Open Forum Infectious Diseases PODCAST

Debating the Top ID Internet Resources with Dr. Monica Mahoney The audio file is also available at: pages/Podcasts

Received 30 July 2020; editorial decision XX XX XXXX; accepted XX XXXX XXXX .

Open Forum Infectious Diseases® © The Author(s) 2020. Published by Oxford University Press on behalf of Infectious Diseases Society of America. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (, which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact [email protected] DOI: 10.1093/ofid/ofaa337

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In a pre-pandemic OFID podcast, OFID Editor in Chief Paul Sax, MD, takes on Monica Mahoney, PharmD, clinical pharmacy coordinator of infectious diseases at Beth Israel Deaconess Medical Center, in a podcast draft. This time, the pair debates their top ID internet resources (COVID-19 excluded). Hi, this is Dr. Paul Sax and I’m editor in chief of Open Forum Infectious Diseases (OFID), and this is the OFID podcast. Important reminder, that’s O-F-I-D not “Oh-fid.” Today, I am totally thrilled to have with me Dr. Monica Mahoney, PharmD, an infectious diseases pharmacist at Beth Israel Deaconess Medical Center where she practices in the outpatient ID clinics and the OPAT [Outpatient Parenteral Antimicrobial Therapy] Clinic and is a nationally known leader and ID pharmacy teacher. She’s also a member of the OFID Editorial Advisory Board. Monica, thank you for joining me. Thank you for having me. So Monica has a predilection for extremely cringe-worthy puns for her lectures, but that’s not why she’s here today. Monica came up with a great idea for our next ID podcast draft, and here it is: We’re going to choose our top five favorite ID internet resources, and here are the rules. Rule number one is that both free and paid sites are eligible, but bonus for free, and paid has to be good value. Rule two is the primary sites of academic journals are out, and that includes such journals as OFID, and The New England Journal of Medicine. And why I listed those two together, who knows. Three, it has to be useful, useful for patient care, or for teaching, or research, or some very useful purpose. And of course, point number four, extra points for cool stuff. So with that as an introduction, Monica, since you’ve taken time out of your busy day to walk all the way over to our hospital, which is, by the way, across the street, you get to go first. All right. Thank you. Okay.

So, the first one that I am going to use is, as you previously called it, the elephant in the room, and I think we’re going to start with it so that people cringe, and if you haven’t guessed what I’m getting at, that would be UpToDate. Yeah, I thought that was going to be up there. Disclosure, I’m one of the section editors for UpToDate, so I  didn’t choose it, but I think obviously it’s a great resource. Tell me why you chose it Monica. Well, one, I think we all love to hate on it, and I don’t know why, because it is a fantastic resource, and I would beg that we all use it daily. So, frequency of use is right there. Broad appeal – you can go to it to look for lots of things. But for some reason we don’t like to use it or quote it. And I  think that there is a time and a place for it. If you need to use it for quick references, doses, side effects to find other references, primary literature to read up on, it is excellent. To their credit, the people who run that operation are extremely diligent about keeping it “up to date,” and that makes it highly referenced and very authoritative. The time and place that you don’t use it – if you’re giving a professional presentation, if you’re giving a final presentation – don’t use that as a citation. Positives, is that broad appeal, used daily, frequency of use, user-friendly. Minus points, you need a subscription. Yeah. It’s not cheap. No. They know that they’re very important, and I don’t know if you remember, but there was an academic medical center in the Boston area a few years ago. Fortunately, neither of our two academic medical centers that decided not to subscribe to UpToDate, and there was practically a revolt by the medical staff. Okay. All right. I’m going to go to my first choice, and my first choice is Okay. And, I  think the CDC [U.S. Centers for Disease Control and Prevention] website is a work of genius. It’s comprehensive. It’s broad. It’s updated all the time. It’s graphically terrific. It shows you sometimes your taxpayer dollars do really good work, and I think it is amazing. So, I use it for all kinds of things. I am not a travel medicine doctor, but of course, all ID doctors get asked travel questions. I use it for that all the time. Not surprisingly, when there are emerging outbreaks, it is the first place you go to find the latest information. They are extremely diligent about keeping it up to date. It has an amazing MMWR [Morbidity and Mortality Weekly Report] panoply of resources with it. Good graphics, as I mentioned. Great stats. Downloadable slides for teaching. All of the

