Podcasts about ceftriaxone

CDC and the World Health Organization consider Neisseria gonorrhoeae an urgent antibiotic-resistant threat because it continuously develops resistance. Microbiologist and Associate Professor at the University of Washington Dr. Olusegun Soge provides a historical overview of past efforts, an update on the current situation, why global surveillance is so important, and a potential new treatment for uncomplicated gonorrhea. View episode transcript at www.std.uw.edu.This podcast is dedicated to an STD [sexually transmitted disease] review for health care professionals who are interested in remaining up-to-date on the diagnosis, management, and prevention of STDs. Editor and host Dr. Meena Ramchandani is an Assistant Professor of Medicine at the University of Washington (UW), Program Director of the UW Infectious Diseases Fellowship Program, and Associate Editor of the National STD Curriculum.  

On episode #76 of the Infectious Disease Puscast, Daniel and Sara review the infectious disease literature for the weeks of 2/27/25 – 3/12/25. Hosts: Daniel Griffin and Sara Dong Subscribe (free): Apple Podcasts, RSS, email Become a patron of Puscast! Links for this episode Viral Trends in respiratory pathogen testing at us children's hospitals (JAMA Network) Changes in respiratory viral testing before and after the covid-19 pandemic(JAMA Network) Expanding measles outbreak in the United States and guidance for the upcoming travel season (CDC Emergerncy Preparedness and Response) Measles cases and outbreaks (CDC Measles (Rubeola)) Facts and myths about measles (LANCET: Infectious Diseases) Protective effects of recombinant zoster vaccine and antiviral therapy against cardiovascular disease following herpes zoster infection (JID) Chikungunya vaccine information for healthcare providers (CDC Chikungunya Virus) Factors to assess when considering use of chikungunya vaccine(CDC) Bacterial Should patients hospitalized forcommunity-acquired pneumonia be treated with additional antimicrobial agents directed against anaerobes? (American Journal of Therapeutics) Antibiotic-induced loss of gut microbiome metabolic output correlates with clinical responses to CAR T-cell therapy(Blood) Effectiveness of ampicillin/sulbactam versus ceftriaxone for the initial treatment of community-acquired pneumonia in older adults: a target trial emulation study(OFID) Male-partner treatment to prevent recurrence of bacterial vaginosis(NEJM) Fungal The Last of US Season 2 (YouTube) Activity of rezafungin against echinocandin non–wild type candida glabrata clinical isolates from a global surveillance program (OFID) Are contemporary antifungal doses sufficient for critically ill patients? Outcomes from an international, multicenter pharmacokinetics study for Screening Antifungal Exposure in Intensive Care Units—the SAFE-ICU study  (Intensive Care Medicine) Parasitic Human alveolar echinococcosis – global, regional and national annual incidence and prevalence rates (CMI: Clinical Microbiology and Infection) Dust to Diagnosis – with MSGERC (FEBRILE) The clinical picture caused by Fasciola gigantica: Analysis of 3,250 patients along the 1995–2019 countrywide spread in Vietnam (OFID) Miscellaneous Reprint of: From medical editors: a call to the global infectious diseases and clinical microbiology community (CMI: Clinical Microbiology and Infection) A hot topic: A climate-focused track for infectious disease fellowship (OFID) Are we being gaslit? A primer for recognizing corporate jargon to overcome gaslighting for the infectious disease workforce (CID) Music is by Ronald Jenkees Information on this podcast should not be considered as medical advice.

MCHD recently rolled out Ceftriaxone for long-bone open fracture care. The podcast crew welcomes our new assistant medical director, Dr. Mike DePasquale, to discuss some background evidence and danger spots within this protocol. REFERENCES: Lack, W. D., Karunakar, M. A., Angerame, M. R., Seymour, R. B., Sims, S., Kellam, J. F., & Bosse, M. J. (2015). Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection. Journal of orthopaedic trauma, 29(1), 1–6. Johnson, J. P., Oliphant, B. W., Dodd, J., Duckworth, R. L., Goodloe, J. M., Lyng, J. W., Sagraves, S. G., & Fischer, P. E. (2024). Prehospital Antibiotic Administration for Suspected Open Fractures: Joint COT/OTA/ACEP/NAEMSP/NAEMT Position Statement. Prehospital emergency care, 28(8), 1063–1067. Muniz, A. D., Gregorio, D. J., Studebaker, S. A., Peth, A. M., Camacho, C. G., Williams, B., Kupas, D. F., & Brown, L. H. (2024). Time Savings and Safety of EMS Administration of Antibiotics for Open Fractures. Prehospital emergency care, 28(8), 1046–1052.

In this episode of Hot Topics, Dr. Nicholas Morris interviews Claire Dahyot-Fizelier, M.D, Ph.D., a professor of anesthesia and intensive care at the University of Poitiers, to explore the groundbreaking PROPHY-VAP trial published in The Lancet Respiratory Medicine. This landmark study investigates the impact of single-dose ceftriaxone prophylaxis on ventilator-associated pneumonia (VAP) in acute brain injury patients. Dr. Dahyot-Fizelier discusses the rationale behind the study, key findings and the broader implications for ICU practices. Tune in to discover how this trial could reshape approaches to infection prevention and improve patient outcomes in neurocritical care. Show notes: https://doi.org/10.1016/S2213-2600(23)00471-X Dahyot-Fizelier C, Lasocki S, Kerforne T, Perrigault PF, Geeraerts T, Asehnoune K, Cinotti R, Launey Y, Cottenceau V, Laffon M, Gaillard T, Boisson M, Aleyrat C, Frasca D, Mimoz O, on behalf of the PROPHY-VAP Study Group and the ATLANREA Study Group. Ceftriaxone to prevent early ventilator-associated pneumonia in patients with acute brain injury: a multicentre, randomised, double-blind, placebo-controlled, assessor-masked superiority trial. The Lancet Respiratory Medicine. 2024 May 1;12(5):375-85.

Happy April! This month for the April 2024 episode of the RCEM Learning Podcast Rob and Liz have got two New in EM segments with Andy and Dave looking at ondansetron in ketamine sedation and the use of antibotics in brain injury. We have a Guidelines for EM looking at the management of hyperemesis gravidarum and we have an interview with Vicky Price from the Society of Acute Medicine. We then end with New Online. If you'd like to email us, please feel free to do so here (04:56) New in EM - Ondansetron in ketamine sedation New in EM - Review article: Efficacy of prophylactic ondansetron versus placebo or control in reducing vomiting in children undergoing ketamine procedural sedation in the emergency department: A systematic review and meta-analysis (Hudson et al., 2024) (16:18) Guidelines for EM - RCOG - Hyperemesis Gravidarum The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69) (01:02:10) Interview with Vicky Price (Society of Acute Medicine) Society for Acute Medicine - Podcasts (01:38:05) New in EM - Antibiotics in brain injury Ceftriaxone to prevent early ventilator-associated pneumonia in patients with acute brain injury: a multicentre, randomised, double-blind, placebo-controlled, assessor-masked superiority trial (Dahyot-Fizelier et al., 2024) (01:51:24) New Online – new articles on RCEMLearning for your CPD Charlotte Davies - Departmental Handover Edward Snelson and Hannah Walsh - Recognising Paediatric Sepsis Fatema Jaffer and Riad Hosein - Congenital cardiac disease

Episode 30! This episode is a little different. We recap the SCCM conference first. THEN we go into PROPHY-VAP or "Ceftriaxone to prevent early ventilator-associated pneumonia in patients with acute brain injury" published January 2024 by Professor Dahyot-Fizelier in Lancet Respiratory Medicine. Then we dive into our long neglected mailbag to review listener questions about MINT, intubation timing, ACORN, and all the steroids in ARDS talkPROPHY-VAP: https://pubmed.ncbi.nlm.nih.gov/38262428/SCCM Steroid guidelines: https://pubmed.ncbi.nlm.nih.gov/38240492/Counter-Point should we use steroids in ARDS: https://pubmed.ncbi.nlm.nih.gov/33422201/sRAGE in NIV and HFNC: https://pubmed.ncbi.nlm.nih.gov/38250011/Anaerobes in Aspiration: https://pubmed.ncbi.nlm.nih.gov/37250794/Anaerobes in Gut: https://pubmed.ncbi.nlm.nih.gov/36229047/Be sure to follow us on the social @icucast for the associated figures, comments, and other content not available in the audio format! Email us at icuedandtoddcast@gmail.com with any questions or suggestions! Thank you Mike Gannon for the intro and exit music!

How can you measure improvement in long COVID? Find out about this and more in today's PV Roundup podcast.

Sudden Cardiac Arrest Risk in Type 2 Diabetes; Atrial Fib and Memory Decline; Ceftriaxone, Lansoprazole, Arrhythmia and Death

Contributor: Meghan Hurley MD Educational Pearls: What is Cellulitis? A common and potentially serious bacterial skin infection. Caused by various types of bacteria, with Streptococcus and Staphylococcus species being the most common. What is Preseptal Cellulitis and why is it more serious than facial cellulitis? Preseptal Cellulitis, also known as Periorbital Cellulitis, is a bacterial infection of the soft tissues in the eyelid and the surrounding area. This requires prompt and aggressive treatment to avoid progression into Orbital Cellulitis. How is Preseptal Cellulitis treated? Oral antibiotics for five to seven days. In the setting of trauma (scratching bug bites) Clindamycin or TMP-SMX (for MRSA coverage) and Amoxicillin-clavulanic acid or Cefpodoxime or Cefdinir. If there is no trauma, monotherapy with amoxicillin-clavulanic acid is appropriate. Check immunization status against H.influenzae and adjust appropriately. What is Orbital Cellulitis, how is it diagnosed, and why is it more serious than Preseptal Cellulitis? Orbital cellulitis involves the tissues behind the eyeball and within the eye socket itself. Key features include: Eye pain. Proptosis (Bulging of the eye out of its normal position). Impaired eye movement. Blurred or double vision. This can lead to three very serious complications: Orbital Compartment Syndrome. This can push eye forward, stretch optic nerve, and threaten vision. Meningitis given that the meninges of the brain are continuous with optic nerve. Endophthalmitis, which is inflammation of the inner coats of the eye. This can also threaten vision. If suspected, get a CT of the orbits and/or an MRI to look for an abscess behind the eyes. How is Orbital Cellulitis treated? IV antibiotics. Cover for meningitis with Ceftriaxone and Vancomycin. Add Metronidazole until intracranial involvement has been ruled out. Drain the abscess surgically. Usually this is performed by an ophthalmologist or an otolaryngologist. Admit to the hospital. References Bae C, Bourget D. Periorbital Cellulitis. 2023 Jul 17. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29261970. Chaudhry IA, Shamsi FA, Elzaridi E, Al-Rashed W, Al-Amri A, Al-Anezi F, Arat YO, Holck DE. Outcome of treated orbital cellulitis in a tertiary eye care center in the middle East. Ophthalmology. 2007 Feb;114(2):345-54. doi: 10.1016/j.ophtha.2006.07.059. PMID: 17270683. Seltz LB, Smith J, Durairaj VD, Enzenauer R, Todd J. Microbiology and antibiotic management of orbital cellulitis. Pediatrics. 2011 Mar;127(3):e566-72. doi: 10.1542/peds.2010-2117. Epub 2011 Feb 14. PMID: 21321025. Wong SJ, Levi J. Management of pediatric orbital cellulitis: A systematic review. Int J Pediatr Otorhinolaryngol. 2018 Jul;110:123-129. doi: 10.1016/j.ijporl.2018.05.006. Epub 2018 May 8. PMID: 29859573. Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII  

O TdC comemora seu quarto ano de existência com mais um episódio comemorativo! Qual o melhor remédio aos olhos do TdC? Ceftriaxone ou Metformina? Noradrenalina ou Alteplase? Enoxaparina ou Carvedilol? Veja essa discussão sem sentido aqui!

This episode reviews three articles about four antimicrobial treatment options for Neisseria gonorrhoeae other than ceftriaxone. View episode transcript and references at www.std.uw.edu.This podcast is dedicated to an STD [sexually transmitted disease] review for health care professionals who are interested in remaining up-to-date on the diagnosis, management, and prevention of STDs. Editor and host Dr. Meena Ramchandani is an Assistant Professor of Medicine at the University of Washington (UW) and Medical Director of the Public Health – Seattle & King County Sexual Health Clinic. 

