Journal Club Updates in Infectious Diseases, Sept 2013 Dr. Katy Thompson Preceptor: Dr. David...

Journal ClubUpdates in Infectious Diseases, Sept 2013

Dr. Katy Thompson

Preceptor: Dr. David Coleman

Case #154 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?

1/5 antibiotics in US is given for sinusitis

To limit resistance, this antibiotic use should be evidence-based

Amoxicillin for Acute Rhinosinusitis

RCT

166 adults

Uncomplicated, acute rhinosinusitis. Definition:

Maxillary pain or tendernessPurulent nasal secretionsRhinosinusitis symptoms for 7-28 days

10 community-based PCP offices


All patients received 1 week supply of supportive tx for pain, fever, cough, nasal congestion:Tylenol 500 mg q6h PRN pain, feverGuaifenesin 600 mg q12hDextromethorphan/guaifenesin 10 mL q4-6hPseudoephedrine 120 mg q12h0.65% saline nasal spray

Treatment for 10 days:Amoxicillin 500 mg tidVs. Placebo


Outcome:

Symptomatic improvement- Y/N

SNOT16 = Sinonasal Outcome Test-16

Zero = no problem to 3 = severe problemNeed to blow noseReduced productivityEar fullnessHeadacheSneezing


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%.


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?

LimitationsNo 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 #154 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 #268M with HTN, DM, CHF presents due to a cough

for 2 weeks. She is requesting a Z pack.

What do you tell her?

Azithromycin is the most commonly prescribed antibiotic in the U.S.

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 – 347,795

Amoxicillin – 1,348,672

No Rx – 1,391,180


Endpoint:CV deathDeath from any cause


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


Cautions:Relative risk vs. absolute riskRetrospective administrative

databases- incomplete clinical information

Case #268M with HTN, DM, CHF presents due to a cough

for 2 weeks. She is requesting a Z pack.

What do you tell her?

Case #3ED 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 BacteruriaRelevance

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

Asymptomatic Bacteruria18 - 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 BacteruriaRandomized 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 BacteruriaSymptomatic UTIs

3 monthsUntreated 3.5% vs. treated 8.8%



Asymptomatic BacteruriaLimitations?

Asymptomatic BacteruriaCautions:

Limited study population

STD symptoms vs. UTI symptoms

Asymptomatic BacteruriaDistortion of native ecology by giving antibiotics

Antibiotic resistance versus virulence

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 tenofovir1579 took tenofovir-emtricitabine1584 took placebo


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


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)


What’s wrong with this study?


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


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)

Thanks for your attention!

Journal Club Updates in Infectious Diseases, Sept 2013 Dr. Katy Thompson Preceptor: Dr. David...

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