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But you know what? That’s where I find them. The other thing that’s on there are the CDC schedules for immunizations, the quick links to the ACIP [Advisory Committee on Immunization Practices] recommendations, the most updated vaccine information statements, which, by law, you have to give to your patients before you vaccinate them. They do have one page where they have user comments and they’re all things like, “You’re great!” “We love you!” Just terrific. I thought you were going to say comments from anti-vaxxers. No, I don’t think they publish those. All right. Okay. Number three. Number three for Dr. Mahoney is... So, this links up with one of your recent blog posts about the 10-year challenge, and the number three website for me is the University of Liverpool, Hep C drug interaction checker. The Hep C, not the HIV one? HIV and Hep C. They have an official website, just Google it. It’s too long to give over the air, but it is free to use. These are very specific questions. So, if you’re not looking up HIV or Hep C medications, maybe not under your interest, but they are phenomenal in my current practice. Answering drug interaction questions, seeing if patients need to alter some of their other medications before starting Hep C therapy, or if we’re changing their HIV regimens. It has been a lifesaver for someone newly going into HIV and Hep C, because I’m coming from the inpatient world. The one caveat that I will say is that they are U.K. sites, so not every U.S. medication is on there, but I’ll take 90-plus [percent] for detailed summary about the interactions, and how to manage them. And even better, you can print out a user-friendly grid with symbols talking about the degree of severity of interactions. Well, I  wasn’t going to tell you, but that was my choice number three. So, I’ll cross it off my list, but I’ll tell you why it was my choice number three. Many of the reasons you’ve mentioned already. I think it’s incredibly easy to use. It’s very well referenced, so if you want to go to the primary studies where the data came from. The other day, I  was in a conversation with someone about whether you could use once-daily dose of dolutegravir with rifampin while treating HIV-related tuberculosis, and of course, the first place I went to show why twice-daily is recommended was the Liverpool site, which shows you that rifampin lowers dolutegravir AUC [area under the curve] by 54 percent, Cmax by 43 percent, and Ctrough by 72 percent, and that’s a lot. And so, it may not matter in people with maybe low viral loads, or high CD4s, but if someone is very difficult to treat, high viral load, or if someone isn’t 100 percent adherent to therapy, that could be substantial. So, anyway, great choice. That was my choice number three, and now I  have to move down to my next choice.

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latest HIV information. It is really a remarkable thing, and I am very proud and very patriotic, sometimes not easy these days, to say that is my number one choice for internet resource. So you took my honorable mention, an extension of the CDC website, FluView. Yes. Weekly updated tracking of influenza, with graphs on susceptibility; amazing Yeah, it’s awesome. Okay. Monica, choice number two for you. Okay. Free website this time. number two on my list is CDDEP. Huh. That’s not on my list at all. That sounds like something that you would get from Russia. So, this is a US-based website, Center for Disease Dynamics, Economics and Policy, They’re also on Twitter, follow them. Okay. So, this is an excellent resource for resistance tracking, graphs, metrics. You can spend hours playing on here. You can either look globally, across the entire world, or focus by country. You can select the specific organism, select a specific antibiotic that it’s resistant to, and you get all these visuals. Wow. Graphs, maps. If you want to look up ESBL [extended spectrum beta-lactamase], you select third-generation resistant Klebsiella or E. coli, you get all these wonderful visuals. If you’ve gotten to any gram negative presentation in the last several years, guaranteed, they use charts and graphs from this. It sounds like a wonderful resource. I have to admit, I believe I have seen it referenced, but I personally do not use it very much. I’m much more of a local antibiogram person, but it’s great to know probably also for finding the susceptibilities of organisms that are not widely reported. Like for example, anaerobes, you hardly ever see anaerobic susceptibilities. There is an anaerobe tab there. Cool. Good one. Moving on to my number two –, the website of the Immunization Action Coalition. The site launched way back into the 1990s – 1994 – but it’s been updated, and it’s now absolutely terrific. Unbelievably user-friendly, and in they have a section called “Ask the Experts,” where all of the most common questions about immunizations are answered by experts. What more could you want? We do e-consults for the entire Brigham enterprise, and some of the most common questions we get are about immunizations. And not surprisingly, I  go to “Ask the Experts” all the time to find the answers to these questions. I pretend that I know them myself. Pulling back the curtain here.

