in the

hospital, urgent care clinic

with influenza like illness.

So here's a just general

thought, the approach.

So during the height of flu season,

if you have influenza like illness,

it's probably influenza.

And so you should only

test people if

that test would make a difference.

And there's some false negatives,

especially using a rapid antigen.

If you're going to treat somebody

anyway and we'll get to treatment

later.

But the test needs to change

your approach.

And so the question of testing

and the question of treatment

are completely separate

and that you don't have to have a

positive test to treat somebody.

And if you're treating

somebody, you don't have to test

them.

And and so think

of these as two completely separate

ideas.

And so antiviral stewardship.

So there's testing. Sure.

Sure. Then there's antiviral

stewardship.

Including me.

When I got influenza, I got better

on my own.

I didn't think I was going to, but

I knew that I would never live it

down if I didn't sort of follow

my own recommendation.

And what I put an asthma expert.

And so I toughed it out.

I made sure my life insurance was up

to date.

My my wife knew where the doomsday

document was, said goodbye to my

kids, but

I got better.

And one of the problems,

the more antivirals we use, you

mean you can develop resistance

and with indiscriminate use,

including with with influenza.

But more problematic is

that there are local shortages

across communities of

Oseltamivir here.

We end up using it off for people

who are showing up who otherwise

do fine.

And then later in the season,

like an 85 year old with

a post stem cell transplant

shows up in hospitalized

or about and may need

hospitalization and they can't get

the drug.

And so that's the bigger problem.

And so we really need to make sure

we are having good stewardship

so that those who have the risk

of complications are the ones that

have the drug available to them when

they need it.

And yeah, everyone else gets

supportive care for me and

lots of fluids.

I took you Antep I Reddick's

and people, William, you lose a lot

of electrolyte. So even if somebody

presents who's out within

48 hours who's otherwise

healthy and going to get better on

their own, they don't need

also time of year.

So this is just the general thought.

So first thing is about whom to test

drivers for separating these

concepts.

So when influenza is not

widespread, I'll tell you how you

know this in a second.

Really?

I mean, there are some epidemiologic

importance of actually testing a few

people, right?

Because you're not going to know if

it's widespread until you

test people to know that the test is

positive. So we can help

epidemiologically know when the

start of flu season is.

But you should also.

So in order to do that, you don't

just start swabbing people,

but test those who would get an

antiviral if it were positive.

So this is hospitalized patient.

So if it's influenza

like illness and somebody who's

going to have to hospitalized, it

also helps to rule in the diagnosis

where they have influenza and it's

not endocarditis or

or or something else that's or

something that's causing it.

You know, anybody who is at high

risk of complications.

I'll explain what those folks are.

There's a giant list

or somebody who has a ongoing

contact with very high risk,

especially infants up to

six months or people with stem cell

transplant like you would know if

they're high risk.

So testing really that small group

of people up front.

And then during times when influenza

is widespread, all

pretty much all influenza like

illness should be assumed to be

influenza.

And so you want to test those who

are hospitalized again.

You want to rule in the diagnosis

and then the treatment

for those who were not hospitalized

or the treatment based on

the risk of complication.

So you should know that if

if it's going to change your

management, I'll get to this and

say, so how do you know if influenza

is widespread?

So the CDC every week

puts puts out this say

and within Mayo, I help sort of

say when we when we push the panic

button and stuff like that.

But you look at your state and

see that there's this map.

So every week they tell you, is it

widespread when it's brown as

brown, red, gray, brown.

It's time to sort of change your

approach to clinical influenza

and the list of people who are at

high risk. So basically people who

are high risk of complications who

should be tested or treated.

So during the height of influenza

season, if one of these folks show

up with

liver disease or living your

pregnancy

and they're having influenza like

illness during the height of

influenza season, you do not need

to test them.

You just need to treat them

cause it's it's presumed

to be influenza.

What aids 12 months or less

in red, because the CDC will

say age twenty four months

or less.

So there's plenty of data there.

So show that those aged 12

months, 24 months actually

do just fine or really not

that high risk of complications.

So within Mayo, within our own

practice here, we say less than 12

months.

If you look at your the CDC

guidance and maybe your local and

you're your local guidance, they may

say 24 more. So there's going to be

a slight discrepancy.

But these are people who are at high

risk and basically should be treated

with antivirals if they develop

influence like illness.

So who is at very high

risk? So these are people let's

say you see

somebody and they say, well, I have

a five month old home

that if they're coming, if they're

otherwise fine, they should get

antivirals

because they're

in close ongoing contact with

somebody who's a very high risk.