Obtain IV Access – get two large bore IVs (18g or larger) Resuscitate – un-crossmatched blood at first, don't forget type and screen! Medicate – Give Pantoprazole always, Octreotide and Ceftriaxone if hx liver disease, reverse anticoagulation if indicated Imaging – Upright CXR to assess for perforation, CTA if concerned for lower GIB Consult – […]

On episode #18 of the Infectious Disease Puscast, Daniel and Sara review the infectious disease literature for the previous two weeks, 12/9/22 – 12/21/22. Hosts: Daniel Griffin and Sara Dong Subscribe (free): Apple Podcasts, Google Podcasts, RSS, email Become a patron of Puscast! Links for this episode Human Rabies in Texas, 2021 (CDC) Human rabies despite post-exposure prophylaxis (The Lancet) The Qatar FIFA World Cup 2022 and camel pageant championships increase risk of MERS-CoV transmission and global spread (The Lancet) An update on eukaryotic viruses revived from ancient permafrost (bioRx) Colistin monotherapy vs combination therapy for carbapenem-resistant organisms (NEJM) Outcomes of Ceftriaxone vs antistaphylococcal Penicillins or Cefazolin for definitive therapy of Methicillin-susceptible Staphylococcus aureus bacteremia (OFID) Salmonella enteritidis cardiovascular implantable electronic device infection (OFID) Evaluation of serotonin syndrome with Linezolid and serotonergic agents at an academic medical center (OFID) Preemptive antifungal therapy for the prevention of invasive candidiasis following gastrointestinal surgery for Intra-abdominal infections (CID) Risk factors and outcomes of invasive aspergillosis in kidney transplant recipients (CID) Predictive performance of gram staining of catheter tips for Candida catheter-related bloodstream infections (OFID) Integrative genetic manipulation of Plasmodium cynomolgireveals multidrug resistance-(JID) Clinical characteristics of patients with calcified parenchymal neurocysticercosis and perilesional edema (OFID) Impact of sequestration on artemisinin-induced parasite clearance in Plasmodium falciparum malaria in Africa (CID) Factors contributing to delayed academic advancement of women in infectious diseases (OFID) Characterization of problematic alcohol use among physicians (JAMA) Alpha-gal syndrome in the ID clinic (OFID) Efficacy and safety of Azithromycin vs placebo to treat lower respiratory tract infections associated with low procalcitonin (The Lancet) Music is by Ronald Jenkees

Episode 123: Spontaneous Bacterial Peritonitis.  Kaitlen defines spontaneous bacterial peritonitis (SBP) and also explains the diagnosis and management.  Written by Kaitlen Roy-Ross, MS4, Ross University School of Medicine. Moderated by Hector Arreaza, MD. Definition:An ascitic fluid infection with no obvious surgically treatable intra-abdominal source (bowel perforation, abscess, perforated ulcer). Commonly seen in patients with cirrhosis and ascites. Patients may have symptoms of fever, abdominal pain, abdominal tenderness, altered mental status, and hypotension.Etiology: The most common pathogens (75%) are gram-negative aerobic organisms. Klebsiellapneumoniae accounts for 50% of the cases. Gram-positive aerobic bacteria (Streptococcus pneumoniae or viridans group streptococcus) account for the remaining cases. Some report E. coli as the most common cause of SBP. Random information: in Korea, Aeromonas hydrophila is an important pathogen of SBP during the summer. Diagnosis: To diagnose SBP, a paracentesis should be performed to analyze the ascitic fluid prior to treating the patient with antibiotics.The ascitic fluid should be analyzed for the following: PMN (Polymorphonuclear cell) count: > or = to 250 cells/mm3 Aerobic and anaerobic culturesSerum ascites albumin gradient (serum albumin-ascitic albumin): this measures portal pressure.If the gradient is > 1.1 = portal HTN is present (cirrhosis, heart failure, large liver malignancy, alcoholic hepatitis, portal vein thrombosis) – SBP is likely.If the gradient is 6 mg/ suggests a gallbladder perforation. No SBP.Treatment:The treatment for spontaneous bacterial peritonitis is broad-spectrum antibiotics. Empiric treatment is indicated if a patient with ascites has any of the following:Temperature > 100 FAbdominal pain or tendernessAltered mental statusPMN in ascitic fluid > 250 (but if there is bacteria in ascitic fluid, start antibiotics stat)Alcohol-induced hepatitis*Important note: Patients on beta blockers should have them permanently discontinued prior to treatment for SBP as beta blockers are associated with worse outcomes. In one study, patients on beta blockers had a 58% increase in mortality risk compared to patients not treated with beta-blockers. Beta-blockers were also associated with higher rates of hepatorenal syndrome and longer lengths of hospital stay.1st line treatment- 3rd generation Cephalosporin Cefotaxime 2g IV Q8H (preferred) or Ceftriaxone 2 g per day2nd line treatment- Carbapenems. Usually reserved for patients with severe disease/critical illness.3rd line- Fluoroquinolones- Cipro 400 mg IV BID to patients with normal renal function. (Patients should not get this if they already receiving it prophylactically.)Duration of treatment:5 days, then re-assess the patient's PMN count:PMN 250 or greater than pre-treatment PMN count > look for a surgical source of infection.If PMN is > 250 but less than pre-treatment value, continue ABX for 48 more hours and then repeat paracentesis. Note: In general, ascitic fluid PMN count should be reduced by at least 25% after 48 hours of antibiotic therapy.Renal failure is the major cause of death in patients with SBP and develops in 30-40 % of the patients. We can decrease this risk by administering IV albumin. IV albumin should be given when the creatinine is > 1 mg/dl, the blood urea nitrogen is > 30 mg/dl, or the total bilirubin is > 4 mg/dl. Treatment with octreotide or midodrine is helpful if renal failure develops.Prevention:Antibiotic prophylaxis can be given to patients with risk factors for SBP. Some risk factors include prior history of SBP, variceal hemorrhage, or an ascites fluid protein concentration of

In this episode, Marion Elligsen, BScPhm, MSc, RPh, ACPR; Keith S Kaye, MD, MPH; and Andrew Shorr, MD, MPH, MBA, discuss key considerations for selecting empiric antibiotic regimens in patients with HABP/VABP in the intensive care unit, including: The role of novel β-lactam/β-lactamase inhibitor combinationsUse of clinical predictions scores (eg, Drug Resistance in Pneumonia [DRIP] score) to predict risk for pneumonia caused by multidrug-resistant pathogensApplication of rapid diagnostic testing in critically ill patients with pneumonia, including current limitationsImplementation of advanced antibiograms and clinical prediction scoresClinical utility of biomarkers for pneumonia (eg, procalcitonin)Application of updated nosocomial pneumonia classifications in clinical practiceFaculty:Marion Elligsen, BScPhm, ​ MSc, RPh, ACPR​Practice-Based Researcher​Sunnybrook Research Institute​Antimicrobial Stewardship Pharmacy Lead​Department of Pharmacy​Sunnybrook Health Sciences Centre​Toronto, Ontario, Canada​Keith S. Kaye, MD, MPHChief  Division of Allergy, Immunology and Infectious DiseasesProfessor of MedicineRutgers Robert Wood Johnson Medical SchoolNew Brunswick, New JerseyAndrew Shorr, MD, MPH, MBA​Director​Pulmonary and Critical Care Medicine​Medstar Washington Hospital Center​Washington, DC​Content based on a CME program supported by an educational grant from Merck Sharp & Dohme Corp. Link to full program:https://bit.ly/3HaZpYwLink to downloadable slideset:https://bit.ly/3UxHoqr

Introduction: False positive RPR. By Hector Arreaza, MD. Read by Alinor Mezinord, MS III, Ross University School of Medicine.  Today we will talk about syphilis. Significant research has been done to determine the origin of this ancient infection. Some experts support that syphilis originated in the New World (the Americas) because the first cases in Europe were reported after the Christopher Columbus crew returned from their expeditions. On the other hand, some people defend the idea of the origin of syphilis in the Old World. Whatever its origin, syphilis is still affecting thousands of people worldwide. According to the World Health Organization, “syphilis in pregnancy is the second leading cause of stillbirth globally and also results in prematurity, low birth weight, neonatal death, and infections in newborns.”[1] The cases in the US are not as high as in other countries, but certain areas have cases higher than the national or state average. Such is the case in Kern County. Our incidence of syphilis is higher than the national average.That's why it is important to screen for this disease. RPR is the most common test to screen for syphilis; however, it may not be completely accurate. RPR is a non-treponemal test that can cause false positive results. On December 20, 2021, the CDC released a letter announcing an FDA alert regarding a high RPR false positive rate when done with Bio-Rad Laboratories BioPlex 2200 Syphilis Total & RPR kit. You may not know which kit was used for the test, but you need to know what to do with a positive RPR. Some conditions associated with false positive RPR include COVID-19 vaccines, tuberculosis, endocarditis, rickettsial disease, recent immunizations (smallpox), and pregnancy. In case of RPR positive, you need to confirm syphilis with a treponemal test, which will be more reliable regardless of the possibility of a false positive RPR. We still need to screen because syphilis continues to increase in our nation. I hope you enjoy this episode.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.___________________________Latent Syphilis. By Carol Avila, MD. Comments by Hector Arreaza, MD. Dr. Avila: I had the amazing opportunity to do inpatient pediatrics during my first rotation at a local hospital, and I often treated patients with neonatal syphilis. I was curious to know what is happening in this area (Bakersfield) that made syphilis (seems to me) a very frequent diagnosis of admission in peds, especially because newborns are impacted by a preventable disease.Epidemiology:The latest update available on the CDC website is the 2020 Surveillance Report of Nationally Notifiable STDs which showed:-In 2020, the national rate of syphilis was about 40 per 100,000 population (all stages).-The rate of national congenital syphilis was about 57 cases per 100,000 live births.-During that year, California was ranked #7 for primary and secondary syphilis (P&S), with a 19.5 per 100,000 population. Nevada was the number #1 state.Local data:In 2018 data, the Kern County Public Health Services Department reported:-A total of 1,520 cases of syphilis (all stages) were diagnosed during that year, about 4 cases/day. It is important to mention that there was a spike in the number of cases of syphilis by 86% compared to the prior year, 2017.-In 2020, 250 cases of congenital syphilis per 100,000 live births were reported in Kern County. Significantly higher than the national average (mentioned above, 40 cases per 100,000 residents). -For primary and secondary syphilis, Kern County was 62% higher than the state average, with almost 35 per 100,000 population, and was ranked #6 in the state of California. -San Francisco was ranked #1.-Bottomline: The rate of syphilis and congenital syphilis in Kern County is higher than the state and national average.Definition:Syphilis is a systemic bacterial infection caused by the gram-negative spirochete Treponema pallidum. Transmission:Syphilis is well known as a sexually transmitted disease; however, while many cases happen due to sexual activity, there are a few other ways that syphilis can also be spread.-It can be transmitted during pregnancy, resulting in congenital syphilis.-Also, passing on syphilis via blood transfusions was very common but is now rare thanks to blood supply screening.-Syphilis transmission is also possible through an organ donor, which nowadays is very rare.-Before healthcare providers were wearing gloves as a standard precaution, it was common for syphilis lesions to appear on their fingers and noses.-It can also be transmitted through close and repetitive contact with mucosal or skin lesions of people with active syphilis.Classification:-Syphilis is divided into stages based on clinical findings. Primary, secondary, and tertiary.-The latent phase occurs between secondary and tertiary. -Patients pass through secondary syphilis and may not realize it.-The most contagious stages are primary and secondary, and syphilis could still be contagious in the early latent phase.-Easy classification: Early (primary, secondary, early latent); Late (tertiary and late latent); Neurosyphilis (which occurs any time).Primary syphilis:-It usually happens 3 weeks after the initial contact with the spirochete, but it can also be seen after 90 days. The bacteria will destroy the local tissue when we see the syphilitic chancre, a painless, well-demarcated lesion with firm, indurated margins. It might go unnoticed; without treatment, the bacteria will spread to the bloodstream, and the infection will progress to the secondary stage.Secondary syphilis:-In the secondary stage, the patient can have a wide variety of signs and symptoms. General constitutional symptoms are common; however, it is characterized by a body-wide rash, prominent in palms and soles. This rash can be macular, papular, or pustular; patients can also develop patches in oral mucosa and tongue, as well as wart-like sores called condylomata lata. Tertiary syphilis:-In the pre-antibiotic era, 15 to 30 years after the initial infection, patients could develop any of the three forms of tertiary syphilis. -Cardiovascular syphilis involves the ascending thoracic aorta. Patients may present with aorticaneurysm or left heart failure. -Gummatous syphilis is uncommon, but it is especially important in patients coinfected with HIV. Gummas can appear in the skin, bones, or internal organs. -Central Nervous System syphilis presents with general paresis, tabes dorsalis, meningitis, hearing and vision loss, and dementia.Latent syphilis:-It occurs when the patient has positive serology for T. pallidum, but the patient is asymptomatic. -Latent syphilis can also be divided into early latent (when the primary infection occurred within the previous 12 months); and late latent syphilis (when the primary stage happened more than 12 months ago.)-Differentiating early and late latent syphilis is vital because the treatment will differ.Congenital syphilis:-The infection occurs during pregnancy.-It can cause miscarriage, stillbirth, or birth defects like nasal cartilage destruction, and frontalbossing, among others. Screening and Diagnostic Testing:-The USPSTF recommends screening asymptomatic, nonpregnant adults and adolescents at increased risk for syphilis infection (Grade A).-The USPSTF recommends early screening for syphilis infection in all pregnant women. as early as possible when they first present to care. -Repeat screening: The CDC and joint guidelines from the American Academy of Pediatrics (AAP) and the ACOG endorse repeat screening, especially for women at risk, early in the third trimester (at about 28 weeks of gestation) and again at delivery.-High-risk patients include men who have sex with men (MSM) and men and women living with HIV. -Also, people with a history of incarceration, a history of commercial sex work, certain racial/ethnic groups (African Americans and Hispanics), and being a male younger than 29 years.How to screen: -Initial screening should be done with a nontreponemal test (RPR or VDRL); if positive, a treponemal test (TP-PA or FTA-ABS) would be the next step. -Nontreponemal tests can be positive in patients with preexisting conditions, e.g., collagen vascular diseases, pregnancy, malignancy, tuberculosis, etc.-The USPSTF also refers to the reverse sequence screening algorithm, where we perform a treponemal test first in those patients that could be missed after a nontreponemal test, for example, people who are homeless, also in nontraditional and nonclinical settings. -A treponemal test will be followed by a nontreponemal test, however, there is no evidence of the accuracy of this screening algorithm, so it is an open field for researchers.-Remember that most patients will have positive antibodies for life, irrespective of treatment or disease stage.Treatment:-One word: Penicillin is the treatment of choice.-Additionally, every patient diagnosed with primary and secondary syphilis should be tested for HIV and other sexually transmitted diseases at the time of diagnosis. Primary, secondary, and early latent syphilis: Benzathine penicillin G, 2.4-million-unit IM, in a single dose.-Children/Infant age > 1 month of age: Benzathine PCN G, 50,000 units/kg body weight IM up to 2.4 million-unit in a single dose. -Children > 1 month with P&S syphilis should be evaluated for sexual abuse.Arreaza:-Pregnancy: Treatment is still penicillin G, if there is a penicillin allergy, desensitization should be done in a controlled setting.-In non-pregnant with PCN allergy- alternatives are doxycycline 100 mg BID x14 days or Ceftriaxone 1 G daily IM or IV for 10-14 days.-For P&S syphilis: clinical and serological evaluation should be done at 6 to 12 months after treatment. Late latent syphilis and tertiary: Benzathine penicillin G, 7.2-million-unit total, administered as 2.4 million units IM each week x3 doses. (2.4 x3 = 7.2). A good strategy is to assume all latent syphilis are late latent. -Follow up with a quantitative nontreponemal serologic test at 6, 12, and 24 months, and compare thistiter with the initial titer at the time of diagnosis.-Special recommendation: Check RPR titer the same day you give the first dose of penicillin.Neurosyphilis: -CSF examination is recommended if neurologic findings are present.-If neurosyphilis is confirmed, it will require aqueous penicillin G, 3-4 million units IV every 4 hours for 10-14 days. Alternative ceftriaxone 2 G IV daily x14 days. Get guidance from an ID specialist. We will continue talking about syphilis in another episode, which was an excellent introduction.____________________________Conclusion: Now we conclude episode number 112, “Syphilis Basics.” Dr. Avila raised our awareness of syphilis in our community and the importance of screening all adolescents and adults at risk of infection, and especially ALL pregnant persons, during their first prenatal visit or as early as possible. Timely treatment with penicillin is important to prevent late complications of syphilis and especially to prevent the devastating consequences of congenital syphilis. This week we thank Hector Arreaza, Carol Avila, and Alinor Mezinord. Audio edition by Adrianne Silva.Even without trying, every night, you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you; send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week!References:1. Data on syphilis, The Global Health Observatory, World Health Organization, who.int, https://www.who.int/data/gho/data/themes/topics/topic-details/GHO/data-on-syphilis,  accessed September 14, 2022. 2. Center for Disease Control and Prevention. (2022, April 11). National Overview of STD.  https://www.cdc.gov/std/statistics/2020/overview.htm#CongenitalSyphilis. 3. STDs in Kern County, Kern County Public Health Services Department, STDS in Kern County 2018, https://kernpublichealth.com/wp-content/uploads/STDs-in-Kern-County-2018-slide-set-comparison.pdf, downloaded on Sep 12, 2022. 4. Center for Disease Control and Prevention. (2022, April 4). Reported Cases and Rates of Reported Cases by State, Ranked by Rates, United States, 2020. https://www.cdc.gov/std/statistics/2020/tables/13.htm 5. Morgen, Sam, Reported cases of STDs in Kern County dropped in 2020, but decrease could be misleading, The Bakersfield Californian, Apr 17, 2022, bakersfield.com, https://www.bakersfield.com/news/reported-cases-of-stds-in-kern-county-dropped-in-2020-but-decrease-could-be-misleading/article_6e7d8d36-bd18-11ec-a98f-7f247bc2517e.html. 6. U.S. Preventive Services Task Force. (2016, June 7). Syphilis Infection in Nonpregnant Adults and Adolescents: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/syphilis-infection-in-nonpregnant-adults-and-adolescents. 7. Center For Disease Control And Prevention. (2022, July 21). Sexually Transmitted Infections Treatment Guidelines. https://www.cdc.gov/std/treatment-guidelines/syphilis.htm. 8. Calonge N; U.S. Preventive Services Task Force. Screening for syphilis infection: recommendation statement. Ann Fam Med. 2004 Jul-Aug;2(4):362-5. doi: 10.1370/afm.215. Erratum in: Ann Fam Med. 2004 Sep-Oct;2(5):517. PMID: 15335137; PMCID: PMC1466700. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1466700/. 9. Royalty-free music used for this episode: Good Vibes Alt Mix by Videvo, downloaded on May 06, 2022 from https://www.videvo.net/royalty-free-music-track/good-vibes-alt-mix/1017292/ 

