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ACEP Now: Vol 36 – No 10 – October 2017

ILLUSTRATION: Chris Whissen & shutterstock.com

Twelve months ago, I highlighted some of the most impactful, talked-aboutStaphylococcus aureus , or interesting articles published across the spectrum of medical journals rolling into 2016. Another year has passed, and it’s time to revisit our ever-growing list before the literature cup runneth over. As always, it is impossible to cover every important article or to cover them in the detail they deserve. Let this serve as a jumping-off point into the maelstrom, but I always encourage you to visit the primary source before making changes to your practice.

Clinical Trial: Comparative Effectiveness of Cephalexin Plus Trimethoprim-Sulfamethoxazole Versus Cephalexin Alone for Treatment of Uncomplicated Cellulitis: A Randomized Controlled Trial¹

It’s been fairly common practice in the age of community-associated methicillin-resistant Staphylococcus aureus to treat non-purulent cellulitis with two antibiotics in order to cover the full range of possible pathogens. This fairly straightforward clinical trial tested the combination of cephalexin plus trimethoprim-sulfamethoxazole (TMP-SMX) versus cephalexin monotherapy. No differences were observed with regard to treatment cure rates, and no specific clinical features predicted failure.

A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses²

Curative treatment for large skin abscesses, those greater than 5 cm in diameter, has been shown to benefit from adjunctive antibiotic coverage. This trial found some of these benefits extend to smaller skin abscesses, although even these “smaller” abscesses still averaged 3 cm in diameter, with surrounding cellulitis of 6 cm. Clindamycin displayed slightly better efficacy than TMP-SMX but also a greater number of adverse events.

Women with Symptoms of a Urinary Tract Infection but a Negative Urine Culture: PCR-Based Quantification of Escherichia Coli Suggests Infection in Most Cases³

The default mode of action in primary care is to treat the symptoms of cystitis as a urinary tract infection, typically without a urinalysis or a urine culture. However, this practice has been called into question because 20 percent to 30 percent of symptomatic patients ultimately have a negative urine culture. These authors performed a polymerase chain reaction–based analysis for uropathogens and found most of these negative urine cultures are false negatives, and we should treat those with symptoms regardless.

Time to Treatment and Mortality During Mandated Emergency Care for Sepsis⁴

New York state requires hospitals to report data regarding the outcomes of patients with severe sepsis and septic shock. A retrospective evaluation of these data shows an apparent small mortality benefit relating to timeliness of administration of antibiotics and completion of a three-hour sepsis bundle (odds ratio 1.04 per hour for mortality). While any effect on mortality is important, the small magnitude of benefit in even these sickest patients suggests diminishing returns for the resources expended to aggressively seek out and empirically treat potential sepsis candidates.

Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock⁵

This is supposedly the next great thing in sepsis, virtually a combination of over-the-counter supplements administered intravenously to those with severe sepsis and septic shock. Mortality in the untreated group was 40.4 percent compared with 8.5 percent in the treatment group. Unfortunately, this is only a before-and-after case series, and the evidence is not strong enough to change practice. Prospective, controlled trials are eagerly anticipated.

Safety of Computer Interpretations of Normal Triage Electrocardiograms⁶

The electrocardiogram (ECG) is a prime culprit behind physician interruptions in the emergency department. Virtually every chief complaint, from chest pain to pelvic pain, seems to be an indication for a triage ECG. About a quarter of these are unequivocally normal, with good agreement between physicians and the automated computer algorithms. Physicians should ultimately interpret each ECG in the context of patient care, but there is no value in interrupting a physician simply to review an ECG if it’s read by the computer as normal.

Cardiovascular Testing and Clinical Outcomes in Emergency Department Patients with Chest Pain⁷

This is another piece of evidence showing the pendulum swing for the management of patients with chest pain. A decade ago, patients with chest pain absolutely needed to have provocative testing immediately, if possible, lest they bounce back dead from myocardial infarction. This review evaluates the effect on downstream outcomes between those who fortuitously (or not) received urgent stress testing after being seen in the emergency department and those who did not. No mortality benefit was identified. Prospective trials testing the utility of routine stress testing are planned.

Be sure to read next month’s issue for Part 2 of our literature highlights.

References

1. Moran GJ, Krishnadasan A, Mower WR, et al. Effect of cephalexin plus trimethoprim-sulfamethoxazole vs cephalexin alone on clinical cure of uncomplicated cellulitis: a randomized clinical trial. JAMA. 2017;317(20):2088-2096.
2. Daum RS, Miller LG, Immergluck L, et al. A placebo-controlled trial of antibiotics for smaller skin abscesses. N Engl J Med. 2017;376(26):2545-2555.
3. Heytens S, De Sutter A, Coorevits L, et al. Women with symptoms of a urinary tract infection but a negative urine culture: PCR-based quantification of Escherichia coli suggests infection in most cases. Clin Microbiol Infect. 2017;23(9):647-652.
4. Seymour CW, Gesten F, Prescott HC, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med. 2017;376(23):2235-2244.
5. Marik PE, Khangoora V, Rivera R, et al. Hydrocortisone, vitamin C, and thiamine for the treatment of severe sepsis and septic shock: a retrospective before-after study. Chest. 2017;151(6):1229-1238.
6. Hughes KE, Lewis SM, Katz L, et al. Safety of computer interpretation of normal triage electrocardiograms. Acad Emerg Med. 2017;24(1):120-124.
7. Sandhu AT, Heidenreich PA, Bhattacharya J, et al. Cardiovascular testing and clinical outcomes in emergency department patients with chest pain. JAMA Intern Med. 2017;177(8):1175-1182.