Tidings from the Citadel: Warfarin in Dialysis

Warfarin Use and the Risk for Stroke and Bleeding in Patients With Atrial Fibrillation Undergoing Dialysis – Mitesh Shah et al. Circulation. 2014;129:1196-1203.

A retrospective cohort study

Population based cohort of patients > 65 years who were admitted in Canada – Quebec and Ontario with a primary or secondary diagnosis of atrial fibrillation. Used ICD-9/10 codes to determine diagnosis and complications such as bleeding and stroke complications. Drug prescriptions were identified by database in Canada where patients > 65 have prescription benefit. Warfarin use was identified by a filled prescription within 30-days of AF diagnosis

Patients
626 dialysis patients and 204,210 nondialysis patients. Did not separate by stages of CKD, but rather HD or non-HD. Dialysis patients were younger, male, CHF, HTN, DM, CAD, and bleeding history.

Dialysis vs Non-Dialysis: CHADS2 >/= 2: 72% versus 55% (indication for anti-coagulation); HAS-BLED >/=3: 85% versus 25%. Similar rates of warfarin prescription (46% vs 51%)

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Stroke
In non-dialysis patients, warfarin users had a lower incidence of stroke (2.19 vs 2.51/100 person-years)

In dialysis patients, stroke incidence was similar for warfarin and non-warfarin users: 3.37 versus 2.91/100 person-years.

After adjusting for confounders – warfarin use had a HR of 1.14 in diaylsis patients. While in non-dialysis patients had a HR 0.87 with warfarin use.

Bleeding
After adjusting for confounders, warfarin use, was associated with a 44% higher risk for bleeding event in dialysis patients and 19% higher risk in nondialysis patients.

 

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Tidings from the Citadel: Accuracy of Lung Ultrasonography in the Diagnosis of Pneumonia

16 studies were included – significant heterogeneity, but of 2359 patients. Heterogeneity was assessed graphically and with a Q test. The Q test should only be used once in a data set to exclude outliers. The reference standard, we considered it to be of high quality if based on CT alone or when it consisted of a final diagnosis made by experts using an integrated synthesis of radiology and laboratory or microbiological data (or both).

The highest risk of bias stemmed from the flow of patients within each study because of an uneven application of the reference test (differential verification bias).

The dispersion of studies in the ROC plane suggests marked heterogeneity.
The 95% CI of the overall effect indicates a sensitivity of approximately 80% to 90% and a specificity of 70% to 90%.

References:
Accuracy of Lung Ultrasonography in the Diagnosis of Pneumonia in Adults: Systematic Review and Meta-Analysis – Ana M. Llamas-Álvarez, MD; Eva M. Tenza-Lozano, MD; and Jaime Latour-Pérez, MD, PhD; . Chest 2017; 151(2):374-382

Tidings from the Citadel: Duration of therapy for vertebral body osteomyelitis

6 weeks of antibiotic treatment is not inferior to 12 weeks of antibiotic treatment for clinical cure at 1 year in pyogenic vertebral osteomyelitis.

This was a study where the attending decided which antibiotic to prescribe. Some concerns of bias were allayed by the similar antibiotic prescription between the 2 groups. Clinical cure was defined as the absence of fever, pain, and inflammatory syndrome at 1 y after treatment. 19% of patients were lost to follow up. Only 18% of patients had MRSA, in some centers this number is much higher, so keep that in mind when using the results of this study. The authors found similar rates of clinical cure, clinical cure + alive, and clinical cure without needing more antibiotics. Adverse events rate were similar between the groups. Thus they deemed 6 weeks non-inferior to 12 weeks.

This was a pragmatic study design with adequate retention of participants. Similar antibiotics were prescribed and the adjudicators were blinded. It seems logical that fewer antibiotics would lead to cost savings and decrease drug resistance (though this study did not show either), 6 weeks of antibiotics is typical unless there are compelling reasons otherwise.

Reference:
Antibiotic treatment for 6 weeks versus 12 weeks in patients with pyogenic vertebral osteomyelitis: an open-label, non-inferiority, randomised, controlled trial. Bernard, Louis et al. The Lancet , Volume 385 , Issue 9971 , 875 – 882. 7 March 2015

 

Tidings from the Citadel: Restarting ART in Patients with OIs

Concern over overlapping toxicities, pill burden, and drug interactions led some clinicians to delay ART initiation in patients with AIDS-related OI. This study demonstrates that initiating early ART is beneficial.
282 patients with CD4 <200 and AIDs-related OI or severe bacterial infection randomized to early ART within 14 days or deferred ART that started after 4 weeks. Improved AIDs illnesses or deaths. The study population consisted predominantly of patients with Pneumocystis pneumonia (63%), cryptococcal meningitis (12%), and AIDS-associated bacterial infections (12%).
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The actual timing of when ARTs were started was 12 vs 45 days, which argues for starting ARTs within 2 weeks and not immediately.
No difference in the occurrence of IRIS (6 vs 9%).
Keywords:
#Early #HIV #Opportunistic infections #Retroviral Therapy #ART #pneumocystis #OI #HAART #Mortality
Reference:
Early Antiretroviral Therapy Reduces AIDS Progression/ Death in Individuals with Acute Opportunistic Infections: A Multicenter Randomized Strategy Trial – Zolopa AR, Andersen J, Komarow L, Sanne I, Sanchez A, et al. PLoS ONE 2009 4(5): e5575.

Tidings from the Citadel: Vancomycin Taper versus Fecal Transplant for Recurrent C Diff

Oral Vancomycin Followed by Fecal Transplantation Versus Tapering Oral Vancomycin Treatment for Recurrent Clostridium difficile Infection: An Open-Label, Randomized Controlled Trial – Susy S. Hota  Valerie Sales  George Tomlinson  Mary Jane Salpeter  Allison McGeer  Bryan Coburn David S. Guttman  Donald E. Low  Susan M. Poutanen  Clin Infect Dis 2017 Feb 1; 64:272

 
Small trial of 30 patients assess 14 days of PO vanc followed by a FMT by enema versus 6-week taper of PO vanc. Primary endpoint was c diff recurrence within 120 days. 56.2% in the fecal transplant and 41.7% in the vanc taper arms had recurrence. 5 patients in the fecal transplant arm had recurrence within 7 days.
No significant difference and the trial was stopped early. Similar rates of adverse events.
Keywords:
#recurrent #cdiff #clostridium #difficile #Vanc #taper #fecal #transplant