On this episode, I discuss ceftriaxone pharmacology, adverse effect, coverage, and drug interactions. Ceftriaxone is currently a drug of choice for the STI Gonorrhea. Pyrls.com has an amazing chart on all the STIs and their drugs of choice that you can get for free when you sign up for a free account! Ceftriaxone is a third-generation cephalosporin that is used for numerous indications such as pneumonia, meningitis, gonorrhea, and many more. It is important to remember that ceftriaxone can cover many staph and strep species but it does NOT cover MRSA. Ceftriaxone does have some risks, particularly in pediatric patients. I discuss elevated bilirubin and calcium binding risks in the podcast.

The Centers for Disease Control and Prevention just updated guidelines for sexually transmitted infections (previously sexually transmitted diseases) for everything by HIV. In this multi-part series, host Geoff Wall will break down what's new and what's changing in practice.The GameChangerA 7-day course of doxycycline in the treatment of urogenital chlamydia is preferred and has been shown to be more efficacious compared to azithromycin. Ceftriaxone should be the treatment of choice for gonorrhea as there have been no “resistance”-related treatment failures identified in the United States at any anatomical site.  Show Segments00:00 – Introduction01:45 – STI Guidelines02:34 – Chlamydia 14:56 – Gonorrhea 28:57 – Closing RemarksHost Geoff Wall, PharmD., BCPS, FCCP, CGP Professor of Pharmacy Practice, Drake University Internal Medicine/Critical Care, UnityPoint Health All relevant financial relationships have been mitigated. References and Resources CDC Sexually Transmitted Infections Treatment Guidelines, 2021Redeem your CPE or CMECPE (Pharmacist)CME (Physicians) Get a membership & earn CE for GameChangers Podcast episodes (30 mins/episode)Pharmacists: Get a membershipPrescribers: Get a membership CE Information Learning Objectives Describe the treatment of Neisseria gonorrhea based on the 2021 recommendationsDiscuss pharmacotherapy options for patients with chlamydia with or without concomitant gonorrhea infections0.05 CEU/0.5 Hr UAN: 0107-0000-22-224-H01-P Initial release date: 06/062022 Expiration date: 06/06/2023 Additional CPE and CME details can be found here.

Drs. Tom Dilworth and Stephanie Shealy May (@stephshealymay) join Dr. Rachel Britt (@RachelBPharmD) in the first episode of Breakpoints Dosing Consults to discuss questions and debates around ceftriaxone dosing. When should we use 1g over 2g? How does critical illness affect what dose to use? Is ceftriaxone the most approachable antibiotic? Tune in for answers to these questions and more!   Learn more about the Society of Infectious Diseases Pharmacists: https://sidp.org/About Twitter: @SIDPharm (https://twitter.com/SIDPharm) Instagram: @SIDPharm (https://www.instagram.com/sidpharm/) Facebook: https://www.facebook.com/sidprx LinkedIn: https://www.linkedin.com/company/sidp/ References Ettestad PJ, Campbell GL, Welbel SF, Genese CA, Spitalny KC, Marchetti CM, Dennis DT. Biliary complications in the treatment of unsubstantiated Lyme disease. J Infect Dis. 1995 Feb;171(2):356-61. doi: 10.1093/infdis/171.2.356. PMID: 7844372. Hasegawa S, Sada R, Yaegashi M, Morimoto K, Mori T; Adult Pneumonia Study Group-Japan. 1g versus 2 g daily intravenous ceftriaxone in the treatment of community onset pneumonia - a propensity score analysis of data from a Japanese multicenter registry. BMC Infect Dis. 2019 Dec 26;19(1):1079. doi: 10.1186/s12879-019-4552-8. PMID: 31878894; PMCID: PMC6933656. Barber KE, Loper JT, Morrison AR, Stover KR, Wagner JL. Impact of Obesity on Ceftriaxone Efficacy. Diseases. 2020 Jul 9;8(3):27. doi: 10.3390/diseases8030027. PMID: 32660113; PMCID: PMC7563366. Herrera-Hidalgo L, de Alarcón A, López-Cortes LE, Luque-Márquez R, López-Cortes LF, Gutiérrez-Valencia A, Gil-Navarro MV. Is Once-Daily High-Dose Ceftriaxone plus Ampicillin an Alternative for Enterococcus faecalis Infective Endocarditis in Outpatient Parenteral Antibiotic Therapy Programs? Antimicrob Agents Chemother. 2020 Dec 16;65(1):e02099-20. doi: 10.1128/AAC.02099-20. Erratum in: Antimicrob Agents Chemother. 2021 May 18;65(6): PMID: 33046488; PMCID: PMC7927845. Herrera-Hidalgo L, Lomas-Cabezas JM, López-Cortés LE, Luque-Márquez R, López-Cortés LF, Martínez-Marcos FJ, de la Torre-Lima J, Plata-Ciézar A, Hidalgo-Tenorio C, García-López MV, Vinuesa D, Gutiérrez-Valencia A, Gil-Navarro MV, De Alarcón A. Ampicillin Plus Ceftriaxone Combined Therapy for Enterococcus faecalis Infective Endocarditis in OPAT. J Clin Med. 2021 Dec 21;11(1):7. doi: 10.3390/jcm11010007. PMID: 35011748; PMCID: PMC8745305. Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, Reno H, Zenilman JM, Bolan GA. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep. 2021 Jul 23;70(4):1-187. doi: 10.15585/mmwr.rr7004a1. PMID: 34292926; PMCID: PMC8344968. Whittles LK, White PJ, Paul J, Didelot X. Epidemiological Trends of Antibiotic Resistant Gonorrhoea in the United Kingdom. Antibiotics (Basel). 2018 Jul 13;7(3):60. doi: 10.3390/antibiotics7030060. PMID: 30011825; PMCID: PMC6165062. Ackerman A, Zook NR, Siegrist JF, Brummitt CF, Cook MM, Dilworth TJ. Comparison of Clinical Outcomes among Intensive Care Unit Patients Receiving One or Two Grams of Ceftriaxone Daily. Antimicrob Agents Chemother. 2020 May 21;64(6):e00066-20. doi: 10.1128/AAC.00066-20. PMID: 32205348; PMCID: PMC7269488. Ulldemolins M, Roberts JA, Rello J, Paterson DL, Lipman J. The effects of hypoalbuminaemia on optimizing antibacterial dosing in critically ill patients. Clin Pharmacokinet. 2011 Feb;50(2):99-110. doi: 10.2165/11539220-000000000-00000. PMID: 21142293. Dailly E, Arnould JF, Fraissinet F, Naux E, Letard de la Bouralière MA, Bouquié R, Deslandes G, Jolliet P, Le Floch R. Pharmacokinetics of ertapenem in burns patients. Int J Antimicrob Agents. 2013 Jul;42(1):48-52. doi: 10.1016/j.ijantimicag.2013.02.021. Epub 2013 Apr 8. PMID: 23578794. Pai MP. Treatment of bacterial infections in obese adult patients: how to appropriately manage antimicrobial dosage. Curr Opin Pharmacol. 2015 Oct;24:12-7. doi: 10.1016/j.coph.2015.06.004. Epub 2015 Jun 25. PMID: 26119488. Mahmood I. Theoretical versus empirical allometry: Facts behind theories and application to pharmacokinetics. J Pharm Sci. 2010 Jul;99(7):2927-33. doi: 10.1002/jps.22073. PMID: 20127826. Kang N, Housman ST, Nicolau DP. Assessing the Surrogate Susceptibility of Oxacillin and Cefoxitin for Commonly Utilized Parenteral Agents against Methicillin-Susceptible Staphylococcus aureus: Focus on Ceftriaxone Discordance between Predictive Susceptibility and in Vivo Exposures. Pathogens. 2015 Jul 30;4(3):599-605. doi: 10.3390/pathogens4030599. PMID: 26264030; PMCID: PMC4584275. Gern BH, Greninger AL, Weissman SJ, Stapp JR, Tao Y, Qin X. Continued in vitro cefazolin susceptibility in methicillin-susceptible Staphylococcus aureus. Ann Clin Microbiol Antimicrob. 2018 Feb 20;17(1):5. doi: 10.1186/s12941-018-0257-x. PMID: 29463249; PMCID: PMC5819674. Bremmer DN, Balada-Llasat JM, Goff DA, Bauer KA. Ceftriaxone Etest non-susceptible methicillin susceptible Staphylococcus aureus time-kill responses. Diagn Microbiol Infect Dis. 2017 Jun;88(2):192-194. doi: 10.1016/j.diagmicrobio.2017.02.019. Epub 2017 Mar 2. PMID: 28291629. Kosowska-Shick K, McGhee PL, Appelbaum PC. Affinity of ceftaroline and other beta-lactams for penicillin-binding proteins from Staphylococcus aureus and Streptococcus pneumoniae. Antimicrob Agents Chemother. 2010 May;54(5):1670-7. doi: 10.1128/AAC.00019-10. Epub 2010 Mar 1. PMID: 20194704; PMCID: PMC2863635. Palmer SM, Kang SL, Cappelletty DM, Rybak MJ. Bactericidal killing activities of cefepime, ceftazidime, cefotaxime, and ceftriaxone against Staphylococcus aureus and beta-lactamase-producing strains of Enterobacter aerogenes and Klebsiella pneumoniae in an in vitro infection model. Antimicrob Agents Chemother. 1995 Aug;39(8):1764-71. doi: 10.1128/AAC.39.8.1764. PMID: 7486916; PMCID: PMC162823. Craig WA. Interrelationship between pharmacokinetics and pharmacodynamics in determining dosage regimens for broad-spectrum cephalosporins. Diagn Microbiol Infect Dis. 1995 May-Jun;22(1-2):89-96. doi: 10.1016/0732-8893(95)00053-d. PMID: 7587056. Garot D, Respaud R, Lanotte P, Simon N, Mercier E, Ehrmann S, Perrotin D, Dequin PF, Le Guellec C. Population pharmacokinetics of ceftriaxone in critically ill septic patients: a reappraisal. Br J Clin Pharmacol. 2011 Nov;72(5):758-67. doi: 10.1111/j.1365-2125.2011.04005.x. PMID: 21545483; PMCID: PMC3243010. Joynt GM, Lipman J, Gomersall CD, Young RJ, Wong EL, Gin T. The pharmacokinetics of once-daily dosing of ceftriaxone in critically ill patients. J Antimicrob Chemother. 2001 Apr;47(4):421-9. doi: 10.1093/jac/47.4.421. PMID: 11266414. Van Wart SA et al., ICAAC 2009, poster # A1-010 Housman ST, Sutherland CA, Nicolau DP. Pharmacodynamic profile of commonly utilised parenteral therapies against meticillin-susceptible and meticillin-resistant Staphylococcus aureus collected from US hospitals. Int J Antimicrob Agents. 2014 Sep;44(3):235-41. doi: 10.1016/j.ijantimicag.2014.05.012. Epub 2014 Jun 24. PMID: 25052866. Zelenitsky SA, Beahm NP, Iacovides H, Ariano RE, Zhanel G. Limitations of ceftriaxone compared with cefazolin against MSSA: an integrated pharmacodynamic analysis. J Antimicrob Chemother. 2018 Jul 1;73(7):1888-1894. doi: 10.1093/jac/dky120. PMID: 29635472. Paul M, Zemer-Wassercug N, Talker O, Lishtzinsky Y, Lev B, Samra Z, Leibovici L, Bishara J. Are all beta-lactams similarly effective in the treatment of methicillin-sensitive Staphylococcus aureus bacteraemia? Clin Microbiol Infect. 2011 Oct;17(10):1581-6. doi: 10.1111/j.1469-0691.2010.03425.x. Epub 2010 Dec 14. PMID: 21073629. Carr DR, Stiefel U, Bonomo RA, Burant CJ, Sims SV. A Comparison of Cefazolin Versus Ceftriaxone for the Treatment of Methicillin-Susceptible Staphylococcus aureus Bacteremia in a Tertiary Care VA Medical Center. Open Forum Infect Dis. 2018 May 18;5(5):ofy089. doi: 10.1093/ofid/ofy089. PMID: 30568987; PMCID: PMC5961173. Check out our podcast host, Pinecast. Start your own podcast for free with no credit card required. If you decide to upgrade, use coupon code r-7e7a98 for 40% off for 4 months, and support Breakpoints.

