IDWeek 2026: Clinical Takeaways, Hot Takes and Regular Bananas

Buddy Creech: [00:00:13] Hey, everybody, this is Buddy Creech and this is let's talk ID. We are here at revenge of the nerds part two. IDWeek Nerd Fest 2026 in Washington, DC. I'm here with Kelly Cawcutt, Paul Sax. Welcome to both of you. How are you?

Kelly Cawcutt: [00:00:30] Thank you. I'm good. I'm glad to be here. Getting to join in on the crew with this one.

Buddy Creech: [00:00:34] This is awesome. I mean, this is an elite crew of well, no, it's neither elite nor are we an official crew. We're a trio. Okay. Yeah. Yeah, yeah. Wait, what flips between trio and then do you have to have four to become a crew?

Kelly Cawcutt: [00:00:46] Okay, what's the number for crew?

Paul Sax: [00:00:47] I'm not sure, but I just think a trio is a more descriptive way of describing three people.

Buddy Creech: [00:00:51] I feel like we're going to need to workshop this a little bit, because crew sounds like we have a mission, maybe even a theme song. Trios look at explosions when they're walking away. I think crews don't, okay. And so I feel like that's a part of what we want to maybe-

Kelly Cawcutt: [00:01:04] It could be both. We could be walking away at the end, too.

Paul Sax: [00:01:06] I like trio because it implies collaboration, you know, like a trio, a music trio.

Buddy Creech: [00:01:11] Yeah. See, Paul, this is this is why they pay you the big bucks is collaboration. That's really good. All right, so we're at IDWeek. We are bringing back an episode that we did last year, which was just kind of give an overview of what we're excited about with IDWeek, what we're learning, what we're most excited about in terms of changes in the field or new data, and then maybe some hot takes about where things are more generally so.

Paul Sax: [00:01:36] And one thing, one thing also is that it's now a year later, you know, we've had another year to adjust to what we talked about last year, which is kind of like the sadness of, of the whole experience of seeing the CDC have its sort of legs cut off at the knees. It was really, really, really awful. But now we're starting to adjust. That doesn't mean we like it, but there's some hope for the future, I think.

Buddy Creech: [00:01:57] And there is an energy here. There is an energy that is at least helpful for me. I always tell friends that this is part science fair, part family reunion because there is such an energy when things are hard. Grants don't get funded, clinical burdens are high. Whatever might be happening, it's really nice to see your people and to be able to connect. And this is a meeting I think all of us try to prioritize just because of that.

Kelly Cawcutt: [00:02:21] Yeah, I will admit, I think it's the first time in, you know, six plus years that I've had people running up wanting to hug everybody when they see people. And I was like, wow, this is amazing.

Paul Sax: [00:02:29] It's a very, very hug, hug, friendly meeting.

Kelly Cawcutt: [00:02:32] Yeah.

Paul Sax: [00:02:33] Which would make my wife very uncomfortable because she doesn't like to hug.

Buddy Creech: [00:02:35] Not a hugger?

Paul Sax: [00:02:36] No, only within the family.

Buddy Creech: [00:02:38] Oh, this is great. See, we're getting inside scoop on the Sax's family right now. This is really good. All right, so, Paul, I'm going to ask you, um, what have you seen already that you're excited about? What are some things that are already sort of piquing your interest in terms of the meeting so far?

Paul Sax: [00:02:52] Yeah. Well, you know, I just went to the late breaker session on antibiotics and there were like three things that really stood out to me that are probably going to change the way I practice at some point in the future, or the way ID doctors practice. Two are, not surprisingly, antifungals because there's like such incredible development in the antifungal space. One is olorofim, which is being compared to amphotericin B in people who can't take azoles and it looks just as good and it's safer. Hooray for that. Anything that puts amphotericin B in the rear view mirror is fine by me. And the other was looking at Rezafungin. Rezafungin compared with, uh, trim sulfa and azole for prophylaxis in stem cell transplant patients. And there it was just as good time free of fungal infections versus good. And Rezafungin, just to remind you, is an echinocandin that has antipneumocystis activity. So you didn't have to use the trim sulfa. And of course, that was the major toxicity signal in the control arm was the trim sulfa related renal effects. And then one other thing to mention, because it's the second most common diagnosis I follow in my clinic, which is nontuberculous mycobacteria lung disease. Kevin Winthrop, who was one of the kings in this area, presented data from the two versus three study, which showed two drugs azithromycin ethambutol compared to azithromycin, ethambutol and inhaled amikacin. And the three drug arm had much better clearance of cultures and also a lower incidence numerically of resistance. So those were three studies I was happy to see randomized clinical trials really, I think potentially practice changing.

Buddy Creech: [00:04:23] Go a little bit further on the amikacin part. What are the rate limiters in treating those folks? Because treatment is really challenging for NTM. And I know it's different in peds than adults. We often just watch the cervical adenitis. But when we get NTM in the lungs, whether cystic fibrosis kids, adults like it's it's difficult.