combinations of antibiotics to test, and which you can infer susceptibility based on the others that you’ve tested, and it demystifies a lot of the testing methods. That’s really excellent. I’m glad you chose one that’s more of a microbiology than infectious disease one, because that broadens our selections. Well, and it’s the backbone. Microbiology is the backbone of ID. Absolutely. Okay, so my choice number four is, believe it or not, NATAP … What is that? … which is the National AIDS Treatment Advocacy Program, which is the brainchild of Jules Levin [MS]. I’m really going old school here. In fact, if you went to, you would think you were transported back to 1996, as far as what the website looks like. It will remind old-timers of those early web pages. It’s got an extremely simple graphic. Does it have that AOL sound logging in to dial up? It practically does, and you almost expect to hear, “You’ve got mail,” in the background. But it’s not just that it reminds you of the 1990s in the way it looks. It also reminds me of 1990s because of Napster – because NATAP, for reasons that are not quite clear to me, seems to be able to get all the recent slides from meetings, even things that are embargoed from many papers, including the full text, the graphics from many papers, and it is just an astounding resource. So, what are the problems? Well, I’ve already alluded to graphically, it’s kind of old school. The search function is totally crazy. You’re just as likely if you search for something on NATAP to find something from 2009 as you are from 2019, or 2020, which means that it’s very cumbersome. In fact, I think you could have an entire YouTube video, “How to use NATAP,” for people who are doing HIV care and research, because there’s so much information on it. I do want to give a shout out to Mark Mascolini. He writes interpretive pieces after major HIV meetings. He’s a terrific writer, and he is, I am pretty sure, the most prolific writer on the site. So NATAP, the National AIDS Treatment Advocacy Program, and you can sign up for their alerts, and they will email you all the latest stuff that comes out. And when it’s around a major conference like CROI [Conference on Retroviruses and Opportunistic Infections] or the International AIDS Conference, you will be deluged with notifications from NATAP. Give it a look. Good to know, because after the last International AIDS meeting, it was difficult navigating their sites trying to get access to the presentations and the information. Yeah. Well, until they shut down NATAP the way they shut down Napster, luckily, those of us in the know, those of us who are listening to this podcast, we’ll be able to access. And by the way, it’s just a secret between you and me. Just us. PODCAST • ofid • 3

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And my next choice is going to be the first paid site that I’m going to choose, and it’s going to be the Johns Hopkins Antibiotic Guide. That’s my choice number three. Mm-hmm (affirmative), reputable. Johns Hopkins, even though I’m saying this as a Harvard faculty member, I’ve got to give them credit. It is extremely concise. It is incredibly useful. It is very nicely referenced, and very easy to navigate. It’s quite simple. It’s not graphically impressive in any way. Minus points from Monica. But you know what, who cares when you just want to get information? Hey! So, I’m going to give you an example. You get your latest neurosurgical infection from a Cutibacterium acnes, previously Propionibacterium acnes, and think about while the patient is very penicillin allergic, what are the alternatives? Go right there and you can find them. The other thing about it is that you can hear in the background the voices of John Bartlett [MD], the former Chief of ID at Johns Hopkins, one of the most brilliant clinical teachers really ever, and now Paul Auwaerter [MD] who’s taken it over. It is terrific. And many, many pharmacists on the program. So, it is updated regularly. Can’t recommend it strongly enough. Plus, a bonus, our hospital has an institutional subscription. We do not. I used to use it when it was free. Next choice Dr Mahoney. Next one is going to be a free one, and I am sad that it’s taken this long to get to it, but it is the free resources available through CLSI [Clinical and Laboratory Standards Institute], specifically the M100 [Performance Standards for Antimicrobial Susceptibility Testing], which is the antibiotic susceptibility interpretation criteria. There are two others available online. The antifungal one, which is the M60, and the development of in-vitro susceptibility quality control, which is the M23. I have not used that one, unfortunately, so not familiar with it. But, the one I want to focus on is the M100. Mm-hmm. So, extra bonus points to CLSI for making this free in the last couple of years, because it used to be a paid subscription. Negative points for making it difficult to find. Seriously, everyone that I talk to, they say, “We just Google ‘CLSI M100 free.’ It gets you where you need to be.” There’s nothing wrong with using a search engine, except that they’ll follow you around forever and they’ll try to sell you VITEK systems, the one that they know that you searched on. So, I might be giving away some trade secrets here, but this is where we all go to look up the susceptibility breakpoints, figure out what makes something susceptible or intermediate, or know what susceptible dose dependence is now. This tells you what

