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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?



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 the U.S.

  • 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 the U.S.

  • Azithromycin – 347,795

  • Amoxicillin – 1,348,672

  • No Rx – 1,391,180


Azithromycin and cv death2
Azithromycin and CV Death the U.S.

  • Endpoint:

    • CV death

    • Death from any cause


Azithromycin and cv death3
Azithromycin and CV Death the U.S.

  • 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 the U.S.

  • Cautions:

    • Relative risk vs. absolute risk

    • Retrospective administrative databases- incomplete clinical information


Case 21
Case #2 the U.S.

  • 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 the U.S.

  • 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 the U.S.

  • Relevance

    • Studies showing that if you have asymptomatic bacteruria, you’re more likely to develop a symptomatic UTI


Asymptomatic bacteruria1
Asymptomatic Bacteruria the U.S.

  • 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 the U.S.

  • 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 the U.S.

  • 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 bacteruria4
Asymptomatic Bacteruria the U.S.

  • Limitations?


Asymptomatic bacteruria5
Asymptomatic Bacteruria the U.S.

  • Cautions:

  • Limited study population

  • STD symptoms vs. UTI symptoms


Asymptomatic bacteruria6
Asymptomatic Bacteruria the U.S.

  • 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 the U.S.

  • 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 the U.S.

  • 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 the U.S.

  • 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 couples3
Daily Post-Exposure Ppx in HIV Discordant Couples the U.S.

  • What’s wrong with this study?


Daily post exposure ppx in hiv discordant couples4
Daily Post-Exposure Ppx in HIV Discordant Couples the U.S.

  • 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 the U.S.

  • 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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