In this episode, we review a potentially practice-changing study. Should we treat PID with three antibiotics? Click HERE to leave a review of the podcast!References:All references for Episode 54 are found on my Read by QxMD collection

Episode 36: Birth Control and HTN.  Gonorrhea treatment update. Use of birth control in hypertension. Explanation of allodynia and hyperalgesia. Tips on contraceptives. Jokes.HAPPY NEW YEARS EVERYONE! Welcome to our first episode of 2021. We are full of hope and optimism for this new year, even though this year is looking just the same so far.Outdated treatment for gonorrhea: Ceftriaxone 250 mg IM and azithromycin 1 gram PO.Updated treatment of gonorrhea: On December 18, 2020, the CDC recommended a new treatment of uncomplicated urogenital, rectal, or pharyngeal gonorrhea with a single IM dose of 500 mg of ceftriaxone (instead of 250 mg). For patients who weigh more than 150 kg (300 lbs), the single intramuscular dose is 1 gram. If chlamydial infection has not been excluded, doxycycline 100 mg orally twice a day for 7 days is recommended (instead of azithromycin). However, azithromycin, 1 g PO single dose, is still recommended in pregnancy.Allergy to cephalosporins: In patients with cephalosporin allergy, a single 240 mg IM dose of gentamicin PLUS a single 2 GRAMS oral dose of azithromycin is an option.Expedited Partner Therapy – EPT: When permitted by state law, the partner may be treated with a single 800 mg oral dose of cefixime, and ADD oral doxycycline 100 mg twice daily for 7 days if chlamydia infection has not been excluded.Test of cure: A TOC is not needed for patients with uncomplicated urogenital or rectal gonorrhea who are treated with any of the recommended or alternative regimens. However, a test-of-cure is recommended for pharyngeal gonorrhea, 7–14 days after initial treatment. Retest: ALL persons treated for gonorrhea should be retested 3 months after treatment. If retesting at 3 months is not possible, we should retest within 12 months after initial treatment.Summary: treat urogenital, rectal, and pharyngeal gonorrhea with single IM dose of 500 mg of Ceftriaxone PLUS doxycycline 100 mg BID for 7 days.  This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. ____________________________Interview to Dr Tammela by Dr Arreaza (unscripted)Highlights of the interview:What measurement is essential before starting combined oral contraceptives? The answer is blood pressure measurement.Dr Tammela is the chief of women’s health in Clinica Sierra Vista. She is a practicing OB/Gyn specialist. Some topics discussed during the interview includes: Why is blood pressure measurement essential before starting combined hormonal contraception?Contraindications to combined hormonal contraceptionThree scenarios and recommend what type of contraception should be used: Patient younger than 35, healthy, well-controlled hypertensionPatient older than 35, well-controlled HTN, or patient of any age with BP 140-160/90-100 mm HgPatient of any age with blood pressure >160/100Continued blood pressure monitoring after initiation of combined hormonal contraceptionWhen to stop CHCTIPS by Valerie Civelli, MD and Patrick De Luna, MS3Which OCP to choose?Tip #1:In general, higher estrogen in birth control pills (35mcg) means better cycle control but worse estrogen-related side effects: such as nausea or breast tenderness. Lower dose estrogen birth control, (typically 20 µg) are better for those experiencing estrogen related side effects and must be taken at the same time every day. Remember: the lower the dose of Estrogen means the higher risk of breakthrough ovulation and breakthrough bleeding. LoLo® is a great option!Dr. Karen Tammela, OBGYN, when asked about her OCP preference for patients, she states, “I pretty much always use monophasic pills. They seem in general to provide improved cycle control. I think most OB/GYN‘s agree...”Tip #2:For patients who c/o bloating, weight gain, hirsutism and acne, think about Yaz®, and its higher dose sister Yasmin®: Drosperinone + Ethinyl Estradiol. Yaz or Yasmin have a special type of progesterone, Drospirinone, which makes it unique. Tip #3:Yaz and Yasmin: Let’s talk about insurance coverage (Family Pact and Kern Health) 12-month Supply may be provided twice in one year. For a 3rd dispense of 12-month supply, TAR is required for prior authorization. If you see this med was not covered, it’s likely the patient has been prescribed two-12/month supplies OCPs already. Submit a TAR in this case for coverage.Tip #4:Yaz or Yasmin are special because it is not just a low androgen option (which is what you look for in a pill for patients in need of acne control), but it is actually an ANTI-androgen, so it is THE BEST OPTION for acne. It also is the best option to reduce pill related weight gain, as the progesterone element (drospironone) acts as a diuretic.  Did you know Drosperinone has antiandrogenic properties equivalent to 25mg of spironolactone? Tip #5:Menstrual headaches? Think Mircette®. Mircette® is good for patients with menstrual headaches, because it reduces the stark drop in estrogen that happens from the active pills to the placebo (and it is the drop that is believed to be the trigger for menstrual headaches) by having a smoother estrogen step-down effect and a shorter placebo pill length. In patients with migraines with aura, it is best to avoid Combined Hormonal Contraceptives, especially if older than 35. Speaking Medical: Allodyniaby Xeng Xiong, MS4Ouch my hair hurts! Are you serious? Yes. There is a condition where a person can experience pain from stimuli that isn't normally painful; the term is called allodynia. But wait, can that pain also be considered hyperalgesia? This is so confusing. Allodynia and hyperalgesia are both related to hypersensitivity to pain, so let’s break them down.  Allodynia is the feeling of pain caused by usually nonpainful stimuli, such as brushing your hair. Allodynia results from increased pain receptors. Some people with migraine may have allodynia and will often describe this experience by saying, “My hair hurts.” Hyperalgesia, on the other hand, is an increased numbers of action potentials and spontaneous discharges in response to painful stimuli leading to a lower threshold. This means a patient will experience more pain with a stimulus that was previously less painful. In practice, patients on high dose opioid may experience hyperalgesia and stroking on their skin can cause pain. The treatment for this condition is to lower the opioids dose.   In the mist of all this medical jargons, allodynia and hyperalgesia are referred to as hypersensitivity to pain. However, their pathophysiology is different. Allodynia is related to stimuli that are generally non-painful which becomes painful upon stimulation, while hyperalgesia is related to stimuli that are generally painful but becomes significantly more painful when stimulated. By this time if you’re still confuse, Allodynia = non-painful stimuli; Hyperalgesia = painful stimuli. I hope listening to this was not so painful for you[3].  For your Sanity: Jokesby Lisa Manzanares, MDFinland has closed its borders, no one can cross the Finnish line.Did you hear the rumor about butter? Well, I’m not going to spread it.A cheese factory exploded in France. Da Brie is everywhere.I have two dogs named Rolex and Timex. They are my watch dogs.The difference between a numerator and a denominator is a short line. Only a fraction of people would understand this.I know a lot of jokes about retired people, none of them work.Now we conclude our episode number 36 “Birth Control and Hypertension”. Dr Tammela explained that whenever you have a patient with uncontrolled hypertension, be alert of the contraindications to hormonal birth control. Dr Civelli and Patrick gave us some interesting tips on birth control pills, and Xeng explained the difference between allodynia and hyperalgesia.  Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Lisa Manzanares, Steven Saito, Valerie Civelli, Patrick De Luna, Xeng Xiong, and Mohammad Suleman. Audio edition: Suraj Amrutia. See you next week! _____________________References:St. Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020; 69:1911–1916. https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm?s_cid=mm6950a6_w#B1_down Onusko, Edward, M.D., Diagnosing Secondary Hypertension, Am Fam Physician. 2003 Jan 1;67(1):67-74. https://www.aafp.org/afp/2003/0101/p67.html#afp20030101p67-t1. Zeng, Thomas, MD, Comprehensive Handbook, Obstetrics & Gynecology, Second Edition, 2012 by Phoenix Medical Press LLC, pages 176-178.

Educational Pearls: The CDC has made new formal recommendations for treating Gonorrhea due to increasing resistance to Rocephin and Azithromycin. New recommendations: Confirmed gonorrhea: Ceftriaxone 500 mg once Empiric treatment: Ceftriaxone 500 mg once followed by 7 days Doxycycline 100 mg BID No longer using Azithromycin due to high resistance Second line: Gentamycin IM Cefixime 800 mg oral Pharyngeal involvement has high resistance rates to second line agents and ceftriaxone is strongly preferred References St. Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911–1916. DOI: http://dx.doi.org/10.15585/mmwr.mm6950a6. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.      