So a stem cell transplant, people

with HIV, with C4 carry

on less than 200 after chemo

or radiation for cancer.

So then there's a question of, well,

so that's whom you test.

Then how do you test?

So it's ideally from nasal

pharyngeal swab, which are

uncomfortable.

But that's where you get the

highest, highest yield.

Your rapid antigen tests are rapid,

but there's relatively low

sensitivity.

A reverse transcriptase PCR

has and by the way, are t PCR

did not stand for real time.

That's reverse transcriptase PCR.

There's another are in the beginning

that suggested it if it's real time,

but that has high sensitivity and

specificity. But sometimes

it's not as rapid as you need.

It's not a point of care test if

it's for our turnaround.

But there are some new point of care

PCR that are available that really

gives you the best of both worlds.

You need to know what you have

to kind of know what to do with it,

especially if if you have rapid

antigens

here, you know you that you may not

be able to test trust a negative

test.

And so for future reference, they

have a whole grid from that from

that guideline on on

the different types of influenza

testing.

So now we get to the treatment

again, the testing question and the

treatment questions are different.

So,

you know, if the testing is positive

or influenza is widespread and

somebody is coming in with influenza

like your.

So you want to give antivirus for

those who are hospitalized with

influenza, that list

of those folks who are high risk of

complications and those

who are ongoing contact

with a very high risk person.

And if you're testing is positive,

that very high risk contact

should also get antivirals.

And this is regardless

of the timing of presentation.

That's why the person who is

otherwise previously healthy, who is

hospitalized with influenza

four days after the onset,

is some CDC data from the

2009 pandemic that showed that

they actually had improved outcomes

even after that 48 hour window.

The 48 hour window actually comes

from.

They were looking at outpatients and

how how well the outcome

was like improvement of influenza

like illness when your outcome is

hospitalized death.

You can sort of suss out some some

key differences, even

if it's for four days out from the

from. From the time of presentation.

And everyone else basically

gets symptomatic treatments, arrest

fluids, acetaminophen.

Do not get asked.

You have aspirin to kids who are

presumed to have influenza because

of the risk of rice syndrome.

So a few different antivirals.

So don't use amantadine or

amantadine anymore because there's

just high risk, high resistance.

And there has since 2009

circulated strains. So neurone

MiniDisc inhibitors are the mainstay

of a therapy.

So also Tam Evere, which the trade

name is Tamiflu most

you've heard of it.

So. Seventy five milligrams twice a

day, or is the name Evere

Relenza as a brand

name to two puffs twice

daily.

And in most patients you just need

five days.

But that's that's

not hard and fast.

You can use longer treatment in

immunocompromised hosts or those who

are hospitalized.

Really just seeing how they're

responding.

You know, if somebody is on ammo

and they're

still doing poorly, I'm not

stopping at

another drug. Is peramivir.

So and it's

a one time dose.

But that one time dose was basically

to get it approved by the FDA

for the use of community quired

community influenza.

If somebody is hospitalized and

super sick and you need an I.V.

drug, you would use

it for much longer than just a

single dose.

I mean, guys are heard to block

severe.

A few.

OK. So this is a new drug.

So it works in two different ways.

The other one's neuraminidase, which

prevents the the

virus from escaping the cell

to so near

remitters inhibitors.

So. So there's blocks where inhibits

and nucleus activity of

polymerase.

And so basically prevents host

RNA transcription from making more

viruses.

And FDA just approved it in October

2018.

Basically is a single dose.

There is a trial in healthy adults

with uncomplicated influenza.

And basically you reduced the

duration of symptoms compared to

placebo.

And basically in the same.

It worked similarly to also

Tamiflu.

So we don't yet know

its role.

And the CDC has not yet recommended

it. And it doesn't has it still

hasn't said in which patients.

Part of the problem is that in those

trials, 10 percent end up having

reduces habitability or resistance

that developed on treatment.

So there is a hot area,

if you're the thing about somebody

who is sicker or immunocompromised,

people who are going to shed virus

longer here.

I worry about the development of

blocks of your resistance in those

patients while on therapy.

And so there are there are studies

in hospitalized patients.

This seems promising this.

Yes. To be published.

But at trial and immunocompromised

host has not yet been done.

And there is a trial looking at the

combination of also Tanvir and

the of Air currently enrolling.

When should you consider bacterial

superinfection?

So if the initial presentation is

with severe disease, really think

about it.

If they get better and then get

worse or they don't get better

within three to five days of

antiviral treatment, most commonly

it's going to be strep pneumo.

