I recently gave an “ID Updates” lecture at AAEM’s Scientific Assembly in Las Vegas, February 2016. Here are the top 10 pearls from my lecture. Some may be review, some more cutting edge. Enjoy!
- Use ultrasound to help guide diagnosis and management of suspected skin and soft tissue abscesses
The literature is mixed on this one but it makes sense to use ultrasound. Ultrasound seems to increase your diagnostic sensitivity and may affect management, especially in those “gray zone cases”. If you are feeling ambitious, use ultrasound after I & D to assess the success of your I & D. Plus, it’s pretty easy to do!
- Although guidelines still recommend solely I & D as the treatment of choice for simple skin and soft tissue abscesses, maybe antibiotics are not so bad!
A recent trial from Talan et al. from NEJM supports the use of antibiotics in skin and soft tissue abscesses. Antibiotics increased clinical cure and decreased complications. The knock on this trial is the included patients would have received antibiotics anyway based on disease severity; nonetheless, antibiotics benefitted patients with little harm.
- First line treatment for suspected sexually transmitted infections (cervicitis, urethritis) is dual therapy Ceftriaxone 250 mg IM and Azithromycin 1 gram po.
Cefixime used to be a first line alternative (instead of Ceftriaxone), however, it is no longer with increasing resistance patterns. Bottom line—give dual therapy! Consider challenging patients who have a PCN allergy with Ceftriaxone. If you’re not going to give dual therapy with Ceftriaxone/Azithromycin, the reason better be good!
- Newest GI recommendations state that antibiotics probably do not reduce symptom duration for uncomplicated CT proven diverticulitis.
Yes, I said it—no antibiotics for acute uncomplicated diverticulitis! Certainly, we would like to see more literature in this area, but the literature we do have show antibiotics do not improve symptoms. Antibiotics may however decrease complications, as per the guidelines. I’d like to see more here, but check out the references and see for yourself.
- Non-operative management of appendicitis is an option.
We’re not here yet in the U.S. but they are in Europe. In the newest Lancet study, 73% of patients who received non-operative management did not require an appendectomy out to one year. Those that failed non-operative management did not have complications of sepsis, abscess, or rupture compared to the operative group. The theory for non-operative management is not all appendicitis is an obstructive process that requires removal; some may respond to medical therapy.
- Timing of antibiotics does not reduce mortality from severe sepsis/septic shock.
CMS dictates we administer antibiotics within 3 hours of diagnosing severe sepsis/septic shock in the ED. It’s a core measure we need to meet. But it does not reduce mortality per a recent systematic review from Critical Care. Timing of antibiotics may be important, but antibiotic selection is probably more important.
- Irrigation pressures do not matter in the management of open fractures.
In the OR, whether patients with open fractures get very low pressure, low pressure, or high pressure irrigation, re-op rates are the same!
- Consider use of corticosteroids in inpatients with pneumonia.
Adjunctive prednisone in pneumonia reduced inpatient stay.
- It is thought that Strep sp. are the predominant organisms in cellulitis. But maybe not!
If Bactrim works as well as Clinda, Strep may not be the king organism in undifferentiated skin and soft tissue infections. Check out the reference.
- Respect lactate!
We know lactate is not specific. But in the setting of infection or suspected sepsis, respect it if it is positive, even if in the intermediate range. Intermediate level lactates had a 30 day mortality of 15%.
Post by: Nilesh Patel, DO (@nnpatel1291)