Paul Sax: [00:04:41] I call it the most common severe chronic disease that nobody has ever heard of. It's like incredibly common to see people with nodular bronchiectasis, NTM infections, and they're predominantly women. It's like in the clinical trials, they're 80 to 90% women, for reasons that are not clear, predominantly post-menopausal women. A lot of them underweight, like long-term underweight. It's not underweight necessarily from the disease. And they're coughing and clearing their throats and they're kind of suffering. And then at the more extreme versions of the disease, we all know that you can have someone who literally dies of wasting and respiratory insufficiency. So we got to have better treatments, have to and the drugs are toxic. The drugs are not very effective. You can't change the underlying host susceptibility. Although with brensocatib for bronchiectasis, we can now start to do that a little bit. And it's just an area that really needs good prospective studies. And that's what I was glad to see this one. The problem with inhaled amikacin specifically is that it is extremely expensive, and it's right now only FDA approved for people who have failed treatment. And this study was in people who have never been treated before. So at least gives me some hope that it will get FDA approved for this purpose and therefore will have more insurance coverage for a broader population.

Buddy Creech: [00:05:58] That's outstanding.

Kelly Cawcutt: [00:06:00] It just makes me think of like on my critical care side, like the zones of the lung though, and like, how well will it perform over time, based on where you actually breathe it in? Right? Because we've seen that with other inhalational things like pentamidine or other pieces of that. And will it be as good as we hope it will, as you broaden it out more and more?

Paul Sax: [00:06:15] Yeah, I don't know. I mean, inhaled antimicrobials do have a space. I mean, we all know this from initially from the cystic fibrosis patients and inhaled tobramycin. I think this is good because amikacin is one of the drugs that's most active against MTM. And Amikacin systemically is potentially very toxic. So it's better to give it this way than systemically. Um, the major side effect that I've seen in my practice has been hoarseness, which in some people is a real problem. But there are ways strategies to help.

Buddy Creech: [00:06:45] But it's got to be better to use a drug like that early in a disease course before you have those pulmonary changes that are going to lead to altered drug disposition in the lungs. To your point, Kelly. I mean, if you're giving it at a point where you've just got some dead lung or poorly perfused lung or poorly ventilated lung, then it's not going to be as effective. So this first line study that's really great.

Paul Sax: [00:07:05] And the other thing is that it's a replacement potentially for rifampin, which is the most commonly used third drug and now is in the guidelines to use that third drug. Rifampin is the drug that everyone loves to hate. I mean it's really a difficult drug to use for reasons that are so obvious to these listeners. But wow, talk about drug interactions.

Buddy Creech: [00:07:24] But it's fantastic around Halloween for the orange discoloration. And you can, you know, half your costumes settled right there.

Kelly Cawcutt: [00:07:31] You seemed it out for October for that. Strong work. [laughs]

Buddy Creech: [00:07:33] That's what I'm here for.

Paul Sax: [00:07:35] It's amazing that a drug like rifampin has to be really important for it to still be used because it is such a pain in the butt. Oh my God. Am I allowed to say that on a podcast?

Buddy Creech: [00:07:46] I think so I think, I think, I think we're not going to get FAA problems there. Yeah, FAA? FCC?

Kelly Cawcutt: [00:07:51] I was going to say FAA, huh? [laughs]

Buddy Creech: [00:07:52] Yeah. The FAA is also not going to give us any trouble. You're still going to be able to fly home. All right. Kelly, tell me what you're most excited about or some stuff that you're already hearing about or things that you may be even involved in?

Kelly Cawcutt: [00:08:04] Yeah. So entirely on my own bias of this, but my like ID critical care, infection prevention heart is really, really excited to start talking about sepsis and hospital onset sepsis and the new multi-disciplinary and society guidelines that have come out about this and kind of the updates from the CDC thinking about adults. Um, sepsis events and the fact that it also finally I think recognizes and pulls in ID in a better way because now you're talking about infection prevention is prevention of sepsis for hospital onset, which is your higher mortality than community onset. And you're talking about the value of stewardship and not just the beginning of stewardship, right? But like the whole sequence of treatment through those sepsis events and how that comes out to our outcomes in sepsis to improve mortality for hospital onset and focus more on that than just purely community onset, which is a huge gap in our care and something we've had a blind side for a long time.

Buddy Creech: [00:09:02] That's outstanding. And what do you think the biggest, as you start to focus on hospital onset sepsis, what are the biggest gaps that if you had just the wish list, like these are the 2 or 3 things we're going to tackle first?

Kelly Cawcutt: [00:09:15] So for me, again, I mean, some inherent bias, but when you look at the data behind it, you know, adult sepsis events, when you look at the data of what causes them, we're talking about non-ventilator hospital associated pneumonias, right? You're talking about leading causes of sepsis, leading causes of mortality in hospitals that we kind of just ignore a lot. There's been a lot of data that says we should be doing more. We should be benchmarking and monitoring and intervening. But it's always hard to get organizations. And I say that broadly, like for hospitals behind it, right? There's no punitive financial issues. You're not being ranked in Vizient or other metrics for those types of infections. And so they don't get the same initiative and resources and support. But yet from a patient, purist perspective, that's what patients are dying of in our hospitals. And it's something that we don't do a lot with.

