Shiva Narayanan

Shiva Narayanan

@shivn.bsky.social

Physician MD, FIDSA. Interests: Inf diseases, bedside medicine, diagnosis, SUD, HIV/HCV. Associate Professor @UMMedschool @IHVMaryland I seek knowledge not followers

2K followers180 following159 posts

Shiva Narayanan
@shivn.bsky.social

A paraplegic patient with a suprapubic catheter was upset and fired me when I wouldn’t culture cloudy urine. Years of “cloudy urine = UTI” had taught him otherwise. Bad medicine doesn’t just overtreat. Repeated enough, it teaches bad beliefs, and makes good medicine look like neglect.

Shiva Narayanan
@shivn.bsky.social

The Jason Arday tragedy makes me wonder if academia should examine how it actually needs fewer heroes and for people with opportunity for accomplishment to remain human and not fall prey to credential inflation and the subsequent ruthless audit.

Shiva Narayanan
@shivn.bsky.social

Cardiology seems to have taken over this week’s @NEJM. Saw DAPT and instinctively thought daptomycin; should’ve stayed a little longer to SAVR all that TAVR.

Shiva Narayanan
@shivn.bsky.social

New @ofidjournal.bsky.social data shows cefadroxil is a robust, well-tolerated oral step-down for Gram-positive bacteremia & osteomyelitis. Rethink the "Linezolid or bust" reflex! academic.oup.com/ofid/article...

academic.oup.comCefadroxil as Oral Transitional Therapy for Gram-Positive Bacteremia With or Without Non-Vertebral Osteomyelitis: A Multicenter Retrospective Cohort StudyIn this multicenter, retrospective cohort study, cefadroxil was an effective and safe oral transitional therapy for bloodstream infections, with or without
Shiva Narayanan
@shivn.bsky.social

week on clinical service and I’ve encountered the holy grail: "bilateral monocular diplopia." Nice to know every specialty has its own version of "bilateral lower extremity cellulitis." #IDsky #MedicalMyths #MedTwitter

Shiva Narayanan
@shivn.bsky.social

Beg to disagree with this conclusion #ABIM - LKA score quartiles explained 0.4% of total variation in LVS use. LKA content probably overlaps with the LVS measures, a seeming circularity, no? jamanetwork.com/journals/jam...

jamanetwork.comLow-Value Services and Longitudinal Knowledge Assessment PerformanceThis cross-sectional study assesses the association of scores on the American Board of Internal Medicine’s longitudinal knowledge assessment and use of low-value services.

Shiva Narayanan reposted

Carl T. Bergstrom
@carlbergstrom.com

1. How common is LLM use in scientific publishing, and how does it vary across field, publisher, journal prestige, author demographics etc.? @kylesiler.bsky.social has new paper in PNAS that addresses this question on a massive scale: 7.3 million papers from Elsevier, PLOS, MDPI, and Frontiers.

pnas.orgThe diffusion of large language models in published academic articles | PNASLarge language models (LLMs) are rapidly changing academic research, raising questions of who is adopting these tools and under what conditions. Th...
Shiva Narayanan
@shivn.bsky.social

PSA about PsA: Blue green sheen, resistance machine, clinically obscene.

Antibiotic Steward 🅱️C🆔🅿️🌟@absteward.bsky.social

Pseudomonas sparing’ antibiotics,is it time to rethink this notion? 🆕Prolonged in vitro exposure of P.aeruginosa to subinhibitory concentrations of Abx lacking intrinsic antipseudomonal activity selects for stable,heritable resistance to antipseudomonal agents #idsky academic.oup.com/jac/article/...

academic.oup.comIn vitro exposure to non-antipseudomonal antibiotics (NAPA) induces Pseudomonas aeruginosa resistance to antipseudomonal antibiotics (APA)AbstractBackground. Pseudomonas aeruginosa readily evolves antimicrobial resistance through regulatory plasticity and stress-adaptive pathways. Clinically,
Shiva Narayanan
@shivn.bsky.social

As we use tools like #openevidence more, what are the guardrails against knowledge collapse? Is it all up to the user's volition, good habits? Can knowledge seeking be an addiction like doomscrolling?

