STOP-IT trial: In patients with intraabdominal infections WITH source control, outcomes were similar between fixed duration (4 days) vs. duration guided by clinical improvement – 2 days after the resolution of fever, leukocytosis, and ileus (mean 8 days). Both intention to treat and per-protocol analysis found no difference. However, the study was terminated early due to funding, and only enrolled half the intended patients.
N Engl J Med 2015;372:1996-2005
- Definition: pneumonia that occurs 48 hours or more after admission and did not appear to be incubating at the time of admission.
- HCAP Removed because many patients who met criteria were in fact not at increased risk for multi-drug resistant organisms, MDROs
- Recommended antibiotics: anti-pseudomonal +/- double pseudomonal coverage +/- MRSA coverage
- MRSA Risks: abx use IV abx in past 90 days, unit where prevalence of MRSA among S. aureus isolates is not known or >20%. No recommendations regarding use of MRSA swab to guide need for MRSA coverage.
- Non-invasive Sputum cultures recommended to guide therapy
- Duration: 7 days
- New CAP guidelines (to include patients from nursing homes) are pending.
Incidence of post-ERCP pancreatitis is 3 to 5%, but can be as high as 16%
- Manipulation of the papilla or thermal injury produces papillary edema and obstruction of the pancreatic duct causing pancreatitis.
- Hydrostatic injury from overinjection of water or saline into the pancreatic duct
- Presence of a foreign material in the pancreatic duct stimulates activation of proteolytic enzymes.
- Reflux of intestinal enzymes into the pancreatic duct.
- Bacterial translocation.
A meta-analysis of 912 patients, found that patients who received NSAIDs were 64% less likely to develop pancreatitis and 90% less likely to develop moderate-severe pancreatitis. A number needed to treat (NNT) to prevent 1 episode of pancreatitis: 15.
Then an RCT of single dose rectal indomethacin or placebo in 602 patients was performed which showed PEP rates of 9.2% versus 16.9%. the use of rectal indomethacin was associated with a 7.7% absolute risk reduction (NNT 13) and a 46% relative risk reduction in PEP. A more recent trial with conflicting data – likely due to the patient population selected and use of pancreatic duct stents.
Rectal indomethacin should be considered in high risk patients.
Protease inhibitors have shown some promise, they are costly, require extremely high NNTs to prevent a single episode of PEP (gabexate 33 and ulinastatin 29)
Octreotide shows promise in preventing PEP.
Employ a wire-guided cannulation technique
Implement alternative technique early in the case in the event of difficult biliary cannulation
The “Scope” of Post-ERCP Pancreatitis by Parth J. Parekh, MD; Raj Majithia, MD; et al. Mayo Clin Proc. 2016
#GI #Pancreatitis #ERCP #post-ERCP #indeomethacin #prevention
The gold standard for diagnosing pneumocystis jirovecii pneumonia is by isolating the bug itself either by DFA or culture. This task is much harder in non-HIV patients as the organism load is much lower. This meta-analysis examined 14 studies, most were retrospective. 2 only included patients with HIV, 8 with both HIV and non-HIV patients with other types of immunosuppression, and 2 with non-HIV immunosuppressed patients.
Using this pool of studies, the authors found that Fungitell had excellent sensitivity 95%, very good specificity 86%, and AUC of 97%.
+ LR 6.9 (5.1–9.3)
– LR 0.06 (0.03–0.11)
The p-value for heterogeneity was 0.31. Two studies lie clearly out of the 95% ellipse.
In cases where obtaining microbiologic samples is impossible, dangerous, or even too difficult – BD glucans may be a way to empirically treat patients with some confidence.
The BNP test alone was more accurate than any history or physical exam finding in predicting CHF as the cause of dyspnea. One must remember that BNP has a range of NPV and PPV depending on the value and you shouldn’t use a single cut point in making clinical decisions.
Breathing Not Properly Study: N Engl J Med 2002; 347:161-167 http://www.nejm.org/doi/full/10.1056/NEJMoa020233#t=abstract
AASLD Practice Guidelines:
Bleeding from paracentesis is relatively uncommon. The routine use of FFP or platelet transfusion is not recommended before paracentesis. You should avoid any engorged veins as most bleeding occurs from the venous circulation.
It may be reasonable to correct patients who have bled before with paracentesis, have hyperfibrinolysis (as they wouldn’t be able to clot effectively due to factor depletion), patients with evidence of overt bleeding from mucosa (epistaxis, vaginal bleeding, etc), or have history of bleeding at puncture sites (like IVs or blood draws).
“Management of adult patients with ascites due to cirrhosis: an update.” Runyon BA. Hepatology. 2009;49(6):2087
You can check factor VIII levels because they tend to be normal to increased in liver disease as it is not produced by the liver, but rather endothelial cells. In DIC all of the factors are consumed, so factor VIII levels will be low.
The other test that maybe helpful is checking a d-dimer. The d-dimer tends to be significantly increased in DIC due to profound fibrinolysis. However, d-dimer levels may also be elevated in liver disease, but usually only mildly elevated.