Antibiotics are wonderful things. They treat and provide life-saving amelioration of symptoms from the common cold, the flu, bronchitis, sinusitis, and otitis – or, more accurately, they don’t. Rather than generalize the treatment with antibiotics for all these illness, it is rather the avoidance of antibiotics that should be generalized, with specific exceptions made as necessary.
The next “-itis” to go under the microscope is diverticulitis. These authors from Iceland and Sweden deserve, at the minimum, kudos for innovation in swimming against the tide. The treatment of acute diverticulitis – a febrile illness with an elevated WBC and left-lower quadrant pain – is generally gram-negative and anaerobic coverage as an inpatient or outpatient, depending on comorbidities. These authors propose that diverticulitis is most frequently a self-limited process, rather than one that requires antibiotics.
This a non-blinded trial of antibiotics vs. non-treatment for CT-demonstrated acute, uncomplicated diverticulitis. Over 600 patients were admitted, with half receiving simple observation and symptomatic treatment vs. half with the same plus antibiotics. 1% of patients in the antibiotic group suffered treatment failure – progression to abscess or perforation – compared with 2% of patients in the placebo group.
Unfortunately, we’re not quite done with antibiotics based on just this study. It is unblinded with variable enrollment between centers, leading to several sources of potential bias. Then, ten patients in the no-antibiotics group crossed over to receive antibiotics for clinical worsening during hospitalization. However, this is still below the 6.5% complication rate the authors thought might be an acceptable failure rate for conservative therapy.
Many more questions to be answered regarding external validity, so hopefully this inspires other investigators to further explore which subset patients will derive benefit from antibiotics in diverticulitis.
“Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis”
www.ncbi.nlm.nih.gov/pubmed/22290281
Month: January 2013
The Future of Heart Failure Admissions
At least, this is how Cardiologists think the Emergency Department should be handling heart failure in The Future.
Specifically, Cardiologists would like us to stop admitting patients with acute exacerbations of established heart failure – and, interestingly, they’re a bit apprehensive about discharging them. Their earth-shaking, practice-modifying innovation is this: observation unit management.
This strategy is founded partly out of interest of the patient’s well-being, but mostly out of interest for the hospital’s financial well-being. In general, heart failure remains one of the most difficult hospital readmissions to prevent. This is important because, suddenly, readmissions within 30 days are no longer reimbursed by CMS. Now, rather than, re-admit patients for free, they’ve decided the New Fabulous Idea is to place them in outpatient observation status – which is a lower level of reimbursement, but still better than nothing. In addition to the other obviously indicated admissions, they also feel some of the gray area discharges would probably benefit from observation, appropriately noting heart failure patients discharged from the ED are at high risk of having subsequent worsening due to a variety of contributing factors.
Overall, as far as actual patient care, there’s probably little difference – somewhat cynically, the entire strategy seems mostly to be an advisory on how to minimize the impact of reimbursement losses from readmissions.
“Is Hospital Admission for Heart Failure Really Necessary? The Role of the Emergency Department and Observation Unit in Preventing Hospitalization and Rehospitalization”
www.ncbi.nlm.nih.gov/pubmed/23273288
And, just as a rather inspirational aside, this is one of the longest disclosures list I have ever seen for an author:
“Dr. Gheorgiade has received support from Abbott Laboratories, Astellas, AstraZeneca, Bayer Schering Pharma AG, Cardiorentis Ltd., CorThera, Cytokinetics, CytoPherx, Inc., DebioPharm S.A., Errekappa Terapeutici, GlaxoSmithKline, Ikaria, Intersection Medical, Inc, John- son & Johnson, Medtronic, Merck & Co., Inc., Novartis Pharma AG, Ono Pharmaceuticals USA, Otsuka Pharmaceuticals, Palatin Technologies, Pericor Therapeutics, Protein Design Laboratories, sanofi-aventis, Sigma Tau, Solvay Pharmaceuticals, Sticares InterACT, Takeda Pharmaceuticals North America, Inc., and Trevena Therapeutics; and has received significant (>$10,000) support from Bayer Schering Pharma AG, DebioPharm S.A., Medtronic, Novartis Pharma AG, Otsuka Pharmaceuticals, Sigma Tau, Solvay Pharmaceuticals, Sticares InterACT, and Takeda Pharmaceuticals North America, Inc.”
Angiography After Cardiac Arrest
This is the worst sort of paper – nuggets of truth mired in systematic flaws. There’s certainly no ill intent by the authors to mislead, it’s simply the nature of this sort of retrospective review.
The PROCAT consortium has been publishing studies of their post-arrest protocols for several years. They’re huge proponents of early coronary angiography following resuscitation for out-of-hospital arrest – and this is another in a string of articles demonstrating that patients going to coronary angiography after out-of-hospital arrest have improved outcomes. Of the 1274 patients in their cohort, 745 received early coronary angiography, 447 identified a culprit lesion, and 347 underwent PCI. The survival rate was 46% in patients undergoing PCI.
However, this number is conflated by other confounding variables known to be associated with good outcomes following cardiac arrest – coronary lesions are likely to be associated with VT/VF, which were also associated with good outcomes. Additionally, significantly more survivors received therapeutic hypothermia than non-survivors, illustrating the massive problem with viewing this sort of report with anything other than reasoned curiosity: rampant selection bias. Patients survived because they were selected for interventions based on individualized prognostic features, treatments were not applied evenly across the population.
There is absolutely a subset of OHCA that benefits from early coronary angiography – but this benefit should not be generalized to the inappropriate allocation of resources associated with taking all OHCA to the cath lab after resuscitation.
“Benefit of an early and systematic imaging procedure after cardiac arrest: Insights
from the PROCAT (Parisian Region Out of Hospital Cardiac Arrest) registry”
www.ncbi.nlm.nih.gov/pubmed/22922264
www.ncbi.nlm.nih.gov/pubmed/22922264
The Latest Prognostication for Stroke
We have a fairly robust vascular neurology program at my institution, and – unsurprisingly – they’re rather pro-thrombolysis. While our disagreements over the efficacy of thrombolysis for acute strokes are generally set aside in a truce stemming from academic and research interests, the main philosophical difference between our services remains this: the difference between eligible and indicated.
Vascular neurology tends to treat these terms as synonymous regarding thrombolysis and acute stroke, while it’s clear from the literature that not every patient benefits from thrombolysis. The most recent issue of Neurology features another prognostic tool, the SPAN-100, which is the simplest by far: NIHSS + age. If this score is >100, fewer patients will benefit from tPA than will be harmed. There’s a quality-of-life discussion to be had regarding individualized treatment decisions in SPAN-positive patients, and this is derived from a very small cohort, but it’s consistent with the remaining literature.
The accompanying editorial is also pro-thrombolysis, but does recognize these scoring systems are important clinical tools in educating patients and families regarding the potential for benefits and harms. Most importantly, this table from the editorial summarizes the growing body of literature available to assist the decision-making process:
I look forward to seeing these develop such that clinicians have better tools with which to separate eligible from indicated.
“Stroke Prognostication using Age and NIH Stroke Scale: SPAN-100″
www.ncbi.nlm.nih.gov/pubmed/23175723
www.ncbi.nlm.nih.gov/pubmed/23175723