Paul Sax: [00:10:05] A good approach, a good effort, I support it.

Kelly Cawcutt: [00:10:08] It'll be hard. [laughs]

Paul Sax: [00:10:08] Even though it's not my area. I still, you know, I do a lot of hospital based medicine though.

Buddy Creech: [00:10:12] So we think about this a lot in peds because we have a couple of different patient populations where their hospital stays might be longer than their entire lives have been up to that point, or maybe even kids who have never left the hospital. So whether that's the newborn ICU, the pediatric ICU, especially the congenital heart disease patients that we care for. And one of the things that we appreciate is these kids, and we're borrowing from the adult literature here is this concept of persistent inflammation and catabolism. And they basically are immunosuppressed, which then only contributes to this idea of hospital onset sepsis events or these weird phenomena where they get inflamed, maybe because they're, I don't know, their chromatin is wide open for pro-inflammatory genes and someone stares at them wrong, and now they're going to make inflammation. It feels like that's one of the hardest things to differentiate right now for us is these folks who have these intermittent inflammatory events versus those who have truly culture documented infections. So they have sepsis physiology. They have life threatening organ dysfunction, but then they're culture negative. And is that a problem of diagnostics? Is it a problem of etiology?

Paul Sax: [00:11:22] I mean, if and they all go on broad spectrum antibiotics.

Buddy Creech: [00:11:24] All of them. that's right.

Paul Sax: [00:11:25] It is a very common ICU consult for doctors. Maybe not from you, Kelly, from people who are not ID trained also, you know, to basically say we have a patient here with sepsis and you go by and cultures are negative and they just have sepsis physiology, you know, high cardiac output and low SVR and low blood pressure. No presser requiring hypertension.

Kelly Cawcutt: [00:11:47] And sometimes you have to be willing to stare down and give the evil eye to the fever or the leukocytosis or that physiology and be like, sometimes we have to wait a little bit, right? And that's really, really hard to do.

Paul Sax: [00:11:57] Yeah, yeah. It is though. I think the early empiric antibiotics after cultures makes sense, of course, but then to be able to stop them if you find nothing, that's the hard part. So how about you, Buddy? What of this meeting is your, are you, is standing out for you, hot take?

Buddy Creech: [00:12:17] Yeah. This is really it's interesting because there's a few of these and I might focus on one of them, but I want to I want to give some honorable mentions to a bunch of these because there's a lot of activity around C diff at the meeting, which is really exciting for me. Um, one of our GI colleagues, Mary Beth Nicholson, has an active research program on how do you differentiate colonization from disease. How do you best treat and then how do we see a vaccine become a reality? Um, and I think there are finally some candidates that are in late stage development that could really be a game changer for how we have an ongoing relationship with C diff and our gut in a way that does not wreak havoc when we mow down all the other.

Paul Sax: [00:12:57] Is it a systemic vaccine or is it a mucosal vaccine?

Buddy Creech: [00:13:01] There are two that are, the one that's latest in development is an intramuscular vaccine that induces strong humoral and cell mediated responses. And that that's sufficient to be able to prevent medically attended C diff disease, we think. But there are others that are in preclinical testing and early development that might actually be able to get rid of colonization as well. So that's one field that I'm particularly interested in. We're watching flu really carefully. So every flu session I'm going to because my goodness we're seeing flu way earlier than we normally do this year. And we don't know what that's going to, what that's going to do. Does that mean we're going to have a more severe year? Does it mean we're going to have just a broader year. Trying to predict flu is just ridiculous.

Paul Sax: [00:13:44] Last year, flu took off in early December, and that's earlier than usual also. And it peaked early and then didn't really come back.

Buddy Creech: [00:13:51] That's right.

Paul Sax: [00:13:52] Last year's flu season was kind of normal after that terrible start.

Buddy Creech: [00:13:55] And it's so strange that all of our respiratory infections, whether those are respiratory viral infections or even bacterial infections, those have just been still very different post-pandemic. There were some things that happened then, either through masking, social distancing, competition from Covid itself during a period of that time. I don't know what drove all of that, but we're still trying to get back into our regular cycle of RSV season, flu season, human metapneumovirus season. So I think the the challenge for us is all of the public health infrastructure challenges that we've had over the last couple of years that spills over into our ability to actually get real time data with high quality on what all of these pathogens are doing. And so we're still working through that.

Paul Sax: [00:14:42] Yeah, it does feel much more normal than it did.

Buddy Creech: [00:14:46] Yes, very much so.

Paul Sax: [00:14:47] The years when we had hardly anything. Yeah. Really strange. And you know, my wife's a pediatrician and she, she was like, this is so bizarre, you know, going to her, her office practice and seeing hardly anything and then all of a sudden seeing incredible number of cases of, for example, group A strep and, you know, raged for a while. And anyway, but it's feeling like it's heading back towards normal i hope.