Episode 30: Street Medicine BasicsThe sun rises over the San Joaquin Valley, California, today is October 2nd, 2020.I have two sneaky children who are always trying to hide during the week to play video games. Well, I read an article that gave some relief to my worried mind about the benefits of videogames. The article was published in 2007, titled “The Impact of Video Games on Training Surgeons in the 21st Century”. The study consisted in having 33 participants (residents and attendings) to answer a questionnaire, go through a training called Top Gun, and play over-the-counter video games. Then the doctors were evaluated in their performance during laparoscopic procedures. The results showed that video game play correlated with 37% fewer errors and 27% faster completion. Conclusion, video game experience skill correlates with laparoscopic surgical skills. Who would have thought that video games may be a practical teaching tool to train surgeons[1]. “Dementia is one of the greatest challenges in healthcare,” said Andrea Pfifer, CEO of AC Immune, a company developing several treatments for Alzheimer’s Disease. There is a new case of dementia every 3 seconds in the world, currently 50 million people live with dementia, and we still don’t have an effective treatment or cure. The main theory of the pathophysiology of Alzheimer’s is the accumulation of beta amyloid in the brain, but anti-beta amyloid therapies have fallen short in clinical trials, making some researchers reconsider this hypothesis[2]. Some underrated targets may include inflammation and vascular factors. But the tau protein, a key element in the formation of neurofibrillary tangles in the brain, is experiencing a starring moment. Semorinemab is the first anti-tau therapy to enter a phase 2 study. Alzhemier’s disease as a multifactorial condition, may need a combination of treatments with anti-beta amyloid and anti-tau medications, among other therapies. We will continue to hope for a cure as the research continues to evolve in the following years.  This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971. “I am only one, but still I am one. I cannot do everything, but still I can do something, and because I cannot do everything I will not refuse to do something that I can do.”– Edward Everett Hale (frequently attributed to Helen Keller)You are only one, but you can do something for someone. This quote is very appropriate for our episode today, and you’ll see later why. This quote reminds me of the story of the starfish thrower[3], and I have to admit that I had an impulsive purchase a few minutes ago, because that story connected me to my youth, and I want to read it again, so I just bought the book in Amazon. The story is about a man who throws sea stars back to the sea to prevent their death. Even though there are thousands of stars, that man decides to change the destiny of one star at the time. We may be only one, and we may save only one star, but for that star you make a difference. I recommend you read that story. It’s inspiring. Talking about inspiring, I had a conversation with Dr Beare about street medicine, I hope you enjoy it.Arreaza: We have Dr. Beare with us – He’s famous around here, loved my residents and staff, thank you for your time, Dr. Beare, Chief Resident Rio Bravo Class of 2019.Beare: Thank you for the invite and kind introduction, I am Matthew Beare, Medical Director of Special Populations at CSV, development and implementation of special programs for homeless, migrant farm workers, and patients who suffer from substance use disorder. Street medicine program, branch of our homeless help, has been in place for one year. It opened in October 2019. Arreaza: Ok so you are doing street medicine, and addiction medicine, and primary care.Beare: Yes, and often there is overlap between the two.Definition of street medicineArreaza: What is street medicine?Beare: From a medical standpoint, street medicine is basic medicine; more of a philosophical approach, and I guess there’s a practical difference as well, but what we are trying to do is provide high level primary care to our homeless, chronically-unsheltered patients, to meet them where they are, as opposed to have them meet in clinic.Our philosophy of street medicine is “ go to the people,” so once a week, every Thursday, we pack up our medical supplies and a small team of us go directly into a variety of homeless encampments here in Kern County, in Bakersfield, and we provide care on site, so that can be everything from preventative care to acute treatment of different illnesses including procedures such as I&D of abscesses, joint injections, we can provide on-site prescription medications, and we can also start the process of starting lab work, sending prescription information to various pharmacies. From a medical standpoint, it’s a high level primary care, but it’s rather the philosophical approach of going to the patient versus having them come to you.Training needed for street medicineArreaza: How did you get started in Street Medicine? Any special training? Motivation? Offered a position?Beare: I got offered position of medical director and I was doing more research on homeless populations and how to better serve them. I was at a conference in Washington DC where I learned about street medicine. I learned about the philosophical approach and felt it was something missing in our community. When I started, I kept making plans like, “I need to go out, we need to start this team,” and eventually it got so bogged down in preparing to go out that we never went out, so finally in October 2019 we said, “forget it, were just going to go out, do what we think is best,” so we just went out, started seeing patients in variety of encampments, and since then we have been molding it to document it better and to make sure we are providing the highest level of care that we can. But there is no official title in it, to date. There is one fellowship in Pittsburgh, in Street Medicine, which is the first of its kind, so anyone interested in becoming an “official” Street Medicine provider can look into that fellowship. What you do in a street medicine visitArreaza: You’re doing this on Thursday mornings, can you describe to us what exactly you do?Beare: We take two vehicles, we do it at 6:30 AM because it gets so hot by mid-afternoon. We have medical backpacks with a myriad of supplies, gauzes, bandages, kits for I&D, kits for joint injections, prescription medications that we work with a special pharmacy so we can prescribe those on site, and we also bring some harm reduction materials such as clean syringes, sharps disposal containers to distribute, condoms, hygiene kits, we try to bring with us essentials such as food, water, sometimes clothing, blankets. You don’t bring food and blankets to patients in clinic, and it is a crucial need so we are trying to fill that need. We travel to our campsites, right now we are covering a couple mile stretch between N. Chester and 24th St, there’s a riverbed that flows along there. We have covered that homeless encampment site over the last 6 months. We park our trucks, and walk along the riverbed. A lot of them are wooded areas or clandestine, so you can’t really see them. And we have been fortunate enough to establish good relationships with these patients so they actually allow us into their campsites and sometimes directly into their tents, it’s pretty rewarding in that regard. A street medicine teamArreaza: What support staff do you have? A nurse?Beare: Street medicine teams across the US are all different, there are about over 180 teams acting across the world right now, and they can all vary in how they are composed. Our team is myself as the medical provider, I have my Medical Assistant who keeps track of everything we are doing, the medications we are giving, and takes notes. We have two outreach workers with us who help the patients talk to housing authority, or if they need to get their driver’s license or social security card, they coordinate all those social aspects, and we have our homeless liaison, who maybe the most important person on the team, who has an extended experience in homelessness or substance abuse who acts as our go-between, who can communicate effectively and teach us the culture of the encampment so we don’t overstep our bounds, and then we have with us often residents and students who come along for education.Street medicine fundingArreaza: How does this get funded?Beare: California right now has very strange laws on where you can and cannot see patients, so it’s difficult to bill for visits that are outside of the four walls of a clinic, and we are actively  working to change that legislation; we are working with CPCA and DHCS to get that changed, but now, our ability to bill, which is how we have any revenue for this, comes from our mobile unit, the giant RV that we go and take with us. We have very little interaction in the mobile unit itself; it’s there in case we need something, but really its parked there in case we need to use it, or for billing purposes.Patients seen in street medicine roundsArreaza: Who can be seen by you? Can anyone be seen by you or it must be a specific population?Beare: When I am on the street there is no consideration given for your legal status, or your insurance status, if you are someone who is unsheltered and you need help, it is our duty to provide that care. Anyone can be seen when we are doing these street medicine rounds. We see the same patients over and over since we are in the same area, but given the transient nature of these patients we often see new patients and, again, whether they are insured, whether they have legal status as a citizen, it means nothing to us, it is the same level of treatment. Arreaza: And you provide vaccines?Beare: Yes, we do. Every year we are fortunate enough that the Department of Public Health gives us a certain number of influenza vaccines that we can give out. Last year we gave out about 100. If someone needs a specific vaccine outside of their annual flu vaccine, we can bring that out with us in an appropriately cooled container and administer it. And it’s not just vaccines, we give on site injections of Ceftriaxone, we give other on site treatment plans as well, preventative vaccinations and preventative care.Documentation of street medicine encountersArreaza: And documentation, is it just like a normal visit?Beare: Yes, it is like a normal clinic visit, and we do that intentionally as we are submitting these for billing, so we try to follow the same standards as with any other patient. We are currently undertaking some research in this community, so some of the documentation is written in a way for us to pull information from those charts, otherwise the documentation is just like any other patient, and if you read the medical record, you might not know this is a street medicine patient, unless you read “this is a street medicine patient.”A word of advice: Just do itArreaza: That’s great Dr. Beare so if there is someone listening to this episode and considering being a street medicine doctor, what are some suggestions or advice you can give to them?Beare: One of the biggest hiccups I saw when I first started, there was so much time spent in preparing, because it is such a unique way to treat the patients there is a tendency to want to do it perfectly. I could have done research for months or years on how to build the perfect street medicine team, but the only reason the team exists now is because we just went out and did it. I think that’s what it takes because if this is something you are considering implementing into your practice or career, just do it, start it, and make it perfect later, start it first. No one is reinventing the wheel here, there is a street medicine institute, so if anyone needs guidance on how this works, they can reach out or to me directly, I am happy to discuss Street Medicine with anyone who is interested (email: Matthew.Beare@clinicasierravista.org, work phone: 661-328-4283).Safety in street medicineArreaza: Have you ever felt that your safety is in jeopardy when you go out and do street medicine?Beare: I’m glad you brought that up. That is probably the number one concern. When you talk to people who have never experienced or seen street medicine, always the first question is “was it safe, was it dangerous?” Let me just start out, again, with the near 200 street medicine teams, to date, there has not been one reported incident of violence against a street medicine provider, I don’t think the same can be said even about clinic visits, and you’re talking about 200 street medicine teams across the world, not just in California, not just in the US, spanning across every continent, except Antarctica, there are street medicine teams and still there has not been one reported case of violence against a street medicine provider. No, I have never felt like my safety was in jeopardy nor was the safety of my team in jeopardy certainly not by any of our patients. However, you are providing medicine in the elements, and the elements can be brutal especially in an environment like this, so you have to be careful to not get dehydrated, you have to wear sunscreen and stuff like that. And we have had some issues with dogs, but you know we haven’t had, no one’s ever been bit, in my street medicine team. So, if you were at all concerned with safety, it’d be the dogs in the area.PPE in street medicineArreaza: In these times of pandemic what PPE do you use? Gloves? Masks?Beare: When we travel we constantly use our surgical mask, and if we are going to any type of COVID testing, we don the full PPE with the gown, the gloves, the N95 with the face shield, the same precautions we use in clinic, nothing too out of the ordinary. For whatever reason, COVID-19 hasn’t affected our homeless population anywhere near what we thought, it’s affected them significantly less than the general population, and there’s some hypothesis as to why that is, and in our experience, in my anecdotal experience, COVID is less common in our patients.Patient-provider relationshipsArreaza: Any anecdotes you would like to share, anything you saw, any crazy procedures?Beare: Crazy is sort of the norm when we go out. We see a lot of stuff that is surreal sometimes. I think if I wanted to share something about the patients we see or any particular patient, it’s the warmth of which our service is received. The relationships we have built are so profound, we are talking about a population that feels like the whole system has turned their back on them, from healthcare to friends, family, and the community at large has turned their backs on them, and so to get to be that ambassador of the people who genuinely care for you and you deserve the same level of care as anyone in our community, that garners an incredibly rewarding relationship. From a medical perspective, we have been able to treat so many people for chronic illness that they haven’t been treated for years. Dr. Franco, our infectious disease specialist, probably has a huge uptick in treatment for Hepatitis C cases because we have connected these patients to healthcare for the first time in years.We have been able to avoid utilization of emergency rooms because we are managing so many acute infections in the field that these patients don’t need to go to the ER every time they get an abscess. It’s been incredibly a rewarding thing in ways that’s difficult to put in words. Now that I’ve done it for a year, I don’t think I could ever go back to not doing this. I don’t think I know anyone in the field who could not do street medicine once they have been exposed.Arreaza: I feel very fortunate to have you here on our podcast today. You are giving us very valuable information, and the residents are going to appreciate this episode. Thank you because the labor you are doing is a labor of love. You have the knowledge and skills, and you are putting it into practice to help the most vulnerable members of our society.Beare: Well I appreciate you giving me a platform to speak on as well. Arreaza: Dr. Beare thank you for being with us, any last words for our residents or faculty or listeners around the world? Beare: If you have any interest, if this strikes a chord with you, please contact me. I will go out of my way to connect you with the right people. If you need anything regarding street medicine, I am always available.__________________________Speaking Medical: Mittelschmerzby Amy Arreaza, FNP-BC (recorded by Graciela Peña, LVN)We would like to present the winner of our prize for this week. Her name is Amy Arreaza, a family nurse practitioner in Clinica Sierra Vista, who also happens to be Dr Arreaza’s wife (the decision of the winner was unbiased and unanimous). Congratulations, Amy, enjoy your gift card. Now, let’s listen to your definition of mittelschmerz, as read by Gracie Pena.As a woman who has experienced mittelschmerz, I can tell you that ovulation pain is no joke! In fact, severe mittelschmerz can be mistaken for appendicitis and can be included on your list of differentials for a patient presenting with Right lower quadrant or pelvic pain. In most cases, however, mittelschmerz is just an annoying or irritating pain that some women have to put up with mid cycle (hence the name mittelschmerz, German for middle pain).  Mittelschmerz is a pain more bothersome than any “pain in the neck” or “pain in the rear” that I have ever experienced. So instead of using those colloquial phrases to show my irritation, next time my husband is getting on my nerves perhaps I'll tell him “You're a big mittelschmerz!” ____________________________Espanish Por Favor: Abscesoby Lillian Petersen, RNHave you heard that you can add an “o” at the end of any English word and turn it into a Spanish word? You can do just that with the Spanish word of this week. Can you guess what the word absceso means? Yes, absceso means abscess. An absceso is a collection of pus that can be located anywhere in the body. An absceso can form anywhere bacteria, fungus and other microorganisms can grow. Commonly, abscesos need an incision and drainage (I&D) if they are external, for example on the skin; and some may need needle aspiration or even surgery in the OR if they are internal. By draining it, some abscesos may get cured, but some may need antimicrobial medication for associated cellulitis, and large abscesos may need regular changes in packing to get cured. Now, you can add this word to your growing Spanish vocabulary, absceso. See you next week!  ____________________________For your Sanity: Jokesby Tammy Hilvers, MDWhy did the driver hold his nose? His car had gas.What kind of pliers do you use in math? MultipliersWhy did the math teacher skip the chapter about circles? They were pointless.What was the silly chicken doing in the garden? Sitting on an eggplant.______________________Now we conclude our episode number 30 “Street Medicine Basics.” Dr Beare explained briefly what he does on the streets of Bakersfield. He shared his motivation, inspiration, and modus operandi. If you would like to expand on this topic, you may send us an email or contact him directly at Matthew.Beare@clinicasierravista.org. Mittelschmerz means “pain in the middle”. It’s a pain experienced by some women during ovulation around mid-cycle. Congrats to Amy for her creative definition and for her . Our nurses had a special participation today, Gracie recorded the definition of mittelschmerz, and Lilli taught the word absceso, which is Spanish for abscess. What a great team we have!   Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This episode was brought to you by Hector Arreaza, Lisa Manzanares, Amy Arreaza, Gracie Pena, Lillian Petersen, and Tammy Hilvers. Audio edition: Suraj Amrutia. See you next week!_____________________References:Rosser JC, Lynch PJ, Cuddihy L, Gentile DA, Klonsky J, Merrell R. The Impact of Video Games on Training Surgeons in the 21st Century. Arch Surg. 2007;142(2):181–186. doi:10.1001/archsurg.142.2.181. JAMA Network: https://jamanetwork.com/journals/jamasurgery/fullarticle/399740 Loria, Keithm, Alzheimer’s research shifting to tau as a target, Managed Healthcare Executive, September 2020, Vol. 30, No. 9, 7-8. Loren Eiseley, The Star Thrower, New York: Harcourt, Brace, Jovanovich, 1978, pp. 171–73, 184. Quote by David B. Haight, https://www.churchofjesuschrist.org/study/general-conference/1983/10/become-a-star-thrower?lang=eng University of Southern California, Street Medicine, https://sites.usc.edu/streetmedicine/ Street Medicine Institute, https://www.streetmedicine.org/

