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Journal Club

Journal Club. Updates in Infectious Diseases, Sept 2013 Dr. Katy Thompson Preceptor: Dr. David Coleman. Case #1. 54 yo F presents with 8 days of runny nose, productive of yellow purulent secretions, and maxillary tenderness Which medications would you offer?

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Journal Club

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

  2. Case #1 • 54 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?

  3. 1/5 antibiotics in US is given for sinusitis • To limit resistance, this antibiotic use should be evidence-based

  4. Amoxicillin for Acute Rhinosinusitis • RCT • 166 adults • Uncomplicated, acute rhinosinusitis. • Definition: • Maxillary pain or tenderness • Purulent nasal secretions • Rhinosinusitis symptoms for 7-28 days • 10 community-based PCP offices

  5. Amoxicillin for Acute Rhinosinusitis • All patients received 1 week supply of supportive tx for pain, fever, cough, nasal congestion: • Tylenol 500 mg q6h PRN pain, fever • Guaifenesin 600 mg q12h • Dextromethorphan/guaifenesin 10 mL q4-6h • Pseudoephedrine 120 mg q12h • 0.65% saline nasal spray • Treatment for 10 days: • Amoxicillin 500 mg tid • Vs. Placebo

  6. Amoxicillin for Acute Rhinosinusitis • Outcome: • Symptomatic improvement- Y/N • SNOT16 = Sinonasal Outcome Test-16 • Zero = no problem to 3 = severe problem • Need to blow nose • Reduced productivity • Ear fullness • Headache • Sneezing

  7. Amoxicillin for Acute Rhinosinusitis • 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%.

  8. Amoxicillin for Acute Rhinosinusitis • 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)

  9. Amoxicillin for Acute Rhinosinusitis • Limitations?

  10. Limitations • No 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

  11. Case #1 • 54 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?

  12. Case #2 • 68M with HTN, DM, CHF presents due to a cough for 2 weeks. She is requesting a Z pack. • What do you tell her?

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

  14. 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

  15. Azithromycin and CV Death • Azithromycin – 347,795 • Amoxicillin – 1,348,672 • No Rx – 1,391,180

  16. Azithromycin and CV Death • Endpoint: • CV death • Death from any cause

  17. Azithromycin and CV Death • 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

  18. Azithromycin and CV Death • Cautions: • Relative risk vs. absolute risk • Retrospective administrative databases- incomplete clinical information

  19. Case #2 • 68M with HTN, DM, CHF presents due to a cough for 2 weeks. She is requesting a Z pack. • What do you tell her?

  20. Case #3 • ED 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?

  21. Asymptomatic Bacteruria • Relevance • Studies showing that if you have asymptomatic bacteruria, you’re more likely to develop a symptomatic UTI

  22. Asymptomatic Bacteruria • 18 - 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

  23. Asymptomatic Bacteruria • Randomized 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

  24. Asymptomatic Bacteruria • Symptomatic UTIs • 3 months • Untreated 3.5% vs. treated 8.8% • 6 months • Untreated 7.6% vs. treated 29.7% • 12 months • Untreated 14.7% vs. treated 73.1%

  25. Asymptomatic Bacteruria • Limitations?

  26. Asymptomatic Bacteruria • Cautions: • Limited study population • STD symptoms vs. UTI symptoms

  27. Asymptomatic Bacteruria • Distortion of native ecology by giving antibiotics • Antibiotic resistance versus virulence

  28. 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 tenofovir • 1579 took tenofovir-emtricitabine • 1584 took placebo

  29. Daily Post-Exposure Ppx in HIV Discordant Couples • 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

  30. Daily Post-Exposure Ppx in HIV Discordant Couples • 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)

  31. Daily Post-Exposure Ppx in HIV Discordant Couples • What’s wrong with this study?

  32. Daily Post-Exposure Ppx in HIV Discordant Couples • 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

  33. Daily Post-Exposure Ppx in HIV Discordant Couples • 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)

  34. Thanks for your attention!

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