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June 3, 2016

Resistance

The story

The CDC is on the hunt this week. Its target: a colistin-resistant superbug in Pennsylvania.

The basics

Resistant bugs are on the rise, and there's a dearth of new antibiotics to treat them. Resistant bacteria infect about 2 million patients per year and cause about 20,000 deaths. Ceftaroline, the last major antibiotic to come to market, debuted in 2011.

The bug

The resistant E. coli bacteria were found in a urine sample from a Pennsylvania woman. The mcr-1 gene makes the bacteria resistant to colistin, a member of the polymyxin family and a last-resort antibiotic for multi-drug resistant bugs. Because the mcr-1 gene is on a plasmid, it can be shared easily with other bacteria. The woman's urine did not carry the dreaded carbapenem-resistant Enterobacteriaceae, a group of bacteria often treated with polymyxin.
Antimicrob Agents Chemother

The hunt

The CDC is interviewing close contacts of the Pennsylvania woman, who has no symptoms of systemic infection as of writing. They're also setting up regional labs to search for, detect, and study antibiotic resistance beginning in fall 2016. Among the unsolved mysteries is how the bacteria, first discovered in China in 2015, found its way to Pennsylvania.

The takeaway

Expect the CDC to take all measures to keep the superbug quarantined. In the meantime, pay attention to your ID attendings when they discuss antibiotic stewardship and handwashing.

Say it on rounds

When you leave walk-in clinic with a headache

Maybe check your blood pressure. A prospective cohort study of 17,000 women found migraines to be associated with a 50% increased risk of cardiovascular events – defined as myocardial infarction, stroke, or fatal cardiovascular disease – over 20 years of follow-up. The underlying pathophysiology remains unclear, but the investigators say doctors should pay close attention to cardiovascular disease risk factors in migraine patients.
BMJ

When your STAT order is blocked by a Foley alert

Medicare penalizes hospitals with high catheter-associated UTI (CAUTI) rates, so it's no surprise that the hospital wants you to think carefully about Foley use. A study in 603 US hospitals over 14 months looked at CAUTI rates before and after implementation of a complex intervention based around education and daily assessments of catheter necessity. The intervention decreased CAUTI rates by 32% in non-ICUs, but failed to decrease ICU CAUTI rates. This video gives a quick summary.
NEJM

When your clinic patient tells you about her nursing home dance party

Get low. A preplanned subgroup analysis of elderly patients in the SPRINT trial found that the trial's main findings – decreased rates of cardiovascular events for intensive (SBP goal < 120 mm Hg) vs. standard (SBP goal < 140 mm Hg) blood pressure control – also apply to ambulatory patients aged > 75 years. Be careful not to generalize, since patients with frailty, diabetes, stroke, heart failure, and others were excluded from participating.
JAMA

Brush up

The DOSE Trial

The DOSE trial of 2011 evaluated diuretic dosing strategies in patients with acute decompensated heart failure. Mega-doses of intravenous furosemide (2.5x the participant's home oral dose) gave patients greater symptomatic improvement but prompted higher rates of transient acute kidney injury when compared to a more conservative dosing strategy. The trial found no difference between drip vs. bolus infusions, though critics note that bolus doses were not given prior to beginning drip diuretics.

Get meta

With drip vs. bolus diuretic dosing. A 2014 meta-analysis of 15 adult studies found that bolus furosemide dosing followed by continuous infusion increased urine output by about 300 mL / day relative to bolus dosing alone. While frequent monitoring of urine output and the careful adjustment of dosing intervals can make bolus dosing as effective as a drip, drip advocates say drip dosing may be more practical for busy residents.

What your geriatrics friends are talking about

Dr. Heimlich. The dude's still got it at age 96, rescuing a diner from hamburger catastrophe at his senior residence home.

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