Join the EMGuideWire crew once again for this month's series on Sepsis in honor of Sepsis Awareness month. Episode 3 will cover antibiotic use and selection. Antibiotics for Sepsis Take a history and perform a chart biopsy first! Consider past infections, bug susceptibilities, healthcare acquired vs. community acquired infection, foreign travel, and comorbidities.  Always check local antibiogram and prior culture results. Septic shock - Start broad spectrum antibiotics within 1 hour. Stable patient - find the source! UA, CXR, and a good skin exam are fast and can help guide antibiotic choice. Remember some patients need surgical management!  Antibiotic choice in septic shock. 1st agent - Piperacillin/Tazobactam (covers GP/GN + Pseudo)  2nd agent - Choose based on patient characteristics Ceftriaxone - simple community acquired infections. Vancomycin - covers MRSA. Meropenem - use for patients with a hx of ESBL. Flagyl + cefepime/meropenem - Use for intra-abdominal infections. Clindamycin - Useful for skin infections (toxin suppression).  Cefazolin - IV line infections, endocarditis, soft tissue infections w/o MRSA (covers MSSA, GAS, GBS).  Summarized by: Travis Barlock, MD PGY-1 References: Alam N et al. 2018. Prehospital antibiotics in the ambulance for sepsis: a multicentre, open label, randomised trial. The Lancet. Respiratory Medicine. 6(1): 40-50.  Dellinger RP, Levy MM, Rhodes A, et al. 2017. Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup: Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2016. Critical Care Medicine. 44(3):486-552.

Amoxicillin, Ampicillin, Cefaclor, Cefazolin, Cefdinir, Cefepime, Cefotaxime, Cefotetan, Cefoxitin, Cefpodoxime, Ceftaroline, Ceftazidime, Ceftriaxone, Cefuroxime, Cephalexin, Clavulanate, Dicloxacillin, Nafcillin, Oxacillin, Penicillin G, Penicillin V, Piperacillin, Sulbactam, Tazobactam This is a volunteer effort put together by medical students to bring you quality audio lectures on the topic of medicine. Our focus is specifically on material that may be covered in the USMLE® and throughout medical school. The first subject that we are covering is pharmacology. Right now, we're a very small team, and we're just getting started, so we may not be able to release episodes on a regular schedule, but we do hope to do so in the near future. We'd love to hear from you! Whether you found an error, believe that some changes should be made to the podcast, or you just think we're doing a great job, please email us your feedback at mededpodcast@gmail.com. Thanks for listening! Music (See link below for more information): "May the Chords Be with You" by Computer Music All-stars is licensed under a CC BY 4.0 License "Where Was I?" by Lee Rosevere is licensed under a CC BY 4.0 License "Night Owl" by Broke For Free is licensed under a CC BY 3.0 License *Disclaimer* - The MedEd Podcast is intended for educational purposes only and it is not intended to replace proper medical consultation from a trained and licensed professional. The improper diagnosis and treatment of disease can lead to injury and death. Contact a qualified healthcare provider about your health concerns. While we will strive to bring the most correct and up-to-date material, the information presented may not always be accurate and is ultimately your responsibility to verify. The MedEd Podcast has no affiliation with The United States Medical Licensing Examination® (USMLE®), or any other affiliations for that matter, and the information presented here is not guaranteed to be representative of information presented on any examination or within the context of medical practice. Any opinions expressed in this podcast belong solely to the creators of said podcast. They do not purport to reflect the opinions of The University of Nevada Reno School of Medicine or the opinions of any other institution with which the creators may be associated. Any opinions expressed in this podcast belong solely to the creators of said podcast. They do not purport to reflect the opinions of The University of Nevada Reno School of Medicine or the opinions of any other institution with which the creators may be associated. Click here for the transcript of this episode, or you can use this URL if the link isn't working: https://docs.google.com/document/d/1n1HR9P44qrKbkr97Nw2aTKXxNi8nuCwfccJ_t1lbvr8/edit?usp=sharing

  This episode we celebrate the release of the new Therapeutic Guidelines - Antibiotic! Jane and Kristin are joined by Senior Editor Jess Gibney and Dr Emily Tucker, ID Physician from Flinders Medical Centre to discuss what’s new and what’s changed. Things we learnt include: How to say Happy Easter in Greek How Therapeutics Guidelines put its expert groups together The process of updating guidelines Why TG is no longer being published in hard copy Changes to surgical prophylaxis recommendations The new inclusion of intravenous Amoxicillin/Clavulanate as a treatment option, and the behind the scenes discussion around the use of this agent, including dosing controversies New advice for Ceftriaxone dosage The choice to expand advice around “watching and waiting” and when NOT to use antibiotics A new approach to the classification of community acquired pneumonia Significant changes to advice around antibiotic allergies (side chains!) Some challenges in updating the paediatric section of the Guidelines Visit the Therapeutic Guidelines at http://www.tg.org.au

This podcast presents an interesting internal medicine case of a patient who initially presented to themselves to the clinic with a chief complaint of a cough, and the chain of events that occurred with this particular case.  Joining Dr. John Peitersen, (Internal Medicine) in the case discussion today include: Dr. Barrett Larson, (Pulmonary Medicine), Dr. James Currie (Lakeview Clinic-Infectious Disease), Dr. Matthew Herold (Emergency Medicine), Dr. David Gross (Radiology), Dr. Susan Bowers (Pathology), Dr. Kevin White (Hospitalist), along with various other providers and Allied Health staff.  Enjoy the podcast. Objectives: Upon completion of this CME event, program participants should be able to: Perform a differential diagnosis on cases presented. Identify limitations of certain tests. Discuss the interpretation of lab results on the cases presented. CME credit is only offered to Ridgeview Providers for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within 2 weeks.  You may contact the accredited provider with questions regarding this program at rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit:  CME Evaluation: 2019 Internal Medicine Case Conference (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition.” FACULTY DISCLOSURE ANNOUNCEMENT  It is our intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.   Show Notes:      This is the case of a 44 year old woman who initially presents for a cough for about a week. She is obese and has OSA. She is on flonase. She had a low grade fever. Exam doesn’t reveal much besides a serous OM and some mild anterior cervical lymphadenopathy. Conservative care was advised, as well as follow-up in the next couple weeks if not improving. Dr. Peiterson now will tell us the chain of events in this peculiar case. Joining Dr. John Peitersen in the discussion today are: Dr. Barrett Larson from Ridgeview pulmonary medicine, Dr. James Currie, Lakeview Clinic infectious disease, Dr. Matthew Herold, Ridgeview emergency medicine, Dr. David Gross, Radiologist with Consulting Radiologists, Ltd, Dr. Susan Bowers, Pathology, Dr. Kevin White, Ridgeview hospitalist, and various others from the provider and allied health audience.      The initial small segment of this discussion had recording difficulty, so our conversation picks up immediately after the initial presentation of the patient.   CHAPTER 1 REVIEW:      So... let’s recap up to this point. So far we have heard input from Dr. Peiterson, Dr. Larson the pulmonologist, Dr. Gross the radiologist and Dr. Bowers the pathologist. So, initially she was seen for what sounds like a viral URI, and was told to f/u if not improving. Well, we all see this kind of case every day, right? She was then treated by phone with Azithromycin; seen by different providers; Reports “crackling in the lungs’, malaise and subjective fever. She has a Son who had strep 9-days ago. Ears look better today. Cryptic tonsils. VSS. Negative strep test. This was felt to be Viral bronchitis.  CXR offered, patient declined due to $.      Five months later, the patient sees a sleep doctor. Continued cough noted. Pulmonary function tests are likely now indicated. Is there mild asthma? PFTs are able to give us a lot of information. Is the FEV1-FVC ratio acceptable.  Yes, it’s above 80 -  in her case. Chance of asthma markedly low. However the diffusion capacity is low at 83. For some reason, she is not absorbing O2. Nothing really going on with her expiratory loop, or any other major issues with this test. Is the patient’s obesity contributing to her poor lung perfusion? Interestingly, her weight has decreased by 15 lbs since her last visit.       Pulmonary physician recommended a CXR, a 4 week post nasal drip protocol. Additionally is a metacholine challenge needed here? Often a pre- and post-neb peak flow will first be done first. Then the metacholine challenge is done if the clinical picture fits. Is it time to rule-in or out asthma and spare someone years of MDI use. Diffusion capacity should be normal in asthma.       Dr. Peitersen reflects on an often asked board question. When to get a chest xray for the complaint of persistent cough. Barring other obvious reasons such as new chest pain, high fever/shaking chills or focal exam findings, The American College of Chest Physicians recommends that if a cough is present for greater than 8 weeks, a CXR is indicated. This patient’s CXR reveals interstitial changes that bring up a broad list of possibilities on the differential. These include CHF, infection, autoimmune disease.      Chest CT non-contrast was now ordered and shows reticulonodular areas and some regions of consolidation that are almost mass like. Other patchy areas noted throughout. No endobronchial findings. Lymphadenopathy is also noted in various areas of the intra- and extra-thoracic regions. CT with contrast is important to see vascular issues, but also to see small hilar lymph nodes. Sometimes contrast can falsely increase the density of a nodule leading you to call it a granuloma. Hi Resolution chest CT is an older term, but current modern CT scans accomplish this . This involves 1 mm cuts vs. 3 mm cuts. Essentially thinner cuts to see nodules better.      The patient is now seeing a new pulmonologist and has normal vital signs, unremarkable lung exam, which is not totally unusual despite a very abnormal looking xray or CT. A PET CT scan is advised and will show hypermetabolic lesions. Essentially it will help find other areas of concerning activity that would be less risky to biopsy. Radiologist generally avoid biopsy of central lesions that are near important organs and structures. Insurance declines the PET CT, but a node was biopsied in the thigh. Dr. Bowers comments that this biopsy could be a low grade lymphoma, although at this point it would need further assessment, but this is a send-out, looking for B and T cell rearrangement. A hematopathologist would also be good to consult with in this case. For now, this is benign specimen.       Another lymph node specimen was obtained, now axillary. This one shows really no other concerning findings. Tiny granulomas are noted. A variety of staining procedures were performed and all were negative. For Dr. Bowers, Toxoplasmosis may need to be considered.   CHAPTER 2:      Toxoplasmosis seems unlikely because this patient is apparently not immunocompromised. The differential dx does include various other infectious etiologies, such as bartonella, brucellosis and Q-fever. Melioidosis as well. Therefore, a travel history such as to SE Asia should be obtained. So, what now? There are about 20 possible infectious etiologies for this presentation...we need to do more tests. But, the patient was lost to follup for some time.       Now it is 16-months later, and she returns to urgent care with cough, fever, increased respiratory rate, O2 sats are marginal and an abnormal lung exam. Mild leukocytosis noted, and anemia which is new. Dr. White interjects with the following questions: 1. Has she ever been treated with a steroid? 2. Did anyone perform laryngoscopy? In the setting of normal chest imaging, these things should be considered. But of course, since her last CT scan was abnormal, a pulmonary etiology is of highest concern. And indeed a repeat CXR shows worsening overall interstitial change along with increase in the density of the azygoesophageal fissure which was noted on previous CT. The UC provider feels this looks like pneumonia. She was treated for pneumonia and a potpourri of other remedies were tried. Unfortunately, she did not follow-up with her medical doctor. She did see her naturopathologist who resumed drops for bartonella and Lyme disease. As Dr. Currie said, though, Lyme Disease does not present with granulomatous lymph lesions.       She now presents to the Emergency department 18 months after the UC visit. She is SOB, coughing, and states she has “chronic lyme disease”. She is 85% on RA. She has SIRS. Leukocytosis, and a respiratory alkalosis is noted. Her CXR shows Left upper lobe infiltrate that is quite dense. This must be followed to ensure resolution. Lactate and influenza were normal. The commentary from Dr. Herold in the audience was that this patient is not quite meeting sepsis criteria, but quite ill all the same. The decision to initiate broad spectrum antibiotics was made. Further history demonstrates that she was diagnosed with Lyme disease at age 10 and has struggled with health issues ever since. The patient had ongoing frustrations about cost of care and so she continued to see her naturopathologist.       Regarding another good exchange between Dr. Gross and Dr. Herold, involved the discussion of using CT to differentiate this very abnormal CXR for infiltrate vs. empyema. Ultrasound can also be employed for thoracentesis if indeed it is empyema.       Dr. Currie also makes the point that "chronic lyme disease" is not a known condition, so that when patients present with this issue or concern, other underlying disease states must be considered.      While CAP is the leading dx, other considerations in the differential still exist. Dr. Curry also states that azithromycin/Ceftriaxone is a reasonable inpatient treatment regimen going forward. She is feeling better on hospital day 2, but her blood cx come back positive in all 4-bottles. Strep pneumonia is the culprit, and is the current, but certainly not chronic reason for her symptoms. TTE was recommended to rule out endocarditis, especially given her chronic issues. Echo showed high right sided pressures, and a CT PE study was done showing no PE. Dr. Gross discusses the CT reading and notes bilateral signifcant hilar and subcarinal lymphadenopathy. Dense alveolar consolidation around the bronchi and layering left sided pleural effusion. Also noted is a large spleen and some prominent retroperitoneal nodes. Hospital day 3 she has left sided chest pain and had an unchanged repeat chest CT.       Dr. Bowers, the pathologist, discussed the blood cell differential and comments that she is anemic and that is the primary issue. All other counts are normal. Mild rouleaux (stacking of cells) is noted on the morphology and prompts you to think about increased proteins, such as monoclonal and fibrinogen. On hospital day 3, the patient was to go home on levaquin. She is supposed to f/u with pulmonary, but then develops another fever and requires O2 once again. Fever after 40-hours of antibiotics is not entirely unexpected in this patient, especially due to her past history and the likelihood of some underlying etiology that has yet to be discovered.   CHAPTER 3:      Okay, so her immunoglobulins are low. What does that mean? Well, this looks like Chronic Variable Immunodefincy disorder. Does she need IVIG? Yes, it is worth a try per the immunologist. Especially since she is having fevers, rigors and need for increased oxygen. Repeat CXR shows some mild improvement in infiltrate, but a bit more of a CHF pattern, perhaps. ID is involved now and they feel that CVID made sense as a diagnosis. Her symptoms improved and no further IVIG is given. In terms of follow-up, the patient has done quite well. No further hospitalizations to date. There were some barriers in her care involving cost and insurance issues. A repeat CT in 2018 was reviewed by Dr. Gross and she still has some reticulonodular infiltrates. No further dense consolidation in the lung. Lymphadenopathy has improved in general. And the spleen is still enlarged. The patient apparently then was referred to another facility and had another node biopsy after she had yet another scan that showed once again some worsenening. IVIG is helpful for these patients and unfortunately is also very expensive. Many of these patients succomb to cancers of various types, as opposed to infection as they once did many years ago.       According to UpToDate, Common variable immunodeficiency is the most common form of severe antibody deficiency in adults and kids. It is somewhat complex, but in general is due to severe antibody deficiency due to impaired B cell differentiation with defective immunoglobulin production. Recurrent infections, chronic lung disease, GI disease and increased susceptibility to lymphoma are common. Besides having very low IgG, IgA and IgM levels, there is also a poor or absent response to vaccinations.      Feel free to comb through the literature on this one, and while it is not ultra common, it is not unreasonable to consider this in your patients who just can’t seem to avoid getting sick on a regular basis, or who happen to have significantly waned immunity to pathogens they were once immunized for.   Thanks to Dr. Peiterson for bringing this baffling diagnosis to our attention, and to everyone else involved in presenting this case.