Buddy Creech: [00:15:10] I hope so, but then it gets impacted by, you know, we've seen more pertussis in the past couple of years than we had seen in the preceding 5 or 10 years combined because of decreasing, um, impact of the vaccine itself. The acellular vaccine just isn't as effective at preventing all causes of infection. It prevents disease very well, but it doesn't prevent infection. We have great baboon model now to show us that an acellular pertussis vaccinated host can easily get pertussis in the nose, easily transmit it to other folks, but they don't get the lower respiratory tract disease, the high white count and all of that. Um, as opposed to wholesale vaccine that does that very, very well. So I think there's going to be some movement in that field as well that I'm really excited about.

Paul Sax: [00:15:54] You know, can I take a little side digression? Is that allowed?

Buddy Creech: [00:15:58] I mean.

Paul Sax: [00:15:59] We have an ICU doctor right here. Yeah, a critical care Kelly. Critical care plus ID. There's a clinical trial which I covered in my What's Hot in Clinical ID talk yesterday, which is called REMAP-CAP. And REMAP-CAP is the first randomized trial of oseltamivir versus no treatment in people with critical illness. And it's now available as a preprint. It's not been peer reviewed yet, but the results are quite striking. The results showed not only did oseltamivir not help, but there was a suggestion that it actually was harmful. And so the study was stopped early because they were clearly not going to see benefit. And then they did a Bayesian analysis and said, there's like a 95 plus percent chance it's harmful for these critically ill patients. You know what they did in New Zealand, I spoke to someone in New Zealand and they said as soon as this study came out, we stopped recommending it for critically ill patients. What are you going to do this season when you have someone in your ICU with influenza?

Kelly Cawcutt: [00:17:00] You know, I think the thing that's really hard about giving oseltamivir in the ICU, like by the time you hit the ICU with influenza, you're already very ill and your absorption is not normal anymore. So like, I never even know if you're getting therapeutic doses of it to start with, which, as you were talking about, is one of the first things I think about was like, I don't even know, like, how much drug did they even get? But I mean, we've been debating the value of oseltamivir forever.

Paul Sax: [00:17:29] I think you're absolutely right. And this is actually one of the reasons why they did the study. And it's fascinating study. And I gather it's going through sort of a slow peer review process because it's not appeared yet in the journals. And I did hear from my friend and colleague, Andy Pavia. He was not happy with what I wrote about it because I said, you know, this really raises questions about whether we should be using this in critical illness because, you know, in that study, exactly what you said, Kelly, the median time before getting treatment was five days. And we know that oseltamivir doesn't really work after 48 hours, but the pediatric perspective might be different.

Buddy Creech: [00:18:06] Well, so this is where Andy's hilarious, right? Internal medicine trained, but a peds. Yeah, he's one of us. So we claim him. We still really, we love oseltamivir in critically ill kids. And I'm a big believer in treating influenza with antivirals. And so there are great data suggesting that the neuropsychiatric symptoms that people have been worried about, they really don't occur at a high enough level to be concerned about it. The biggest issue for us in pediatrics is the nausea and vomiting that comes with oseltamivir. So what we typically would suggest is take it, if the kid starts vomiting or having troubles with it, okay, stop it. But that probably only occurs. I mean, pediatricians will estimate that it happens 50 or 60% of the time. It probably only occurs 10 or 20% of the time. So it's worth trying in those situations. We're still believers, and this may end up being a place where kids are not little adults. Or it may be prescient to say maybe there isn't much bang for the buck by the time you get out there. And we need to be using lots of baloxavir or zanamivir or.

Paul Sax: [00:19:07] I mean, baloxavir has a completely different mechanism of action. And, you know, I just treated someone with baloxavir, which is finally a little bit more accessible than it was. You know, the company has made it more affordable and it's in more insurance plans. And so this is a, you know, a guy in his late 60s and he got terrible flu. And, you know, he had within the window, he got it. I said if it's too expensive, let me know, there are ways of getting it cheaper. He says, he says no, my insurance covered it. So interesting.

Kelly Cawcutt: [00:19:32] Yeah. And I think too, like kids versus adults, like I think about the adult pathophysiology of respiratory failure and the evolution into ARDS, right? Like no antiviral turns that around, right? And so the question really is, you know, is this truly like a viral pneumonia? And we're trying to correct it? Or are we moving into that ARDS phenomenon where days, right. Five days is kind of more ARDS to me. And like, would it really rescue that? Probably not.

Paul Sax: [00:19:58] Maybe if they'd started it earlier.

Kelly Cawcutt: [00:19:59] Right.

Paul Sax: [00:20:00] When you actually look at the forest plots in that study where they compared symptoms for five days or more, or symptoms for fewer than five days, there was actually a much worse outcomes than the people who had longer symptom duration. So anyway, just a quick sidebar.

