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Journal Club. Updates in Infectious Diseases, Sept 2013 Dr. Katy Thompson Preceptor: Dr. David Coleman. Case #1. 54 yo F presents with 8 days of runny nose, productive of yellow purulent secretions, and maxillary tenderness Which medications would you offer?

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journal club
Journal Club

Updates in Infectious Diseases, Sept 2013

Dr. Katy Thompson

Preceptor: Dr. David Coleman

case 1
Case #1
  • 54 yo F presents with 8 days of runny nose, productive of yellow purulent secretions, and maxillary tenderness
  • Which medications would you offer?
  • How would you explain your medication choice to the patient?
slide4

1/5 antibiotics in US is given for sinusitis

  • To limit resistance, this antibiotic use should be evidence-based
amoxicillin for acute rhinosinusitis
Amoxicillin for Acute Rhinosinusitis
  • RCT
  • 166 adults
  • Uncomplicated, acute rhinosinusitis.
    • Definition:
      • Maxillary pain or tenderness
      • Purulent nasal secretions
      • Rhinosinusitis symptoms for 7-28 days
  • 10 community-based PCP offices
amoxicillin for acute rhinosinusitis1
Amoxicillin for Acute Rhinosinusitis
  • All patients received 1 week supply of supportive tx for pain, fever, cough, nasal congestion:
    • Tylenol 500 mg q6h PRN pain, fever
    • Guaifenesin 600 mg q12h
    • Dextromethorphan/guaifenesin 10 mL q4-6h
    • Pseudoephedrine 120 mg q12h
    • 0.65% saline nasal spray
  • Treatment for 10 days:
    • Amoxicillin 500 mg tid
    • Vs. Placebo
amoxicillin for acute rhinosinusitis2
Amoxicillin for Acute Rhinosinusitis
  • Outcome:
  • Symptomatic improvement- Y/N
  • SNOT16 = Sinonasal Outcome Test-16
  • Zero = no problem to 3 = severe problem
    • Need to blow nose
    • Reduced productivity
    • Ear fullness
    • Headache
    • Sneezing
amoxicillin for acute rhinosinusitis3
Amoxicillin for Acute Rhinosinusitis
  • Result:
  • Symptomatic improvement:
  • At Days 3 and 10, symptomatic improvement was the same for both placebo and Amoxicillin groups (34% vs. 37%, 78% vs. 80%)
  • However, at day 7, more people in the Amoxicillin group reported feeling better 56% vs 74%.
amoxicillin for acute rhinosinusitis4
Amoxicillin for Acute Rhinosinusitis
  • Result:
  • Change in SNOT-16 score from day zero:
  • Day 3: 0.59 (Amox) vs. 0.54 (Placebo)
  • Day 7: 1.06 (Amox) vs. 0.86 (Placebo) p-value 0.2
  • Day 10: 1.23 (Amox) vs. 1.20 (Placebo)
limitations
Limitations
  • No stratification by fever (though did stratify by sx severity)
  • Only based on one antibiotic
  • Time of year – allergies affecting results
  • Adherence to antibiotics
  • Bias in who’s performing study- academic vs. industry
  • Clinical versus statistical significance
case 11
Case #1
  • 54 yo F presents with 8 days of runny nose, productive of yellow purulent secretions, and maxillary tenderness
  • Which medications would you offer?
  • How would you explain your medication choice to the patient?
case 2
Case #2
  • 68M with HTN, DM, CHF presents due to a cough for 2 weeks. She is requesting a Z pack.
  • What do you tell her?
azithromycin and cv death
Azithromycin and CV Death
  • Tennessee Medicaid Program
  • All patients 1992-2006 prescribed Azithro
  • Excluded persons at immediate high risk of death from other causes
  • Ages 30-74
  • Control groups: Those taking Amoxicillin or similar patients not taking antibiotic
azithromycin and cv death1
Azithromycin and CV Death
  • Azithromycin – 347,795
  • Amoxicillin – 1,348,672
  • No Rx – 1,391,180
azithromycin and cv death2
Azithromycin and CV Death
  • Endpoint:
    • CV death
    • Death from any cause
azithromycin and cv death3
Azithromycin and CV Death
  • 5-day treatment course
  • Estimated 47 additional CV deaths / 1 million tx courses
  • Sudden cardiac deaths
