Other hospitalists practice in areas where the opposite is true. Aman D. Sabharwal, MD, is associate medical director, Inpatient and Hospitalist Services for Jackson Health Systems and practices primarily at Jackson Memorial Hospital, which serves a large indigent population in south Florida. While he agrees that some HIV patients are being well-managed because of advances in antiretroviral therapy, these are not the patients seen by hospitalists in his group.
“A majority of our HIV-positive patients come in for illnesses or opportunistic infections that are due to their HIV,” he says. “Most of these patients are either noncompliant with their medications or have low CD4 counts. Generally, the acute issue for which they are admitted is generally unrelated to the medication itself—it is probably due more so to the lack of medication.”
Dr. Baudendistel reports that he and fellow hospitalists at California Pacific Medical Center are also seeing more immune reconstitution illness, in which the reconstituted immune system exhibits an “overexuberant” reaction, causing unique presentations. For example, patients with low CD4 counts who have clinically silent infection with Mycobacterium Avium Complex, hepatitis B, or a variety of infectious agents may experience a significant boost in their CD4 count with antiretroviral therapy. The resurgent immune system can then mount a response to these previously quiescent pathogens, causing a flare-up of symptoms.
“If the primary site of occult disease is the lungs, a respiratory exacerbation will occur; if in the liver, as in the example of hepatitis B, a significant hepatitis can ensue,” says Dr. Baudendistel.
Call in Consultants: Keep a Low Threshold
As the management of HIV becomes more sophisticated, hospitalists should frequently consult infectious-disease and consulting pharmacy colleagues. “I think the hospitalist is very well-equipped to deal with the acute illnesses that these patients have,” notes Dr. Hollander. “Most hospitalists feel less comfortable with the details of managing the chronic medical regimen—particularly the antiretroviral drugs, which they don’t have an opportunity to prescribe, manage, and monitor over time.”
Dr. Baudendistel concurs: “As a hospitalist, what I face with these patients—especially if they come in with an illness unrelated to HIV—is trying to figure out how a drug I am thinking of prescribing for their heart disease or kidney failure will impact their HAART therapy. Is there going to be some hidden interaction that I’m not aware of because I don’t deal with those medications every day?”
It is precisely when weighing those questions about chronic therapy when hospitalists would be best served to quickly consider consulting either a primary physician or the appropriate consultant about the details of the medication regimen. “In most cases, you’re going to want to continue that regimen during hospitalization for other intercurrent problems,” he says.
When possible, it’s a good idea for the hospitalist to touch base with the primary HIV provider, says Dr. Bell. “There are sometimes subtleties to the care that are not necessarily transmitted in a faxed document or in information the patient brings to the hospital. Those subtleties—about doses of antiretroviral drugs or changes in regimen—can make big differences.”
Hospitalists should inform themselves of the potentially harmful effects of antiretroviral drugs, as well as the potential harm in stopping them. “It takes an awareness of knowing what the potential problems are to know when to utilize a consultant,” says Dr. Bell. “As doctors, we are appropriately aware of the power of medications, and it’s not uncommon when the clinical picture is unclear for physicians to think, ‘First do no harm—let me stop these medications.’ One has to be aware of the fact that stopping a medication doesn’t happen in a vacuum.”