Buddy Creech: [00:20:16] I love this stuff. No, I mean, we're getting high level. These are good. These are good takes right now. Great. But I don't know that they're hot enough.  Andy thought that was a pretty hot take, if he reaches out to you.

Kelly Cawcutt: [00:20:29] I mean we're entering flu season,

Buddy Creech: [00:20:29] Okay, you know.

Kelly Cawcutt: [00:20:31] Timing is everything.

Buddy Creech: [00:20:31] The crew, the trio has spoken. Two of the three. I don't know what duo of trios, I don't know. Now there's six of us. I don't know, I'm not sure what's happening. All right. Um, I want to know more broadly now. It's like hot takes outside of the meeting. What's happening in the field, what's happening in ID? We're not going to care about critical care.

Kelly Cawcutt: [00:20:50] Yeah that's fine.

Buddy Creech: [00:20:50] I mean, I appreciate that, but yeah, critical care, they scare us. They'll put lines in us and stuff.

Kelly Cawcutt: [00:20:54] Um, we try not to. At least I do. [laughs]

Buddy Creech: [00:20:55] Okay, good. Um, what are some hot takes? Kelly. We're going to start with you about just what are you interested in? What are some things that are a little controversial that you're excited about, where that goes in the next little bit, or even reflections on the last year or so?

Kelly Cawcutt: [00:21:10] Yeah, actually, now that you said lines. Yeah, yeah. Um, I think one of the things that is really exciting to me is kind of the trajectory we've been on now for several years of, you know, less is more. Switch off IVs, get the lines out earlier, you know, get to oral therapy earlier and earlier and earlier, which I think is really exciting. And it's exciting both because it makes the patients so much happier.

Paul Sax: [00:21:32] Oh yeah.

Kelly Cawcutt: [00:21:32] Right? It's so much easier. There's so many less adverse events and there's so many less central lines with all of those subsequent complications that are really important. And so seeing more of that transition. But I think like the onus is also on us. When I reflect on hospital practice, it's very easy when someone is going to be in the hospital, say for like another week or two, or just leave them on their IV therapy until discharge, when we really probably need to push that harder and harder on our inpatient side of care to be like, no, you go to orals now, get the lines out. Like we don't need these even in the hospital setting anywhere near as long as we're going.

Paul Sax: [00:22:08] I completely agree, and I'm thrilled to hear you say that, because you might influence some of your ICU colleagues who like, "can we keep the line in?"

Kelly Cawcutt: [00:22:15] Right.

Paul Sax: [00:22:16] Try to get the line out.

Kelly Cawcutt: [00:22:17] Yes. Please try to get it out as soon as possible. [laughs] Thank you.

Buddy Creech: [00:22:20] So the hot take here is you don't have to treat every infection with parenterally administered antibiotics, even the hard ones.

Paul Sax: [00:22:29] I am going to choose for one of my hot takes a parenteral antibiotic.

Buddy Creech: [00:22:33] Oh let's go. Let's hear it.

Paul Sax: [00:22:34] So it is part of a theme of what I think is a real fundamental change in how we manage people with IV antibiotics. And it's not switching to orals because everyone agrees that's a good thing. But it's the use of the long acting glycopeptide dalbavancin. Dalbavancin, the price has plummeted. You know, we've gone from a $5,000 for 1500 milligram dose down to a generic price that our hospital gets for $600. That's a secret I'm not going to let. Don't tell anybody. But we are now getting $600 for a 1500 milligram dose. One dose can treat skin and soft tissue infections for a couple of weeks. A second dose a week later is the equivalent of 4 to 6 weeks of IV antibiotics. I'm telling you that Dot's trial and the generic availability of this drug has transformed our usage of dalbavancin, and our use in the hospital has gone up and up and up. Now, of course, if Brad Spellberg were here, he'd say, switch to orals. What are you using that drug for? But there are some people for.

Buddy Creech: [00:23:36] The right patient.

Paul Sax: [00:23:37] Yeah, this is better. You know, they don't have to remember to take anything. The two things I'm worried about with this excess use, or excess, this increased use of dalbavancin. One is that it's going to uncover a toxicity that we haven't seen because we've been using it so little because it was like break glass in case of emergency. That was the only usage we had for it. The other worry I have is of course, is selection of glycopeptide resistant organisms, in particular staph aureus. But that's been pretty rare. I mean, it has been reported but it's been pretty rare. So that's a hot take. Dalbavancin. The Dalbavancin era is has arrived.

Kelly Cawcutt: [00:24:13] Yeah. We use a lot of dalbavancin.

Paul Sax: [00:24:14] There you go.

Kelly Cawcutt: [00:24:14] Our ER does it as their preferential, like you have skin and soft tissue infection. It's on their protocols. But from the ID perspective, we use a lot of it. I think the only thing that's unfortunate is in that discussion of like hospital treatment, like we have to discharge you and get you to our infusion center to give the dose so that I'm keeping you on something in between.

Paul Sax: [00:24:33] I have heard that some centers are doing that. It's a way of gaming the system. But now that the price has come down.

