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Feb 22, 2019

Repeat offender

The story

With big gun antibiotics seeing heavier use, the hunt is on for new tools to fight superbugs. Here’s how plazomycin performed in its debut.

The background

The sun sets, seasons change, and your patients with complicated urinary tract infections (UTIs) recur. The bladder is a safe haven for multi-drug-resistant (MDR) bugs. Empiric therapy with fluroquinolones and cephalosporins is no longer recommended in complicated UTIs due to widespread resistance, and carbapenems and other go-tos are facing crises of their own. And while aminoglycosides are popular for MDR UTIs, many superbugs have defense mechanisms that diminish the efficacy of conventional agents.

The study

EPIC compared plazomycin, a new aminoglycoside designed to evade common defense mechanisms of resistant bacteria, to meropenem in 600 patients with complicated UTIs. Plazomycin met the study's primary endpoint of noninferiority to meropenem as measured by composite cure rate at day 5, but the results looked stronger with longer follow-up. At around 18 days after treatment, more plazomycin patients achieved composite cure and microbiologic eradication, and at 30-day follow-up, fewer plazomycin patients had microbiological recurrence (3.7% vs. 8.1%) or clinical relapse (1.6% vs. 7.1%).
NEJM

The takeaway

Plazomycin shined in late comparison tests against tried-and-true meropenem.
Expect more efficacy trials for this agent in MDR settings.

Say it on rounds

When your prank page finds its way to the department chair

If you're in shock, pinch yourself. Abnormal peripheral perfusion following resuscitation is a marker of poor critical care outcomes. A RCT of 420 patients with septic shock compared traditional lactate clearance-guided resuscitation to a resuscitation protocol guided by peripheral capillary refill response time. Patients in the cap-refill arm had a 28 day all-cause mortality of 35% compared to 43% in the lactate arm, though the results did not meet statistical significance. A better-powered study will be needed to prove efficacy.
JAMA

When you can sleep through anything

A blood draw? Probably not. SIESTA combines EMR order alerts (e.g. are you sure this patient needs overnight vitals? And do you really want to order heparin for 5 AM?) and staff counseling to promote sound patient sleep in the hospital. A comparison of two Chicago inpatient units found that a SIETSA unit saw nighttime room entries drop by 44% compared to a usual care unit. Patients also reported fewer sleep disruptions for vitals or medications.
J Hosp Med

When your black weekend has you down

Hospital bacteria probably aren't helping. An analysis of 1,000 participants in the Flemish Gut Flora Project is among the first human studies to link microbiome composition to mental health. Using gene sequencing results from fecal samples, the authors found 2 species – Coprococcus and Faealibacterium – consistently associated with high quality-of-life indicators and 2 species – Coprococcus and Dialister – depleted in depression. Further analyses linked specific microbial synthesis compounds to markers of wellbeing.
Nat Microbiol

Brush up

Aspiration pneumonia

We all micro-aspirate in our sleep, but it’s the macro events that cause rip-roaring aspiration pneumonia. Symptoms can develop within hours of aspiration. Diagnosis is clinical, and infiltrates on chest x-ray are usually in gravity dependent lung segments. Impaired swallowing and inefficient cough reflex place patients at high risk, so be especially watchful of recently extubated patients. Use site of acquisition (community vs. healthcare setting) and risk for MDR bugs to guide initial antibiotic therapy.

What's the evidence

For aspiration risk with common medications? A 2017 retrospective cohort of 140,000 admissions found that antipsychotic use was associated with a significantly greater risk of aspiration (adjusted odds ration 1.5) in hospitalized elderly patients. In general, watch out for anything that can interfere with swallowing, including sedatives, antipsychotics, and antihistamines in elderly or high risk patients.

What your bioinformatics friends are talking about

Thumbs up for personalized medicine. Thumbs down for China’s use of DNA collection techniques to track and label members of the Uighur ethnic group. 

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