The largest challenge facing the infectious disease community in the 21st century is the increasing number of resistant organisms found in various disease processes. The reason is much more complex than the over prescribing of oral antibiotics for sore throats. This is not to say that good antibiotic stewardship is an important concept because it is but it must be recognized that the medical challenges of the human population today is much more complex than any other time in our history on Earth.
Medical technology has allowed many human beings to not only survive but thrive with a number of medical illnesses that would have been fatal sixty–seventy years ago. The cornerstone of these advancements has been the introduction of antibiotics. Think for a moment how antibiotics aid in reducing mortality of infectious disease processes such as pneumonia, cellulitis and diverticulitis. Without antibiotic use in these areas think what the annual rate of mortality would be in this country alone. Also, it cannot be forgotten how the prophylactic use of antibiotics for invasive procedures prevents the complication of an infectious process post procedure.
It has already been stated that inappropriate antibiotic therapy contributes to resistance formation but a secondary question needs to be asked what about antibiotic use for those suffering from recurrent infections? Two areas of interest include:
- Recurrent chronic sinusitis: a huge problem in the United States, especially, the Southeast
- Recurrent cutaneous MRSA infections.
In my practice, there have been numerous patients with recurrent chronic sinusitis that have been diagnosed with an underlying gamma globulin immunodeficiency that once addressed the need for antibiotic therapy annually dropped significantly. Though the number of patients with an underlying gamma globulin deficiency is far less, I am currently following several patients who are no longer taking prolong courses of anti-MRSA antibiotics frequently because of continuous outbreaks by addressing the underlying cause with IVIg therapy.
Recently I diagnosed a woman with Hyper-IgE syndrome with recurrent MRSA infections and since receiving IVIg therapy her MRSA and underlying psoriasis has become much more manageable. There also been several patients who developed immunoglobulin deficiency after receiving chemotherapy either for breast cancer or lymphoma.
Lately, I have had several patients who did not have problems with recurrent bacterial infections until they were well into their fifth or sixth decade of life. In most of these cases, an underlying immunoglobulin deficiency was identified. In one case, an older woman with MGUS (Monoclonal Gammopathy of Unknown Specificity) was found to also have CVID. Since receiving IVIg therapy she has not had any further bouts of cellulitis.
It is my belief that immunoglobulin deficiencies are under diagnosed in this country. That the ever-changing complexities of our patients due to increasing life expectancy which creates more genetic diversity along with patients living longer with chronic disease will push the envelope for the medical management of patients. Clinical reasoning will be more necessary than ever in treating patients who do not fit into the generic clinical outcome model. The challenging question then becomes if one infectious disease practitioner is seeing all of these patients with immunoglobulin deficiencies the same may be true for other infectious disease practices and clinics.
In order to help combat the growing treat of antibiotic resistant organism there must be a bridge between Immunology and Infectious Disease. This bridge has to be more than the one question relegated to the Infectious Disease certification exam annually. There must be a concise approach doing a comprehensive immunoglobulin workup on patients once standard medical management has failed. This in turn will give clinicians one more arrow in the quiver in the battle against antibiotic resistant organisms.