Kelly Cawcutt: [00:24:40] Yeah, I'm hoping we'll see.

Paul Sax: [00:24:41] Because really, before it was all to avoid having it in the DRG, which is sort of an artificial thing, we were told that if we discharge them that day and gave them a dose in our infusion unit, it still counted towards the hospitalization. So we were, they would say to us, discharge them home and have them come back the next day for the infusion. And that was never going to happen. Never, never, never.

Kelly Cawcutt: [00:25:04] Especially for the patients you're trying to select sometimes for Dalbavancin, you're like, no, now.

Paul Sax: [00:25:08] Yeah, exactly. So I'm basically, you know, now that the price is what it is, and I think it'll go lower as they start competing with the generics, it's going to become standard to give it a time of discharge or even during the hospitalization.

Kelly Cawcutt: [00:25:21] I think that during the hospitalization is really appealing. But it's also appealing like to me, like we've seen this happen several times. Someone's gotten their dalbavancin right and they come back in. They had a staph aureus bloodstream infection and they got dalbavancin. They come back in for a secondary reason. And also they're back on vancomycin because nobody realizes that they're still therapeutic. And you're like, no, they don't need anything else. And making sure you capture that to avoid additional adverse events from unnecessary drugs is a gap. Like, I don't know how to identify that to the teams right away because we don't get called for that necessarily.

Buddy Creech: [00:25:52] Mhm.

Paul Sax: [00:25:52] Mm.

Buddy Creech: [00:25:53] Those are really good.

Paul Sax: [00:25:54] Thank you. Yeah, yeah. What about you?

Buddy Creech: [00:25:56] Uh, my hot take is going to be on measles because I feel like it has to be a pediatrician.

Paul Sax: [00:25:59] It has to be.

Buddy Creech: [00:26:01] I think we are dangerously close to seeing, um, not just our measles elimination status being revoked in the US and in North America, but really getting to a place where there are certain pockets in the US where circulation is happening even more than just these local outbreaks that pop up and get contained. So my hot take is I think we're very, very close to more routinely recommending vaccine at nine months of age or so. So we're working around this space with Hana El Sahly at Baylor to look at just circulating antibodies to measles, both the ones that bind, but also the ones that neutralize. And what we have found, at least, is that by the time infants are six months of age, the overwhelming majority do not have any detectable neutralizing antibodies to measles in a microneutralization assay. And that now means that 6 to 12 month olds are vulnerable. And this is one of the most common questions we're getting from pediatricians in our area to say, should I start vaccinating? And we already do it. If there's a local outbreak, we already do it if they're internationally traveling, but we don't do it very young because we're worried about interference with the vaccine. And I think now with these data, that babies don't have as much as we thought they did, and they certainly don't have as much as they did 50 years ago because of changes in epi, I think we might come more in line with what the WHO recommendations are, which is nine months vaccinating, and then boost them again, not at four years, but at 18 months. And really go ahead and get those two doses in just as soon as we can in order to provide maximum protection. So that's my hot take. Is that out of necessity, we're going to have to start vaccinating those who are willing to be vaccinated against measles.

Paul Sax: [00:27:39] I mean, I hear the things, you know, the Pennsylvania outbreak is really out of control. I mean, so far it hasn't come to Boston, Massachusetts, but I'm worried.

Buddy Creech: [00:27:52] It will. You're a plane ride away from everywhere.

Kelly Cawcutt: [00:27:54] Yeah I know right.

Buddy Creech: [00:27:55] Yeah. And I think it's really challenging for me because I think one of the challenges has been this concept of, oh, the childhood schedule is too crowded and all of this. And it most certainly is not. I mean, our infants see far less antigenic stimuli than they did 30 years ago, right? Certainly less than when we were kids getting our vaccines. Um, but trying to convince folks to get MMR even earlier when they're not even willing to get it at 12 months, our work is going to be cut out.

Kelly Cawcutt: [00:28:20] And some of the unique recommendations that have come out about that vaccine in general that aren't necessarily evidence based, but sure, throwing more confusion, right?

Paul Sax: [00:28:27] Oh yeah.

Kelly Cawcutt: [00:28:28] And mistrust and distrust into the general community about that.

Buddy Creech: [00:28:31] I think that's right.

Paul Sax: [00:28:32] Yeah, that's right.

Kelly Cawcutt: [00:28:33] So I have a question because now you made me think about this as you talked about outbreaks. So you talk about seeing clinical cases of an outbreak. But one of the things that we've seen, at least I think we've seen a lot more of over the last several years, is the wastewater monitoring. And looking for measles in wastewater, do you get ahead of the clinical outbreak by vaccinating earlier based on wastewater? If you are so lucky to have access to that in your area. Because I think that's a different strategy than we've had in the past.

Paul Sax: [00:28:59] Oh, absolutely. And in fact, our hospital epidemiologist was notified that there was measles virus detected in the wastewater. And just in case people are wondering, they can tell the difference between the vaccine virus and the natural virus. And it was the natural virus. So you're right. I mean, we are going to see cases, you know, right now. I mean, since most cases people recover without a problem, you know, there are going to be subclinical and mild cases in the community before we start seeing the really sick kids.