Show notes at pharmacyjoe.com/episode374. In this episode I ll: 1. Discuss a review article about musculoskeletal toxicities in patients receiving concomitant statin and daptomycin therapy 2. Answer the drug information question “Is there any benefit in de-escalating ceftriaxone to cefazolin?” The post 374: Musculoskeletal toxicities in patients receiving concomitant statin and daptomycin therapy and the benefit of de-escalating ceftriaxone to cefazolin appeared first on Pharmacy Joe.

Back by popular demand, Prof Jason Roberts joins Dan to discuss ceftriaxone. They discuss situations where ceftriaxone is useful (spoiler: it's not "being an inpatient") and some pharmacokinetic quirks.

Disclaimer: This is the unedited transcript of the podcast. Please excuse any typos. Jeff:  Welcome back to Emplify, the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum, and I’m back with my co-host, Nachi Gupta. This month, we’ll be talking Updates and Controversies in the Early Management of Sepsis and Septic Shock. We have a special  episode for you this month… We’ve brought Dr. Jeremy Rose, one of the peer reviewers, and a sepsis expert, on with us to talk through the content this month. Jeremy: Dr. Jeremy Rose here. Thanks for having me in on this conversation.  I’m always happy to talk about this topic because it’s clearly important.  There’s a great deal of confusion around sepsis and I hope that in the next couple minutes we can clarify things in a way that really help your average front line doc trying to get it right. Nachi: So Dr. Rose, before we get started, tell us a bit about your background and your interest in sepsis… Jeremy: I’m the Assistant Medical Director and Sepsis Chair at Mount Sinai Beth Israel in Manhattan.  For those listening, my hospital probably looks a little bit like yours.  We’re busy, interesting, and just a little rough around the edges.  We like it that way.  More importantly, though, we mirror the national averages regarding sepsis.  Roughly half of in-hospital mortality is associated with septic  in some fashion.  Pretty incredible when you think about it.  Half. Jeff:  Sepsis chair... clearly this is an important topic if it warrants it’s own chair at a major hospital in NYC. But getting back to the article this month. This month’s issue was authored by Faheem Guirgis, Laurent Page Black, and Elizabeth DeVos of the University of Florida, Department of Emergency Medicine. Nachi: And it was peer reviewed by Michael Allison, Assistant Director of the Adult ICU at Saint Agnes Hospital, and Jeremy Rose and Eric Steinberg of Mount Sinai Beth Israel. Jeff: So as well all know Sepsis is bread and butter emergency medicine, but, what is sepsis?  It seems that every month or so we have a new guideline, bundle, definition, or whatever… I think it’s best to start with the basics -  At its core, sepsis is a dysregulated response to infection that can be life-threatening. Nachi: Right and it’s the combined inflammatory with immunosuppressive features of sepsis that lead to the devastating organ dysfunction and even death. Optimal management of septic patients has been a source of intense research, stemming from the landmark study by Rivers in 2001. Jeremy, can you give us a little historical context there? Jeremy: Rivers was a real pioneer.  He found a 16% mortality reduction with randomization to an early aggressive care bundle.  Amazing work.  That being said, many components of that bundle have since been disregarded.  For example, Manny Rivers would measure CVP in all of his patients, something we rarely do. Nachi: Not to cut you off and steal your thunder there, but we’ll get to the most recent updates in management shortly. Let’s first talk definitions and terminology, and specifically, diagnosis, which is definitely a big elephant in the room. As Jeff mentioned a few minutes ago, diagnostic criteria have undergone so so so many changes. Jeff: Yes it has! 1991 marked the first standardized definition.  Then in 2001, sepsis-2 was introduced.  In 2014, the Society of Critical Care Medicine and the European Society of Intensive Care Medicine started a task force, and by 2016, updated definitions were out again! Sepsis-3!! A lot of this came after the realization that SIRS was just too broad and was overly sensitive and non-specific. Jeremy, why don’t you take us through Sepsis 3. Jeremy: So just to back up a little and frame this: Here’s the fundamental problem:  As we likes to say, “there’s no troponin for sepsis.”  And if you look at our patients, we tend not to miss the hypotensive, tachycardic, febrile patient.  We know they’re septic.  But how do we find the ones who don’t look as sick.  Frequently elderly, possibly with normal-ish vitals and no fever.  Those can be a lot harder to spot, but they may indeed be septic.  Also, for research purposes we have to have a common definition, so Sepsis 3 came up with something called the SOFA score. The problem with the SOFA score is that its difficult to perform in the ED.  It has parameters like bilirubin that often aren’t available when we want to screen out very sick patients.  Fortunately there is the abridged version qSOFA, which identifies non-icu patients who are at high risk of inpatient mortality. So here it is, and if you get one thing from this episode, this is it: There are ONLY 3 criteria to the qSOFA.  3 Criteria. RR > 22; AMS; SBP 2. So quite a few changes! Jeff: And Jeremy, sticky topic coming up here. Center for Medicare and Medicaid Services (or CMS) quality measures - They haven’t really caught on to and adapted to Sepsis-3 yet, have they? Jeremy:  The CMS mandate is based on the presence of SIRS criteria. Sepsis 3 is based on SOFA.  This is definitely confusing.  Part of the challenge in discussing this topic is separating out the QI guidelines from what is actually relevant to patient care based on the latest evidence-based medicine. Nachi: That seems fair.  We’re really going to put you in an uncomfortable spot for a second and push you here Jeremy. Do you have any insight into why CMS isn’t interested in following the mountains of research that have led to sepsis-3? Is there a reason they are sticking to their current criteria? Jeremy:  I think some of it is the slow pace of bureaucracy and the time that it takes to develop a consensus on management.  Even if we can agree on who is septic, it’s really hard, if not impossible to link the care to a pay-for-performance metric which is what CMS ultimately would like to see.  That’s not how Sepsis-3, or for that matter, SIRS, was designed to be used.  You’re trying to take a tool which was originally designed for research and mold them into a tool used for pay for performance. Nachi: What a struggle. The CMS metrics are slightly different from the 2001 sepsis guidelines also. Take a look at Table 2 of the article for a quick comparison of sepsis-3, 2001 sepsis, and cms side-by-side. And for those on twitter, we’ll be sure to tweet this table out too for your review. Jeff: With so many different scores and definitions, I think that adequately sets the stage for the challenge this month’s authors faced coming up with real evidenced based guidelines. Nachi: Oh absolutely.  And to make matters worse - this is a HUGE problem. We’re talking up to 850,000 ED visits annually in the US, and 19 million cases worldwide. Compounding this, sepsis results in death in approximately 1 out of 4 cases. Not only is it lethal, it is also very costly -- 17 billion dollars per year in the US alone! Jeff: And don’t forget importantly the 30-day hospital readmission rate. Sepsis is coming in at a higher readmission rate and cost per admission than acute MI, CHF, COPD, and PNA. Nachi: Let’s speak briefly on the etiology and pathophysiology of sepsis: we all know that sepsis is due to local infections that then become systemic. Previously, it was believed that the bacterial infection itself was the cause of the clinical syndrome of sepsis. However, we now know now that the syndrome of sepsis is due to the inflammatory and immunosuppressive mediators that were triggered by the infection. Normal immune regulatory safeguards fail and this leads to the syndrome. And interestingly, several studies have shown that critically ill septic patients experience reactivations of specific viruses that were previously limited to patients with severe immunosuppression. Jeff: Definitely something to look out for in your critically ill septic patients.  We should talk  briefly about the most common inciting infections that lead to sepsis. In order, these are: pneumonia, intra-abdominal infections, and urinary tract infections. No surprises there! Nachi: Yeah, that basically parallels my own experience, so that’s reassuring!  That takes us to our next potentially controversial topic - blood cultures.  Jeremy - we’re going to punt this one back to you Jeremy: This is another interesting topic that has received plenty of attention.   CMS loves blood cultures.  It’s an easy metric to track.  That doesn’t mean they’re always helpful.  We looked at our patients with lactates between 2.1 and 4.0 which had “severe sepsis.”  These patients were normotensive though, In other words, the ones that aren’t that sick.  We found that blood cultures are useful about 20% of the time.  That’s not bad.  So what do we do? We draw cultures before pushing antibiotics.  Is that helpful? Sometimes yes, does it waste money?  Debatable.  Does it help us meet our metrics, yes. Jeff: And I think that gets at the crux of the problem here: we don’t want to delay antibiotics on anybody, but we must balance this with the potential harm of further increasing the drug resistant bacterial population via sound antibiotic stewardship.  Remember also that there is a broad differential for sepsis, with several “sepsis mimics”. To name a few, we have PE, MI, CHF, acute pulmonary edema, DKA, thyroid storm, GI bleeds, drug intoxications, and withdrawal syndromes, just to name a few.  In case that wasn’t enough check out Table 3 of the article. Nachi:  And we already mentioned the leading causes of sepsis, that’s pneumonia, intra abdominal infections, and uti’s. But remember the source can be anywhere. Be sure to also think of pyelonephritis, central line associated bloodstream infections, prosthetics, endocarditis, necrotizing fasciitis, and meningitis. Jeff:  I don’t think we need to dwell on this much longer - basically the differential is huge.  Let’s move on to my favorite section - prehospital care. Jeremy: 20 pages of evidenced based recommendations and your favorite is the prehospital section, what’s up with that? Jeff: I’m an EMS fellow, what can I say… Anyway, on to my favorite section -- prehospital care.  This is always a hot topic because the prehospital period is a special opportunity to get early interventions in for septic patients  as 40 - 70% of all severe sepsis hospitalizations arrive via EMS. Nachi: And in one study taking place in a large metropolitan area, prehospital care time was over 45 minutes, and less than  37% arrived with IV access. Of course, these numbers would vary significantly based on where you practice. Jeff: So get this -- one study showed that out-of-hospital shock index and respiratory rate were highly predictive of ICU admission. So clearly early recognition and therapy may play a role here. Another study, however, showed knowledge gaps by advanced EMS providers in diagnosis and management of sepsis. And yet another study showed that only 18 to 21% of confirmed septic patients were suspected of having sepsis by EMS. Out of hospital fluids were started in only half of patients with severe sepsis. In essence, there is likely a strong role here for pre hospital protocols for identifying and treating sepsis. Nachi: In terms of pre hospital treatments though, prehospital IV fluids haven’t been shown to improve mortality, but have been associated with shorter hospital stays. Prehospital sepsis protocols have been described, but in general more research is needed in this area. Jeff: While prehospital care hasn’t yet been shown to improve the prognosis of septic patients, those presenting via EMS do have shorter delays to initiation of antibiotics, IV fluids, and early care bundles. EMS should focus primarily on stabilizing vital signs and providing efficient transport. If it’s possible to establish an IV and initiate fluids without delaying transport, EMS should do that as well. Nachi: And of course, oxygen for the hypoxic patients! Moving on to history and physical for your presumed septic patient. Jeremy, what are the big hitting things here that you always ask and check for, and that you make sure your residents are doing? Jeremy:  After ABC’s and glucose, AMS is really important, it’s in the QSOFA SCORE.  