But you start adding staph aureus to

the picture.

So basically you start thing about

communicating quite pneumonia

therapy, but also making sure

you had MRSA coverage.

When do you suspect resistant

influenza is going to get also

Tamiflu resistance?

So if somebody was already on at the

time of year prophylaxis in the

developed influenza, it's an immuno

or immunocompromised host with

severe influenza or has ongoing

PCR positivity with ongoing critical

illness, people

who are sort of given suboptimally

dosed antivirals and still

remains sick.

So we've got to do at that point,

you know, send the Assa lab to send

a flu swab, actually to a

public health lab to to

actually test to see if it's

resistant.

Then you really need an I.D.

console, because we're going to

start hemming and hawing about

should we use inhaled zanamivir.

So also of resistance

to doesn't

or doesn't relate to is an

AMA very resistant.

So it's likely going to be continue

to work.

You know, start thinking about using

I.V. peramivir, which can overcome

some low grade resistance,

then, you know, starting about

adding blocks of air, although

that's all

these things are things that we

would consider

which patients get primary

prophylaxis.

Now, this should not be done

routinely.

You can consider this during an

institutional outbreak in a nursing

home, basically until the the

operations has stopped or in

a very high risk patient.

We talk about that list really.

Those transplant patients, while

influence is widespread in most

common dose, is gonna be awesome.

Tamary or 75 milligrams once daily

rather than twice daily.

So why do we have a better back

sevak vaccine?

I always get this and there's a

compelling read

from CIDRAP, the Center for an

Infectious Disease Research and

Policy written by Mike

Osterholm, actually help with this.

So the current vaccine we use

is actually approved in 1968

and that's what we're using now.

At that time, we didn't have PCR to

determine efficacy.

Were you basing this on serologic

studies that it went based on that

the efficacy was 70 to 90 percent,

but it turned out that this that's a

serology endpoint

underestimated influenza infection

in those who were already

vaccinated. So that artificially

raises the vaccine efficacy

and they actually figure this out.

I called the old McDonald paper, but

it was MacDonell from 1955,

actually found this and we sort of

ignored it.

But when you start looking actually

PCR studies to EFIC for efficacy,

that efficacy is closer to 40 to 60

percent.

And the current vaccine targets

the globular head of neuraminidase

and haemagglutinin,

which is the basically what your

body reacts to in antigenic

early, but it's also the most

variable.

And so that's why we need a new

vaccine every year, whereas there

are some minor antigenic

determinants that actually fairly

conserved.

But, you know, the thing is that

those antibodies need to be able to,

you know, kill the virus and

confer, sterilizing immunity.

The problem is that there is a t

there's all these candidate vaccines

out there, but it takes

a ton of money to get them

from sort of conception all the way

to licensure and

is called the valley of death.

And when you have an existing

vaccine that works, OK,

we're still recommending measure.

Please still get it.

It's hard to sort of push to get

the funding and things like that to

get a new vaccine.

Now, there was a new universal

vaccine candidate that started the

first human trial.

Unfortunate this had to be stopped.

I don't know why yet.

So unfortunate that didn't quite

work out for the next of the talk.

I want to summarize a little bit

about prophylaxis and

immunocompromised hosts.

So I'll ask this.

So which of the following patients

should receive pneumocystis

prophylaxis?

So if somebody with AML receiving

seven plus three induction

chemotherapy patients, the fuselage

B cell lymphoma, receiving our

CHOPE, rheumatoid

arthritis, receiving rear tucks, him

ab similar psoriatic arthritis of

receiving infliximab or

someone with HIV, but the city

for count of 250.

But who has thrush?

OK. Fantastic.

Most guys got this one right.

And we'll get to that or the

explanation here.

So when I'm looking at

people's eyes, I have an

immunocompromised house.

I don't know what that means

in that basically there's different

arms of the immune system.

And you can and those things do

different things.

And there's a difference.

Somebody who has on a gram of soil,

you may draw for a month and

somebody who's, you know,

neutropenia to, you know, two

thousand for a couple of days.

So sell your immunity.

So steroids, AIDS,

that sort of thing will impact this.

So mycobacteria, yis, dimorphic,

Fungai like histo, plasma,

intercellular viruses like CMB.

Those are the things we think about

humoral immunities, thing about

bacteria, extracellular viruses

from neutrophils. We think about

bacteria and mold.

If someone's who's a splenic thing

about a encapsulate organism such as

strep pneumo H flu is

someone that's terminal compliment

deficiency. Thinking about Neisseria

infections that we're also using,

Aquiles, a map.