Buddy Creech: [00:29:27] But I think this is really important because that's the challenge, is before we start to see kids going to the hospital with pneumonia or encephalitis, before we see in 5 or 10 years the cases of SSPE that develop because of a child being infected during infancy, we're just going to see very mild nonspecific fever rash. And that's not going to be enough to motivate people to test. Because it looks like every other viral infection of childhood in many ways. And so not only do we have people that aren't trained to identify measles because they haven't had to, we have parents who are just going to treat it like any other febrile rash illness and may not even go to the clinic or the.

Kelly Cawcutt: [00:30:06] Because they've never seen measles either.

Buddy Creech: [00:30:08] Right. And their parents haven't even, you know. Not only the parents, but the grandparents may not have seen measles.

Paul Sax: [00:30:14] I haven't seen one case in my career.

Buddy Creech: [00:30:17] I mean, that's -

Paul Sax: [00:30:18] Amazing.

Buddy Creech: [00:30:19] Impressive.

Paul Sax: [00:30:20] In my career. One case of measles.

Kelly Cawcutt: [00:30:22] I don't think I've seen any.

Buddy Creech: [00:30:23] Let's talk about this. Because before 1957, if you were born before 57.

Paul Sax: [00:30:28] Everyone.

Buddy Creech: [00:30:28] Everyone was infected to the point that we're just going to assume you're immune. You don't even need a vaccine, right? And yet now between all of us, we've had a combined case count of like two. That's impressive.

Paul Sax: [00:30:39] Yes.

Buddy Creech: [00:30:39] So it turns out, this is a hot take. Vaccines work.

Paul Sax: [00:30:43] Yeah, yeah.

Buddy Creech: [00:30:43] Hot take, hot take. You heard it here first.

Kelly Cawcutt: [00:30:46] Super hot take. [laughs]

Buddy Creech: [00:30:46] Let's Talk ID.

Paul Sax: [00:30:47] I agree with you.

Buddy Creech: [00:30:47] I love it. So all right. So last year, um, we, uh, we took a deep dive on our names.

Paul Sax: [00:30:52] Okay. That was my idea.

Buddy Creech: [00:30:54] Yeah, that was pretty impressive. I think you should, because it was, um, we learned some stuff. Let's just say that we learned some stuff.

Kelly Cawcutt: [00:31:01] I learned to make sure that go by saxophone and not fax or faxophone. I got that.

Buddy Creech: [00:31:06] That's right. This is good.

Paul Sax: [00:31:07] Remember, my last name is not F as in Frank Ax, but S as in Sam Ax.

Buddy Creech: [00:31:13] That's good.

Paul Sax: [00:31:14] Yes.

Buddy Creech: [00:31:14] So I don't know how to take us home. I mean, you were. You're one for one so far.

Paul Sax: [00:31:18] Ok. I'm going to do the next one. Ready? Ready. And, um. Show of hands. Who wants to go first? I'm going to ask. Okay. All right.

Buddy Creech: [00:31:26] I'll go first. I can do this.

Paul Sax: [00:31:29] Um. All right. So I want you to share with me something that people in your family make fun of you about.

Buddy Creech: [00:31:37] Oh, yeah. Okay. Um, that list is really long.

Paul Sax: [00:31:40] Okay, but choose one.

Buddy Creech: [00:31:41] I'm considered sometimes the social pinata. Um, just easy to hit. And you usually get good stuff out of it. My current favorite, since we're talking about ID issues, is I rapidly cycle through the Kubler-Ross stages of grief every time I go on service. So I'm a physician scientist. I'm on service about four times a year, and as soon as I get there, we transition on Wednesdays, I go through an absolute denial. Am I really on service today? And then I get angry at the silly consults that come through. Then I start bargaining. If I'm really nice, maybe they won't call me about the dumb stuff. Then I get really depressed. I'm on service for way longer than I want to be, and then I finally get to a place of acceptance. And my kids have learned just to tease me mercilessly in those first 36 hours where I'm rapidly cycling through that. So that's my ID specific one.

Paul Sax: [00:32:28] You're vulnerable.

Buddy Creech: [00:32:29] I'm, you know, I'm living out loud. You know.

Paul Sax: [00:32:32] Just imagine if you were a private practice ID doctor, and you were always on service.

Buddy Creech: [00:32:37] I would be the most miserable person in my family that could exist.

Paul Sax: [00:32:41] Yeah I think there is actually, I mean, because the first year of my clinical job, I was on a five months a year, which is like almost half the year. And I had a little bit of the experience of what it's like to be on so, so much. Yeah. And you do actually acclimate to the sensation of being on, you know, being on service all the time.

Buddy Creech: [00:33:00] Absolutely. But it takes a minute. It takes a minute.

Paul Sax: [00:33:02] Yeah, yeah. But five months I don't do five months anymore, but I do, I do still more than more than four weeks.

