Oct 20, 2017

Two timer

The story

As a resident, your instinct to double cover sick patients is as strong as the impulse to justify your consults before they can be blocked. But what does the evidence say?

The background

When your overnight nursing home admission rolls to the floor with florid sepsis, double coverage – using two anti-Gram negative rod (GNR) antibiotics with different mechanisms of action – is appealing. But the supporting evidence is hazy: several randomized trials have failed to show that these regimens improve mortality or decrease sepsis-induced organ damage. The Surviving Sepsis Campaign recommends double coverage only for critically ill patients with severe sepsis who are at high risk for multi-drug resistant organisms like Pseudomonas.

The study

A retrospective single-center study compared empiric double coverage vs. monotherapy in 500 patients with confirmed single pathogen septic shock. A β-lactam and aminoglycoside (think pip-tazo and tobramycin) was used in about two-thirds of double coverage regimens. Doubling up was associated with better mortality outcomes in sub-analyses of neutropenic patients and patients with confirmed Pseudomonas infections, yet there was no difference in mortality between the overall study groups. 
J Antimicrob Chemother

The takeaway

You're probably already double covering when you have resistant Pseudomonas in mind, so it's reassuring that this study found benefit. On the whole, your GNR-infected patients with robust neutrophil counts and low risk for Pseudomonas remain appropriate candidates for monotherapy.

Say it on rounds

When all of your patients crash at the same time

Emergencies can feel like an epidemic. A nationally representative survey of HPV infection found that HPV-related mouth and throat cancer in men has surpassed cervical cancer in women. From 2011 – 2014, 11 million men and 3 million women were found to have oral HPV infection, and men were six times more likely than women to have high-risk HPV strains associated with head and neck cancers. Smokers, men who have sex with men, those with multiple sex partners, and men with concurrent genital HPV infection were at greatest risk. 

When your Coumadin game is on point, but you're still last in your fantasy league

Guess-and-check may become more of a 90s thing. An RCT of 1,650 patients taking warfarin after elective hip or knee surgery compared genotype to clinically-guided dosing regimens. A composite endpoint of adverse outcomes was lower in the genotype-guided group (11% vs. 15%), driven mostly by less bleeding and better INR control. Since warfarin is cheap and provides top-notch efficacy when INR is in the therapeutic window, precision dosing may expand the medication's use in the era of novel anticoagulants.

When you spend your downtime with CSI and Law and Order: SVU

It's a bit late to jump into forensics, but you know from all pop culture murder mysteries that lovers are the culprit more times than not. A look into the FBI's Uniform Crime Reports found that states with relinquishment laws, which prohibit domestic abusers from firearm possession and require abusers to surrender existing firearms, had lower rates of intimate partner homicide than states without relinquishment laws. Rate reduction was found only when abusers were forced to surrender firearms, rather than when state laws simply prohibited firearm purchase.

Brush up


For as much as it dominates your night shifts, delirium remains under-recognized. Sneaky onset stems from hypoactive delirium, which represents 75% of all cases and is tough to identify in the hubbub of the hospital day-to-day. Risk factors include old age, subclinical dementia, and poor hearing or vision, while precipitating factors include drugs, pain, infections, urinary or fecal retention, and electrolyte disturbances. Use the Confusion Assessment Method (CAM) to assist with diagnosis in the ICU.

Get meta

With antipsychotics for delirium in elderly patients. An analysis of 19 studies found no reduction in duration or severity of delirium, hospital length of stay, or mortality when antipsychotic agents were used for delirium treatment. There are no FDA-approved drugs for delirium, and when using off-label antipsychotics, be careful to account for the the risk of extrapyramidal symptoms, excess sedation, and prolonged QT interval.

What your public health friends are talking about

Beauty comes in all shapes and sizes, and now condoms do too. The manufacturer Global Protection Corp. claims that men aren't using condoms because they don't fit, and has gone live with a line of 60 length and circumference combos. They avoid the whole XS to XL thing by using random letters and numbers for different sizes.

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