Now, the hematologists have created

terminal complement efficiency.

So we actually can see that in

people without any

genetic deficiencies.

So in cellular immunity,

highroad, so high dose

corticosteroids thing about

pneumocystis prophylaxis

if that annual risk is great and

three point five percent.

And basically that means if they're

on greater than 200 milligrams of

prednisone for over a month,

if you use these trimethyl or

something with ox's, although you

have a few other options in help and

damaging once monthly.

But basically, if it's someone who

can get trauma himself

with Taxol, that's what you should

be using.

So, you know, in

patients who have HIV,

it's based on the Cedefop account.

So if you're in a Coxie endemic

area, you should start doing it

during when they're sitting for kind

of lessoned 250.

Once somebody has a city for Coleson

200 or they have

an AIDS defining illness or thrash,

you should start nemesis at

prophylaxis. So even if they're c.D

for Kinder's 250, you should

use.

So try to thrussell from the toxo

will also work for prevention of

toxo.

But they're seeing if they can't

take trauma themselves with ox's all

in their city, four counties, less

than one hundred issues, Daptone

or a Tovo clone

with promethazine and leucovorin.

And then if it's less than 50,

if you prevent Max and

make it back here, maybe I'm

intrapersonal, Larry.

Complex, which is once weekly,

is it? Or Myson or twice daily

Clarissa's myson.

So patients were getting TANF alpha

inhibitors. Make sure you're

screening for tuberculosis

so either skin test or

quantifier on.

And if it's positive,

starting one of these regimens.

So nine months of ice and Iron Age

or Iron Age plus where if

a Pantene or I or

a lot of different options, ideally

you want to wait two months prior to

starting the TANF alpha inhibitor

wasso also assess for current

or prior hepatitis B infection.

And somebody has antigen positive

while they need treatment.

And if someone has antigen negative,

but they've been exposed a core

antibody positive, you do need a

monitor for reactivation every three

months.

And really, if somebody is living in

the Midwest or a

desert southwest, high index

of suspicion for primary infection

or reactivation of histo or Coxie

for solid organ transplants.

And this is based on the on the

transplanted organ and what,

immunosuppression.

So, again, screening for all TBI

do pneumocystis prophylaxis for six

to 12 months.

You know, if there a mismatch for

CMB. So

there would.

So the donor is positive.

The recipient was negative for four

prior c.v that you need to give them

prophylaxis.

But if the recipient was already

positive and you think about doing

that prophylaxis three to six months

or just two weekly testing

for CMB Viremia.

And then these solid organ patients

really want a cycle of air for about

30 days preventing HSV and.

If you're living in a Coxie endemic

area, often these patients are going

to get flu cars off or at least a

year for lung

transplant. And think about doing it

Dreft for at least six months.

This is a little bit more controversial

of a recommendation.

If someone's receiving a B cell

depleting agent, really rare toxin,

that's a high risk of happy

activation.

So not obviously,

if it's a happy antigen positive,

you need to give treatment or talk

to a hepatologists by getting

treatment. But also and those who

are engin negative but have been

previously exposed so the can't core

antibody positive, high risk

of reactivation in those patients.

And they should need treatment.

You know, pneumocystis prophylaxis

is controversial and I don't

recommend it across the board,

really looking at if their

cellular immunity is depleted enough

that you should do it

for neutropenia.

So most of this is going to be

hematologic malignancy.

So the neutropenia fever risk is

based on the duration and depth.

So most solid organ.

Patients and most lymphoma

patients actually don't need much in

the way of prophylaxis.

But if someone is a ALAL,

you need to include pneumocystis

prophylaxis because of the kind of

treatment they're gonna get.

Someone who has AML

prophylaxis during neutropenia.

This includes an anti mold agent

such as for Cortazar, pose a Khazaal

or have a kind of zoning

antibacterial prophylaxis.

So either levofloxacin

or self-denying Sefton here and

then HSV or VCP prophylaxis

with a cycle levere.

They've had a bone marrow transplant,

similar kinds of prophylaxis during

neutropenia. Then after engraftment,

again, Molde prophylaxis,

pneumocystis prophylaxis, at least

six months antibacterial.

So using penicillin to prevent

strep pneumo for about a year

is over again for about a year.

And then initial weekly monitoring

for CMB reactivation.

Her patients were a splenetic, so

their big thing is, is vaccines

and pneumococcal vaccine

meningococcal, including

the new B vaccine H flu

vaccine, an annual influenza vaccine

in high risk groups, including

immunocompromised hosts, people or

otherwise immunocompromised.

