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Oct 20, 2017

A day late and a dollar short, but here it is, the Ercast summer Journal Club. As per usual, boy genius Adam Rowh, MD is in the house to give his take on the medical literature. In this episode, we discuss

  • Cervical spine clearance in the intoxicated patient (can you remove the collar if they have a negative CT?)
  • Is there utility to giving antibiotics to patients with simple cutaneous abscess?
  • Thrombolytics don't give long term benefit to patients with submissive pulmonary embolism
  • Haloperidol is good for what ails you (if you have gastroparesis)
  • Steroids for bronchitis

Also mentioned in this show

  • Boneyard RPM IPA
  • Follow us on Facebook. It's the new information portal for updates, questions, etc. If you want to contact me personally, use the contact link on this webstie
  • Now on to the education....


Do patients with simple abscesses need antibiotics?

The answer for much of the antibiotic era has been no. I and D is sufficient treatment. But with the rise of MRSA, that thinking has been questioned. A paper by Talan in 2016 investigating TMP-Sulfa vs placebo for uncomplicated skin abscess suggested that TMP-Sulfa conferred a higher cure rate after I and D. Now comes a study of similar ilk but an additional treatment arm.

Study Basics

  • Title: Daum, Robert S., et al. "A placebo-controlled trial of antibiotics for smaller skin abscesses." New England Journal of Medicine376.26 (2017): 2545-2555.PMID: 28657870
  • The patients: 786 patients with abscesses 5 cm diameter or less.
  • The treatment: After I and D placebo, patients received either placebo, clindamycin, or TMP-Sulfa
  • Primary endpoint: Clinical cure. This includes improvement of the treated abscess but ALSO no new abscesses forming elsewhere (that will come into play later)
  • The results: Compared to placebo, both clindamycin and TMP-Sulfa improved short-term outcome. Clinical cure was 83% clinda, 81% TMP-Sulfa, and 69% placebo. NNT of 8. There was not much difference between the different antibiotics, but big a difference compared to placebo

Looking under the hood (examining the details)

  • Treatment effect was only when staph was the culprit. When there was no staph isolated, the outcome was not influenced by antibiotics
  • Average surrounding erythema was over 2cm. This suggests that there was some cellulitis in these patients. Prior to this study, the common practice was to treat these patients with antibiotics. We recognize that it's not always easy to delineate between redness from the abscess itself and spreading cellulitis. Our point of contention, that these abscesses also had cellulitis, may be making a big deal out of a small thing (or it could be the most legitimate criticism of the paper).
  • Treatment failure was mostly formation of new abscess and not worsening of the original abscess. While this is certainly a measurable effect, is it really a treatment failure? We argue that it is not. What's probably happening here is decolonization on some level. That is pure conjecture, of course, and it's certainly possible that there was autioinfection from the main abscess. 
  • Our bias:  We don’t want to give extra antibiotics. Coming into this paper, we were looking for any faults in the study that could confirm an 'antibiotic stewardship' approach.  If this was a paper showing even a small benefit for thrombolysis in the treatment of pulmonary embolism, we would look at in the exact opposite manner-where is the signal of benefit that says we might help patients.  
  • Will this change our management? Both Rob and Adam say it will not. We will continue to treat simple cutaneous abscesses (without surrounding erythema) with I and D alone. If the abscess is a recurrence or it is a patient with multiple abscesses, we will consider antibiotics.


C-spine clearance in the intoxicated patient

An intoxicated patient with moderate trauma has a pristine looking, completely normal, CT of the cervical spine. Do we need them to continue wearing their cervical collar until clinical sobriety? Enter our next study