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encouraging people to take preventive TB therapy who are otherwise quite reluctant. Because, typical story is you’re talking to someone who maybe has a reactive test, or has a positive test on the IGRA, and they’re about to start a TNF [Tumor Necrosis Factor] blocker. And they think, “I couldn’t possibly have tuberculosis,” or they could blame it all on their childhood BCG [bacille Calmette-Guerin] immunization, which of course doesn’t cause a positive IGRA. And then when you show them that, “Oh my goodness, you have a 10 percent chance of getting active tuberculosis,” then they’re much more likely to take preventive therapy. So, that’s my fifth choice. Now, I  said it looks simple. It’s actually not so simple. When you look at the “About” tab, they give you the mathematical calculations that are required to do these estimates. And so, let me just say, it’s not recommended for the math averse. So, that is my fifth and final choice. One of our astute ID fellows introduced me to that website earlier this year. We were going over treatment options for a patient, deciding between rifampin or INH [isoniazid], and of course, all the drug interactions that came up, and then he pulled up that website, saw what the risk was, and we decided to manage the drug interactions. Beautiful. Okay. Honorable mentions, Monica. Okay. The first is the ACCP ID PRN email listserv. This one might not be fair. American College of Clinical Pharmacy, Infectious Disease, Practice and Research Network. It is… A listserv? … a listserv. How old-fashioned! It is a message board and email distribution system that connects over 2,000 ID pharmacists across the U.S., similar to what I imagine is the IDSA Emerging Infections Network. Great. Okay, any other honorable mentions? Last honorable mention would be our neighbors to the North, Tons of fantastic patient information, graphics and posters on how to use antibiotics more appropriately. Excellent. Yes, they have some really good stewardship information. All right. My honorable mentions: They are the repository for the U.S. guidelines for HIV treatment prevention, perinatal guidelines, you name it. Of the commercial CME [continuing medical education] sites for HIV, I  think Clinical Care Options does a terrific job. Disclosure, I’m a frequent contributor there, but if you need slides for studies, excellent. I think the Sanford Guide electronic version is outstanding. I do recommend it. We do not have an institutional

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What’s your next choice Monica? So, choice five, there are so many great resources that I could have mentioned. So, I thought, “Well I’m a pharmacist, what are the typical questions that I get asked? Where can I really be a resource to my clinicians?” And this one you might not have heard of, but it’s a database called Natural Medicines. It’s a paid subscription. I have access because I’m adjunct faculty for some of the pharmacy schools in the Boston area. And this is an online database that checks for drug interactions between herbals, and supplements, and non-FDA [U.S. Food and Drug Administration] approved products… Interesting. ... and prescription medications. It’s tricky because there are so many different formulations of natural products. You type in garlic and you get 100 different options to choose from, and then knowing the strength. There’s a lot involved. We learned about how St. John’s wort interacts with pretty much everything, but we haven’t heard about any of the others. So, it’s a great resource because I don’t want to discourage my patients from taking them if they believe in them and it’s working, but we want to make sure that it’s safe and it’s not interacting with anything that they’re on. It’s a very important piece of clinical medicine. Very niche. People don’t realize sometimes when they’re taking natural or homeopathic products that they can interact with real medicines. And I have to say I’m kind of a naysayer on these things, especially when people talk about vitamins and mega vitamins, but that’s a different story. I do appreciate that you introduced us to that site. I will say that using this resource, I tend to agree with you with some of these natural products, but when I have evidence to back up and say, “One, they’re not regulated by the FDA, we don’t know what’s actually in there. And then two, there’s a potential to interact with your cholesterol or your heart medications,” patients are more apt to possibly discontinue. Great. Okay. My fifth and final choice is The Online TST/ IGRA Interpreter, and TST stands for Tuberculin Skin Test and IGRA stands for Interferon Gamma Release Assay. Well, the title says it all, and this is a very simple website, although don’t let the simplicity fool you. Kind of like a Mozart Sonata, there’s a lot of complexity in the background in what seems to be very simple. So, what you do is you’re sitting there with your patient, and you enter your patient’s demographic information, the TB risk factors, as well as the results of their IGRA or TST or both, and you press the button and voila. It gives you a lifetime risk of that person developing tuberculosis, both with and without preventive therapy. It is truly miraculous. I have to give credit to my friend and colleague Dr. Howard Heller [MD, MPH] for introducing me to it several years ago. And I  have found it extremely useful in

subscription. I did have a “Free Gift” of the Sanford Guide for a while, because I wrote a piece on it on my blog. I also want to mention, which is the nontuberculous mycobacteria It’s great for patients; amazing educational materials. And last but not least, AIDSVu, for the epidemiology of HIV, especially in the United States, is really terrific.

All right, Monica. Thank you very much for coming up with this great idea and for joining me today. This is once again, Paul Sax from OFID. We have been talking with Dr. Monica Mahoney, a PharmD at the Beth Israel Deaconess Medical Center, and we’ve been drafting our top ID resources on the internet. Thanks, Monica. Thanks, Paul.

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Open Forum Infectious Diseases PODCAST Debating the Top ID Internet Resources with Dr. Monica Mahoney The audio file is also available at: https://ac...
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