We have a history of sepsis.

Consider giving penicillin

daily.

They should have a prescription

for a maximum clarey lactic acid

receptor near On-hand already

filled. If they are somewhere they

can't get to medical care

within a few hours.

They should start taking the medication

if they start to feel poorly.

Have a February Ilona's.

And for patients who have terminal

compliment efficiency, this is often

an inherited efficiency.

But now we're giving a Kulas a MAB.

And so often if there is

an inherited deficiency, we can

either give penicillin daily or

monthly injections have been shown

to be effective or give

penicillin daily throughout the

treatment of alcoholism and to

prevent Neisseria infections.

A final topic, asymptomatic

bacteria. We'll get this.

So which patient populations

should receive screening and

treatment for asymptomatic bacteria?

So a 35 year old man with spinal

cord injury, a 70 year old community

dwelling woman, otherwise healthy

55 year old man prior to cystoscopy

or a forty five year old woman

two months out from renal

transplant.

I'm glad that this is split.

And those if you pick D..

That's what we used to do.

But we found that we were using a

lot more antibiotics than we needed

to and leading to resistance.

And so that's actually no longer

recommended. It's really if they're

a month out or

more, stop it.

So we have some new guidelines

by TSA.

So basically the update to the

previous one, 2005,

the 2005 one

actually recommended against testing

and treatment except during

pregnancy or prior to an invasive

urologic procedure through the new

update.

Basically, you said the same thing,

but they look at a few other

populations and

and also like, well, I've got this

guy who's baseline doesn't really

talk much and now has some

mental satis changes.

I don't know, it could be UTI.

So what to do with those patients

who are non non localising?

And basically the main push is to

reduce the unnecessary antibiotic

use. One is because of resistance,

conferring more resistance and then

also rising

rates of C. diff.

So the consensus here

is populations unite towards the

screen, meaning asymptomatic

patients, healthy children, healthy

adults, healthy older adults.

So basically healthy people.

Patients who are diabetic, patients

who have indwelling urinary

catheters. Patients with spinal cord

injuries don't screen them

if they're asymptomatic.

So the screening and pregnant women.

So there's a study in the Netherlands

to say it may be safe

not to treat low risk women.

But right now, we're not quite at

the point where we can generalize

this. So the current recommendations

to obtain a culture at

one time, one of the initial visits

and if positive doctors treat

short, short course, are really four

to seven days.

And there's not really recommendation

yet on on whom to retest

or how to retest, when to retest.

And I'm suspecting this is a this is

a moving target.

And we may get the next iteration.

We'll see what happens if we still

need to be screening pregnant women.

But right now, the recommendation is

do at least one time screening and

treat if positive.

Now, in older adults with cognitive

or functional impairment,

it's hard to distinguish being

symptomatic and asymptomatic

bacteria, especially if they're

baseline.

You know, they if now they have

mental Satur changes and can't tell

you if they have to Syria.

So the recommendation now is

initially look for other causes

and observe. Don't start

antimicrobials unless.

And then if you'd rule those things

out, then you

start thinking about looking for and

testing for

urinary tract infection.

So this is where the change happened

for immunocompromised homes for

renal transplant is now

no longer recommended to screen.

After one month and

there's still there's actually no

clear data that screening within one

month is helpful

in terms of outcomes.

And in terms of screening

for so neutropenia, eggs,

there's no for high risk patients

or people with low and C's

for a great them seven days.

There's no clear recommendation what

to do.

And for Suran in low risk

patients, they basically

have the same risks and outcomes of

of people who are not neutropenic.

My general recommendation is not to

screen patients

who are neutropenic.

However, for urologic procedures

where you're expecting some score,

some sort of mucosal trauma

screening is recommended.

Part of the procedure and

basically want to give the treatment

based on what the what their culture

show is really

one to two doses

around the time of the procedure

rather than just doing shortcutting

with some sort of drug, but rather

doing it based on what the culture

show.

And for those who have

artificial urines, sphincter or

penile prostheses, for those

there is no really recommended not

to screen.

Now, that is a take some questions

if you started in 2018.

I started this or took this one.

So I give a talk about influenza and

this is the best answer.

So do you ever consider the

possibility that flu is celebrating

the one 100th anniversary of the

Spanish flu of 1918?

And we are the food at the party,

which I love that answer a question,

and I'm still looking for the 2019

winter. But anyway, thank you very

much for your attention.

I will take whatever questions you

guys have.