Buddy Creech: [00:33:07] I love it.

Kelly Cawcutt: [00:33:08] Yeah.

Paul Sax: [00:33:09] Okay. So Kelly what I mean, you don't have it does not have to be ID themed. Yeah. In fact, the one example I'm going to give is not ID themed.

Kelly Cawcutt: [00:33:16] Yeah. No. I also was trying to think it through what would make the most sense. I really do actually think the most common thing I hear is like, I am just the biggest nerd in our family because. And part of that is because I'm like a first gen college grad. But then like, I read obsessively, like I read a lot of books in a year. And so, um, my husband is the movie watcher and I'm the book reader, so our kids will make fun of me all the time. They're like, oh, mom's reading a book. Looking for a book. Buys too many books, listening to something.

Paul Sax: [00:33:47] Do you have a big stack by your night table or?

Kelly Cawcutt: [00:33:49] Oh yeah, the TBR is legit. Oh, absolutely. It is ridiculous and will never, ever be caught up. Um, but I average about 100 a year, which is

Paul Sax: [00:33:58] Wow.

Buddy Creech: [00:33:58] Wow.

Kelly Cawcutt: [00:33:58] Which when I first got out of. I'm gonna go with sort of out of the pandemic. I was like, I stopped reading anything for fun. And I was like, I don't wanna read anything. I don't even want to read a journal again. And then I was like, you know what? I used to read obsessively when I was a kid? And I start reading and like my first year, I read like 12 books and I was like, ah, you know, we'll try again. And then I like slowly upped it. And once I got like to about 70 in a year and I count any chapter book by audible or like real book, like I don't count like books I read to my kids or whatever. Right. But, um, yeah, I mean, I'm a very fast reader and I listen when I commute all the time.

Paul Sax: [00:34:30] Oh, gosh. So it's very, very admirable. And I wouldn't tease you, I would, I was gonna say it's.

Buddy Creech: [00:34:34] That's great thing to get teased about. You're too awesome of a reader?

Kelly Cawcutt: [00:34:37] Yeah. It doesn't come across that way to your, like, teenage son so much. But to be fair, I was really excited because then I totally bought the ID Foundation like "Talk Nerdy to Me" t shirt, and I'm like, I'm gonna wear this at home while reading things and really annoy them all.

Buddy Creech: [00:34:50] This is incredible. All right, Paul, you gotta bring us home. I want vulnerability right here.

Paul Sax: [00:34:53] All I have is a story. And but my family will never let me live it down. We were actually traveling together, and the kids were in the back, and my wife's in the front, and I'm driving and we pull into a Starbucks to order breakfast. And people wanted various things. And I'm ordering the coffee and I'm ordering the yogurt. And then and someone said, and I want a banana. And so since I had ordered things with various descriptions I said, so I'll have a coffee with half and half, and I'll have a yogurt with granola and I'll have a regular banana. And they said, dad, all bananas are regular. And so ever since then, whenever a banana is described in my house or that one appears, they say it's a regular banana because this is all you get.

Buddy Creech: [00:35:40] This is awesome. Because if you could have said a grande banana, you could have said a venti banana, and that could have been worse. I think regular was the safe.

Paul Sax: [00:35:48] Regular banana. So this is the owner of that phrase. No one else has used it.

Buddy Creech: [00:35:52] Every time I see you now, I'm 100% going to bring a banana and just kind of stick it in your bag and you're gonna be like, why is there four? Why are there four bananas in my bag? This is going to be my new commitment to you.

Paul Sax: [00:36:04] Thank you.

Buddy Creech: [00:36:04] This is amazing.

Kelly Cawcutt: [00:36:05] It's like ducking someone where you leave the little rubber duckies. Now you're gonna banana.

Buddy Creech: [00:36:09] This is what our crew is going to be known for. We're gonna be the banana crew. Yeah.

Kelly Cawcutt: [00:36:12] Yeah, the regular banana crew.

Buddy Creech: [00:36:14] Regular bananas.

Paul Sax: [00:36:14] Banana trio.

Buddy Creech: [00:36:15] A trio of bananas, even. Um, all right. Well, we, um, we have fully ripened, and it is time to draw this to a close. It's really fun to see you guys in person. It's really fun to be here in DC. Yeah. For our listener, if you if you're not coming, uh, to IDWeek often make this a priority. It's really good to be with your people. It's really good to be encouraged to learn to contribute to what we're doing, uh, at IDSA and at PIDS. For more information about that, for the recap of the meeting, make sure that you pay attention to the website. And until next time, Kelly. Paul. Thank you. This has been Let's Talk ID. Paul, you get one last word.

Paul Sax: [00:36:53] It's more than one last word. I want to say thank you. Thank you. Thank you, Kelly. Thank you, Buddy.

Kelly Cawcutt: [00:36:58] Thank you guys. It was great.

Buddy Creech: [00:36:58] Super fun. All right. Bye

Paul Sax: [00:37:01] Bye.

Kelly Cawcutt: [00:37:01] Bye