Shiva Narayanan reposted

University of Minnesota Infectious Diseases
@umn-idim.bsky.social

🚨A new study by incoming fellow Dr. Okuno, mentored by faculty Dr. Boulware and Dr. Bahr, evaluates the association between therapeutic LPs and survival in patients with Cryptococcal Meningitis. The Findings: repeat LPs are a life-saving intervention across diverse patient populations. #IDSky

academic.oup.comLumbar Puncture Frequency and Patient Survival Among Persons Hospitalized with Cryptococcal Meningitis in the United StatesAbstract. Elevated intracranial pressure contributes to high mortality in cryptococcal meningitis. We evaluated the association between therapeutic lumbar
Shiva Narayanan
@shivn.bsky.social

Proof to start to abandon this practice academic.oup.com/cid/advance-...

academic.oup.comIs 3 Really What We Need? Relative Effectiveness of Benzathine Penicillin G and Doxycycline Treatment Regimens for Late or Unknown Duration Syphilis in 6 US Jurisdictions, 2016–2021In this retrospective cohort analysis using surveillance data, appropriate serological response by 24 months was comparable among persons with late or unkn
Shiva Narayanan@shivn.bsky.social

The 3-dose regimen for late latent syphilis rests on remarkably thin evidence. The logic: organisms dividing more slowly in long-standing infection require prolonged treponemicidal penicillin levels → hence weekly benzathine penicillin G (BPG) ×3.

Shiva Narayanan
@shivn.bsky.social

“To say that physicians are good or bad would be to imply that there are well-accepted standards of performance and random audits to judge them by; but there are none.

Shiva Narayanan
@shivn.bsky.social

Their nearly total freedom to determine the context of their professional activities and their own standards within this context, especially in the private office where much of medicine is practiced, precludes any rational conviction about the effects of their efforts.”

Shiva Narayanan
@shivn.bsky.social

The 3-dose regimen for late latent syphilis rests on remarkably thin evidence. The logic: organisms dividing more slowly in long-standing infection require prolonged treponemicidal penicillin levels → hence weekly benzathine penicillin G (BPG) ×3.

View full thread
Shiva Narayanan
@shivn.bsky.social

PK data for BPG: • Young adults, single 2.4 MU dose: – 0.2 µg/mL at 48h--> – 0.05 µg/mL at 6 days-->– 0.02 µg/mL at ~13 days. Elderly adults, same dose: – ~0.04 µg/mL still present at 20 days So a single 1.2MU BPG dose maintains “rheumatic-fever-level” penicillin for ~2–3 weeks, depending on age.

Shiva Narayanan
@shivn.bsky.social

The 3-dose regimen for late latent syphilis rests on remarkably thin evidence. The logic: organisms dividing more slowly in long-standing infection require prolonged treponemicidal penicillin levels → hence weekly benzathine penicillin G (BPG) ×3.

View full thread
Shiva Narayanan
@shivn.bsky.social

So what can we conclude? ➡️The 3-dose late latent syphilis regimen is built on an assumed treponemicidal level. ➡️ There is no data about this dosing in the HIV era!! ➡️There are differences in PCNG levels in young vs old populations. (PCN is renally excreted). Perhaps one dose is ok in older pts?🤔

Shiva Narayanan
@shivn.bsky.social

➡️Can we do 2 doses instead of 3? ➡️More importantly, what is late latent syphilis in PLWHIV? Is it one year? 6 months? No prior titers? ➡️With Benzathine penicillin shortages, I think this is not moot.

Shiva Narayanan
@shivn.bsky.social

The 3-dose regimen for late latent syphilis rests on remarkably thin evidence. The logic: organisms dividing more slowly in long-standing infection require prolonged treponemicidal penicillin levels → hence weekly benzathine penicillin G (BPG) ×3.

View full thread
Shiva Narayanan
@shivn.bsky.social

More recent PK simulations suggest levels may dip below 0.02 µg/mL around 2 weeks — but those models often use 1.2 MU, not the 2.4 MU dose used for syphilis (PMID 25182635)

Shiva Narayanan
@shivn.bsky.social

The 3-dose regimen for late latent syphilis rests on remarkably thin evidence. The logic: organisms dividing more slowly in long-standing infection require prolonged treponemicidal penicillin levels → hence weekly benzathine penicillin G (BPG) ×3.

Shiva Narayanan
@shivn.bsky.social

What is a “treponemicidal” level of penicillin? No one actually knows. Older literature (PMID 20604419) assumed a penicillinemia of ~0.03 IU/mL (~0.02 µg/mL) — described vaguely as “several times the serum and tissue levels needed to kill T. pallidum.” This was assumed to be an "insurance" dose

Shiva Narayanan
@shivn.bsky.social

To anchor this to something better studied: rheumatic fever prophylaxis. For decades, the accepted minimum effective penicillin level to suppress group A strep is ~0.02 µg/mL. → That’s why BPG is dosed every 4 weeks, with q3-week dosing only in higher-risk populations.

Shiva Narayanan
@shivn.bsky.social

Is #SONIA one of the most important public health relevant infectious disease studies? 30% patients were hypoxemic and 9% had hypotension. Rather surprised by the high mortality of nearly 25% in groups which would reflect a really high PSI (class V) #IDsky