Study Basics

  • Title: Schreiber, Martin, et al. "Cervical spine evaluation and clearance in the intoxicated patient: a prospective western trauma association multi-institutional trial and survey." (2017). PMID: 28723840
  • The patients: About 10,000 moderate trauma patients, of who approx  3000 were TOX positive  (alcohol, drugs, or both). The average injury severity score was 11 (moderate trauma).
  • Intervention: CT cervical spine
  • Primary outcomes: Incidence and type of cervical spine injuries, accuracy of CT scan, and the impact of TOX+ on the time to cervical spine clearance
  • The results: In the TOX positive  group, CT had a sens=94%, spec=99.5%, and NPV=99.5% for all Csp injuries. For clinically significant injuries, the NPV was 99.9%, and there were no unstable cervical spine injuries missed by CT (NPV=100%). One patient in the Tox + but CT negative group had a central cord injury. When CT cervical spine was negative, TOX + led to longer immobilization vs sober patients (mean 8 hrs vs 2 hrs, p<0.01), and prolonged immobilization (>12hrs) in 25%.
  • Author take home: CT-based clearance in TOX+ patients appears safe and may avoid unnecessary prolonged immobilization

This conclusion mirrors the EAST guidelines on cervical spine collar clearance in the obtunded adult blunt trauma patient:

In obtunded adult blunt trauma patients, we conditionally recommend cervical collar removal after a negative high-quality C-spine CT scan result alone. This conditional recommendation is based on very low-quality evidence but places a strong emphasis on the high negative predictive value of high quality CT imaging in excluding the critically important unstable C-spine injury.

Haloperidol for Vomiting

The lament for droperidol's absence from our pharmacopeia continues unabated, yet there is another shining star: haloperidol. What's old is new when it comes to treating severe nausea and vomiting. Long recognized in the palliative care world as the cat's pajamas for management of nausea, haloperidol is finally getting the recognition it deserves.

Study Basics:

The study: Ramirez, R., et al. "Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department." The American journal of emergency medicine (2017). PMID:28320545

The patients: Retrospective study of 52 patients with diabetic gastroparesis treated with 5mg IM haloperidol.

The comparator group: The SAME PATIENTS on ED visits when they didn’t get haloperidol! You can't get better matching characteristics than that.

The results: Using haloperidol in this group of patients decreased amount of opiates given and admissions but not ED or hospital length of stay. There were no complications seen in patients given haloperidol

Systemic lytics don't work for intermediate risk PE

This has been a subject of much debate over the past decade and there has been signal that there may be a benefit in function outcome when thrombolytics are given to so-called intermediate risk pulmonary emboli- not hypotensive but right ventricular dysfunction and a positive biomarker. The biggest research article to date says lytics don't improve outcome.

Study Basics

The study: Konstantinides, Stavros V., et al. "Impact of thrombolytic therapy on the long-term outcome of intermediate-risk pulmonary embolism." Journal of the American College of Cardiology 69.12 (2017): 1536-1544. PMID:28335835

The patients: About 700 patients with intermediate risk PE given either Tenecteplase of placebo. Intermediate risk PE defined as RV dysfunction confirmed by echocardiography or spiral computed tomography of the chest. Myocardial injury confirmed by a positive troponin I or T test result.

The results: At 3 year follow up, there was no significant difference in mortality, functional limitations, pulmonary HTN, or RV dysfunction.

Our take home: When we first saw this paper, we were giddy because here was evidence that would show, once and for all, that lytics were an effective treatment for this cohort. The cold hard data says quite the opposite: lytics don’t make a difference in long term outcome. The best evidence we have to date suggests that there is no justification to give systemic thrombolysis to a stable patient with intermediate risk PE. Will catheter directed lysis prove any better, or are there certain high risk groups under the 'intermediate' umbrella who would benefit? Time will tell. 


Prednisone for cough

Study Basics

The study: Hay, Alastair D., et al. "Effect of oral prednisolone on symptom duration and severity in nonasthmatic adults with acute lower respiratory tract infection: a randomized clinical trial." Jama 318.8 (2017): 721-730. PMID:28829884

The patients: 400 patients with cough for less than a month and at least 1 lower tract symptom like phlegm, chest pain, wheezing or SOB in the past day. Patients received either 40 mg of prednisolone or placebo daily for 5 days. The primary outcomes were duration of cough and mean severity of symptoms on days 2 to 4.

The results: Steroids did not make a difference

Our take home: WTF!? Of course steroids didn’t work! Only 6 percent of patients had wheezing and only a handful had crackles.  Does a patient with an undifferentiated acute viral respiratory infection benefit from steroids? Apparently not. We tend to prescribe patients to these patients who DO have wheezing, but this supports our practice of not using them in patients who don't.