Bisher AKIL, MD

Archive for July, 2011|Monthly archive page

Resistant Gonorrhea

In General Health on July 21, 2011 at 12:22 am

Recent reports from the West Coast and from Japan described a new strains gonococci (gonorrhea, GC) and that is a concern. Here is a summary and update. The current recommendations for treating Neisseria gonorrhoeaeinfection involve the use of a cephalosporin plus either azithromycin or doxycycline. In May 2011, the CDC reported the isolation of azithromycin-resistant gonococci from five male patients at a sexually transmitted disease (STD) clinic in California. Then earlier this month, a report presented at a meeting of the International Society for Sexually Transmitted Diseases Research in Quebec City, described a
strain of N. gonorrhoeae highly resistant to ceftriaxone . The organism was discovered in samples from Kyoto, Japan[ Ohnishi M et al. The new superbug Neisseria gonorrhoeaemakes gonorrhoea untreatable? — First high-level ceftriaxone resistance worldwide and public health importance. 19th Biennial Conference of the International Society for Sexually Transmitted Diseases Research, Quebec City, Canada, July 2011. Abstract O3-S4.01] The strain shows four- to eightfold higher levels of resistance to ceftriaxone than any previously described isolate, according to the meeting abstract. The organism is also resistant to “all other cephalosporins, as well as most other antimicrobials tested.”The strain’s resistance to ceftriaxone, the last line of defense against treatment failures in the disease, represents “a large public health problem,” the abstract says. It continues: “The era of untreatable gonorrhea may now have been initiated.” – Now, the CDC urges confirmation of treatment success, especially in MSM in the western U.S., by having patients return for testing (preferably with culture) 1 week after treatment. Patients with cefixime treatment failure should be retreated with 250 mg of ceftriaxone intramuscularly and 2 g of azithromycin orally. In cases involving ceftriaxone treatment failure, an infectious diseases expert and the CDC should be consulted. All isolates with decreased cefixime or ceftriaxone should be reported to local or state health departments and, ultimately, to the CDC ( Source: [Centers for Disease Control and Prevention (CDC). Cephalosporin susceptibility among Neisseria gonorrhoeaeisolates — United States, 2000–2010. MMWR Morb Mortal Wkly Rep 2011 Jul 8; 60:873.] _ Comments: Confirmation of the infection (cultures) should be obtained when GC is suspected, then proper treatment as described above need be given, then a repeat of the culture, now that we have this serious threat. Treaters should not cut-corners .BA

Transmission of HIV-1 Infection could be prevented with Early Antiretroviral Therapy

In HIV on July 20, 2011 at 12:49 am

A study published online by the New England Journal of Medicine , enrolled 1763 couples in which one partner was HIV-1–positive and the other was HIV-1–negative; 54% of the subjects were from Africa, and 50% of infected partners were men. HIV-1–infected subjects with CD4 counts between 350 and 550 cells per cubic millimeter were randomly assigned in a 1:1 ratio to receive antiretroviral therapy either immediately (early therapy at the time of enrollment in this study – median CD4 was 442 cells/ml3) or after a decline in the CD4 count or the onset of HIV-1–related symptoms (delayed therapy when CD4 counts were below 250 cells/ml3). Results: As of February 21, 2011, a total of 39 HIV-1 transmissions were observed (incidence rate, 1.2 per 100 person-years; 95% confidence interval [CI], 0.9 to 1.7); of these, 28 were virologically linked to the infected partner (incidence rate, 0.9 per 100 person-years, 95% CI, 0.6 to 1.3). Of the 28 linked transmissions, only 1 occurred in the earlytherapy group (hazard ratio, 0.04; 95% CI, 0.01 to 0.27; P<0.001). Authors conclusion: The early initiation of antiretroviral therapy reduced rates of sexual transmission of HIV-1 and clinical events, indicating both personal and public health benefits from such therapy [ This article (10.1056/NEJMoa1105243) was published on July 18, 2011, at]. Comment: this, with previously published studies, are strong evidence for early treatment, decreased transmission between discordant couple and controlled HIV replication _ I believe this is much more useful data that pre-exposure prophylaxis data, where we treat the healthy! BA


In SMB & CVM on July 20, 2011 at 12:12 am

When I first started this blog, I also took on the task of building a medical practice in NYC as well as keeping my practice in Los Angeles. I travelled weekly between LA and NYC, I started clinical research work  in NYC, and took on new teaching responsibilities in NYC. In early May 2009, William , my son, was born. This turned out to be a lot for one person, so I gave up blogging. Now, I am a little more steady, so I decided to start again.  For those who come back reading this blog, I am sorry it took so long. For my new readers, a warm welcome. Stay tuned. Bisher