    • Azithro – 22 people died (65 sudden cardiac deaths / 1 million tx courses)
    • Amox – 29 people died (22 sudden cardiac deaths/ 1 million tx courses)
    • No Rx – 33 people died (24 sudden cardiac deaths/ 1 million 5-day periods)
  • Among highest CV risk group, 245 / 1 million tx courses
azithromycin and cv death4
Azithromycin and CV Death
  • Cautions:
    • Relative risk vs. absolute risk
    • Retrospective administrative databases- incomplete clinical information
case 21
Case #2
  • 68M with HTN, DM, CHF presents due to a cough for 2 weeks. She is requesting a Z pack.
  • What do you tell her?
case 3
Case #3
  • ED patient, 25F presents for STD check. Develops chest pain, admitted for rule out MI.
  • They sent a urine culture, which returns >100,000 CFUs of E.coli.
  • What do you do?
asymptomatic bacteruria
Asymptomatic Bacteruria
  • Relevance
    • Studies showing that if you have asymptomatic bacteruria, you’re more likely to develop a symptomatic UTI
asymptomatic bacteruria1
Asymptomatic Bacteruria
  • 18 - 40 years old
  • Sexually active with 1 partner over the past 12 months
  • One symptomatic UTI treated in past 12 months
  • Currently asymptomatic
  • With urine culture with >= 105 CFUs on 2 consecutive specimens
asymptomatic bacteruria2
Asymptomatic Bacteruria
  • Randomized to receive antibiotic or not (369 women vs. 330)
  • No placebo used
  • Pts returned at 3, 6, and 12 months for repeat urine cultures
  • Asked to return sooner if symptoms
asymptomatic bacteruria3
Asymptomatic Bacteruria
  • Symptomatic UTIs
  • 3 months
    • Untreated 3.5% vs. treated 8.8%
  • 6 months
    • Untreated 7.6% vs. treated 29.7%
  • 12 months
    • Untreated 14.7% vs. treated 73.1%
asymptomatic bacteruria5
Asymptomatic Bacteruria
  • Cautions:
  • Limited study population
  • STD symptoms vs. UTI symptoms
asymptomatic bacteruria6
Asymptomatic Bacteruria
  • Distortion of native ecology by giving antibiotics
  • Antibiotic resistance versus virulence
daily post exposure ppx in hiv discordant couples
Daily Post-Exposure Ppx in HIV Discordant Couples
  • 4747 serodiscordant couples
  • From Kenya and Uganda
  • Followed for 36 months
  • RTC, double-blind, placebo-controlled
  • Studied the seronegative partner: (62% males)
    • 1584 people took tenofovir
    • 1579 took tenofovir-emtricitabine
    • 1584 took placebo
daily post exposure ppx in hiv discordant couples1
Daily Post-Exposure Ppx in HIV Discordant Couples
  • All participants got:
  • HIV-1 testing with counseling before and after
  • Individual and couples risk-reduction counseling
  • Screening and Tx for other STDs
  • Free condoms with training and counseling
  • Referral for male circumcision and PEP
  • Offered Hep B vaccination
daily post exposure ppx in hiv discordant couples2
Daily Post-Exposure Ppx in HIV Discordant Couples
  • Endpoint:
  • Seropositivity in partners previously HIV-negative
  • 17 infections in the tenofovir group (0.65/100 person-years)
  • 13 in the tenofovir-emtricitabine group (0.50/100 person-years)
  • 52 in the placebo group (1.99/100 person-years)
daily post exposure ppx in hiv discordant couples4
Daily Post-Exposure Ppx in HIV Discordant Couples
  • What’s wrong with this study?
  • Ethics
  • Strong emphasis on adherence- monthly visits with seronegative partner and pill counts
  • Limited study population- only heterosexual
  • Safety of Tenofovir in pregnancy, renal function, breast-feeding, bone mineral density
daily post exposure ppx in hiv discordant couples5
Daily Post-Exposure Ppx in HIV Discordant Couples
  • BMC Resources:
  • +HOPE prenatal clinic- advice for HIV+ women who are pregnant or want to become pregnant
  • Dr. Margaret Sullivan (sees all concordant or discordant HIV+ patients contemplating pregnancy)
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