June 8, 2017

Background: Cellulitis is a common emergency department (ED) presentation. Despite the fact that diagnosis remains relatively straight forward, complexity remains in management in terms of the causative agent and appropriate antibiotic regimen. Though beta-hemolytic Streptococci are the most common causative agents there is increasing prevalence of community acquired methicillin-resistant Staphylococcus aureus (MRSA). Cephalexin has long been used to treat uncomplicated cellulitis because of it’s activity against streptococci and methicillin-sensitive S. aureus (MSSA). Despite the current Infectious Disease Society of America (IDSA) recommendations against routine coverage of MRSA, trimethoprim-sulfamethoxazole (TMP-SMX) is often added to cephalexin (Stephens 2014). While there are other single options for coverage, they either have suboptimal MRSA coverage (i.e. clindamycin and doxycycline) or are more expensive (i.e. linezolid). Without reliable ways to determine which patients need MRSA coverage, it is unclear which patients with uncomplicated cellulitis need to be discharged with MRSA coverage and which will do fine with a single agent.

June 5, 2017

The Background: Nearly 50% of patients in the U.S. with cirrhotic liver disease develop ascites over a 10-year period of observation, placing them at risk for developing spontaneous bacterial peritonitis (SBP) (Runyon 2012). It is estimated that 12-25% of patients with ascites in the ED will have spontaneous bacterial peritonitis (SBP) but the classic triad of fever, abdominal pain, and worsening ascites is often absent (Borzio 2001)(Runyon 1988). With a mortality rate approaching 40%, rapid diagnosis and evidence-based treatment is critical in the management of patients presenting with SBP (Salerno 2013).

SBP is diagnosed via cell count and differential of ascitic fluid obtained by paracentesis demonstrating an elevated polymorphonuclear leukocyte (PMN) count ( 250 cells/mm3). Treatment focuses on appropriate antibiotic therapy. A third-generation cephalosporin is the treatment of choice as they are typically effective in covering the three most common isolates from infected ascitic fluid: Escherichia coli, Klebsiella pneumonia, and Streptococcus pneumonia (Runyon 2012). Intravenous albumin administration is often added to the management of these patients but the utility for improving morbidity and mortality is questionable. The benefit of albumin infusion in SBP is not entirely known, although multiple possible mechanisms have been identified. Albumin has been demonstrated to mitigate endotoxemia, block lipopolysaccharide-stimulated neutrophil activity, and modulate nitric oxide activity, mitigating systemic vasodilation and capillary leak (Salerno 2013).

May 1, 2017

Background: Just a few months ago the surviving sepsis campaign published their international guidelines for management of sepsis and septic shock [1].  There has been a lot of talk in the FOAM world about sepsis 3.0 and this is the first update since the introduction. This was a 67 page document that made a total of 93 statements on the early management and resuscitation of patients with sepsis or septic shock.  1/3 of the statements were strong recommendations and just over 1/3 were weak recommendations. Instead of going through every component of this document, we thought we would discuss one of the potentially biggest components of sepsis care that  would affect clinical practice for those of us on the front lines. One of the main reasons we have seen a mortality decrease in sepsis overtime is due to the proactive nature health care professionals have taken in sepsis management.  The so called ABC’s of sepsis management: Early identification, Early fluids, and Early antibiotics. One of the biggest components of this is early identification of these patients.

REBEL Review 80: Oseltamivir (Tamiflu) for Treatment of Influenza

Created April 10, 2017 | Infectious Disease | DOWNLOAD

April 7, 2017

Background: The overall mortality in sepsis has decreased quite a bit in the last decade or so, however for a subset of patients, like those with Septic Shock, the mortality still remains high (as high as 50%).  There have been hundreds of studies trying to identify the holy grail to decrease mortality further, but one has not been found thus far.  Marik PE et al [1] published a study in Chest 2016 that has found a potential front runner.  In addition, the authors go on to say, in order to have an impact on a global scale, treatments would not only need to be effective, but also cheap, safe, and readily available; the authors of the following paper may have found just that..
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