Unfortunately, this can be hard in many septic patients where they’re baseline mental status is less than perfect.  The other thing is to try and find the source.  Finding the source lets you make wise choices about therapy. Jeff:  Great point about the mental status - so many of our older population have an altered baseline, but recognizing changes from that baseline is key. Nachi:  Absolutely, with that in mind, let’s talk diagnostic studies, especially lactate.  Where I trained, basically everybody was getting a lactate, even tired looking residents seemed to be having their lactates checked, and trust me, they weren’t looking that good... Jeremy:  Brace yourself: lactate is really important in septic patients.  That being said, not every cause of elevated lactate is sepsis.  There is this animal called Type B lactic acidosis can come from numerous drugs like albuterol. Just because you see elevated lactate doesn’t mean you can forget about the other causes.  That being said, we know that patients with sepsis do better when they clear lactate. Jeff: Seems like the evidence is definitely in favor of serial lactate testing… Jeremy: For sure.  At least until you have a reasonable trend towards improvement.  We know lactate clearers do better.  We’ve looked at our own lactate numbers.  Interestingly, the takeoff point for sepsis seems to be around 2.5.  Meaning that patients with altered vitals and lactates above 2.5 tend to do worse.  But, there is a broad ddx to elevated lactate.   What is true, though, is that lactate is a marker for badness.  If your patient’s lactate is rising, yours should be too. Nachi: I bet I’m a “lactate clearer”. I may add “lactate clearer to my CV,” sounds impressive.  But I digress…  Next up we have Procalcitonin.   Since procalcitonin becomes elevated in those with bacterial infections, intuitively, this should be a valuable marker to assess in potentially septic patients.  Unfortunately procalcitonin lacks negative predictive value so most literature supports its use in diagnosing pulmonary infections and for antibiotic de-escalation. Jeff: Good to know, I’ve seen it being used a lot more recently and wondered how evidence based this test was. Jeremy:  Honestly, I don’t see Procalcitonin changing ED management at the moment.  If you’re   waiting for Procalcitonin to start antibiotics or fluids, you’re waiting too long. Nachi: Moving on, let’s talk imaging.  Based on current studies, the authors recommend focused imaging only.  In addition, they also note that our good friend, the point of care ultrasound, likely plays a role, as in one study, POCUS demonstrated a 25% improvement in sensitivity from clinical impression alone. Jeremy:  I think there are two ways POCUS comes in.  One, lung ultrasound can be really useful to find that occult pneumonia or differentiating pneumonia from CHF.   Two, your ultrasound is your best tool for assessing volume status.  I try to look at the IVC of all my septic patients and echo them when possible. Nachi: Right.  So now we’ve examined, drawn labs and cultures, checked a lactate, may be obtained imaging… next up we should probably start treating the patient. Whether you like it or not, we have to discuss CMS. Jeremy: Just to clarify before we start.  CMS defines “severe sepsis” as SIRS + infection with a lactate of 2.1-4.0. Septic shock is SIRS + infection with hypotension or a lactate > 4.0. That’s where we’re at. Jeff:  Good point.  Back to treatment: within the first 3 hours, for any patient with sepsis and septic shock, you must measure a lactate, obtain 2 sets of blood cultures, administer antibiotics, and give an isotonic fluid challenge with 30 cc/kg to patients with hypotension or a lactate greater than 4.   Then, within the first 6 hours, you must apply vasopressors to achieve a MAP of at least 65, re-assess volume status and perfusion, and remeasure a lactate. Nachi: This begs the question - are these recommendations evidenced based? Jeremy…. Jeremy: I’m so glad you asked that . Let’s start with fluids. Patient’s need adequate fluid resuscitation.  Interestingly there are 3 large RCT’s, PROMISE, PROCESS and ARISE,  that compared a Rivers type bundle to usual care.  Surprisingly, they showed no difference.  But when your drill down into these 3 trials, you see that “the usual care,” now generally includes at least 2 liters of fluid. Jeff: Ok, so it seems that there is some pretty good data to support a rapid fluid challenge of at least 30 cc/kg.  But how do we determine who needs more fluids and how much more they need.  There must be an endpoint to all of this? Jeremy: Another million dollar question. 30cc/kg is probably a good place to start.  How much is too much?  I think we need to be smart about our fluids.  Some patients will need less and some will need much more.  So, I remind my resident’s to be smart about fluids.  Sono an IVC, trend a lactate, follow a urine output, do a passive leg raise, even check JVP.  I mean just because you haven’t seen a unicorn doesns’t mean they’re not real.  Do something to monitor volume status. Nachi: Very important. Put your ultrasound skills to work here. They’ll only improve as you practice more.  Jeff, let’s get started on the ever important topic of antibiotics. Jeff: Sounds good.  Current guidelines recommend that broad spectrum antibiotics be administered within the first hour of presentation for those with sepsis or septic shock, ideally with blood cultures being drawn beforehand. In one study, every hour of delayed abx administration was associated with an 8% increase in mortality.  Since this 2006 study, other studies have had mixed results - with studies showing increased odds of death with delays in abx administration and others showing only a benefit in those with septic shock with or without hypotension with no benefit to those without shock. Nachi:  In terms of antibiotic coverage - you need to consider the site of infection, local resistance patterns, the presence of immunosuppression, and the patient’s age and comorbidities.  Table 5 of the article is very thorough and should be kept as a quick reference. Jeremy do you have any specific recommendations for our listeners on how we should approach antibiotic usage in the septic patient? Jeremy: I like to think about antibiotics a little more simply than referencing a table.  I ask a couple questions.  Does my patient need MRSA coverage ?  Does my patient need Pseudomonal coverage?  If the answer is no and no, then narrow your coverage.  You don’t necessarily have to use a bunch of Vanco, or a big gun antipseudomonal like Pip/tazo.  Also, have a look at your local antibiogram.  I can’t tell you how many times this changes prescribing habits for even things like simple UTIs.  I’m going to stray into some controversial territory here. The benefits of sepsis protocols are measured one patient at a time, but the harms are only measured in the aggregate.  What does that mean?  CMS metrics have caused us to  use to use more broad spectrum antibiotics.  As a result, we’re seeing more resistance.  My resident’s tell me to make it easy, give em VZ (that’s vanco/zosyn) and it kills me.   Every time you put a Z-pack into the world a pneumococcus gets it’s wings. So think more about your antibiotics, and know your local biograms. Jeff: That’s a great way to think about it, I fear I’ve given a lot of pneumococci wings during my training…  Next we’re on to vasopressors.  The data is pretty clear on this one - norepinephrine is the recommended first line vasopressor for septic shock.  In numerous trials comparing Norepi to dopamine, NE was far superior, with dopamine increasing arrhythmias in one trial and associated with an increased risk of death as compared to NE in another trial. Jeremy:  So here’s a question I get all the time: How can I give Norepi without a central line.  Let’s use Dopamine, its safe peripherally.  Ok, so follow that through.  We’re going to give a drug to increase blood pressure by constricting blood vessels, but don’t worry, it’s safe peripherally.  What does that mean?  It means it doesn’t work!!  It doesn’t give much blood pressaure.  Dopamine is a lousy pressor.  It causes a lot of tachycardia, which is not what you want in failing septic hearts.  So what do we do if we don’t have a central line?   We start norepi peripherally into a large bore IV for the time it takes us to get a central line.  That’s where the evidence is.  There’s a mortality benefit to NE over dopaine in septic shock. Jeff:  Right, this month’s authors note peripheral pressors may be safe for brief periods in settings with close monitoring.  While this is commonplace in some hospitals, others haven’t yet jumped on that bandwagon. I think it’s important to mention that this is becoming more and more commonplace, even in the prehospital realm.  With the service I fly for, we routinely start peripheral vasopressors without hesitation.  But this isn’t limited to the air.  Many ground 911 services have also adopted peripheral vasopressors in a variety of settings. Nachi: I’m sure there are many trials to come in the future documenting their safety profile, but moving on to the next pressor to discuss... vasopressin. This should be your second line vasopressor for septic shock.  In the VASST trial, low-dose vasopressin was found to be noninferior to NE.  In other trials, vasopressin also appeared to show a potential benefit in those with AKI and sepsis, although the subsequent VANISH trial (perhaps the best name for a clinical trial so far) failed to demonstrate a benefit to vasopressin titration with regard to renal outcomes in septic shock. Vasopressin has also been shown to reduce NE dosing when administered at a fixed dose of 0.03-0.04 units/min. Jeff: Next we have epinephrine.  In one study epinephrine and NE were equivalent in achieving MAP goals in ICU patients with shock, however several of those receiving epi developed marked tachycardia, lactic acidosis, or an increased insulin requirement.  The increasing lactic acidosis could confound the trending of lactates, so in those requiring inotropy in addition to some peripheral squeeze - the authors recommend adding dobutamine to norepinephrine instead of starting epinephrine. Although, keep in mind, this can lead to some hypotension so remember to start at low doses. Nachi: Phenylephrine, a pure alpha adrenergic agent, is next and should be considered neither first nor second line, but it may have a role as a push dose agent while preparing other vasoactive agents. Jeff: And lastly, we have angiotensin 2.  One recent 2017 study examining the role of angiotensin 2 in those with septic shock already on 0.2 mcg/kg/min of NE found that those receiving AT2 had significant improvements in MAPs as well as cardiovascular SOFA score at 48h with no difference in mortality.  Unfortunately, these benefits do not come without risk as AT2 may increase risk of arterial and venous thrombosis and potentially thromboembolism.  Clearly, one study isn’t enough to change practice, but it’s certainly food for thought. Nachi: So that wraps up vasopressors. Jeremy, we’re on to corticosteroids -- another hotly debated topic. When do you give steroids in sepsis? Jeremy:  Hmmm steroids, this is an age old question.  No study has clearly supported the blanket use of steroids in septic shock. Several like CORTICUS and ADRENAL showed no difference.  I will use hydrocortisone for pressor refractory shock. Meaning, you’ve tried everything else, so you might as well try.  Also, I do tend to avoid Etomidate, given the possibility of adrenal suppression and that there are several other induction agents, notably Ketamine  that don’t have this problem. Jeff: Those trials are certainly important, thanks for bringing them up - Especially with all the FOAM content out there, it’s incredibly important to look back at the data to understand where certain recommendations are coming from.   Anyway… one quick note on blood transfusions before we move on to special populations - Although part of the original early goal directed therapy, thanks to data from the TRISS trial which showed no difference in outcomes with a transfusion goal of 7 vs 9, transfusions are reserved for those with a hbg of less than 7. Jeremy:  One population we should make sure to mention and be careful with is end stage liver disease.  In the ER, we tend to miss SBP alot.  Mostly because these patients have lots of reasons to be sick and they already have elevated lactate because of their deceased clearance.  My practice is to give a dose of Ceftriaxone and sent a diagnostic tap to patients who are sick and have ascites. Nachi: Alright Jeremy, let’s talk controversies in sepsis. We’re giving you all the big questions this month! Jeremy:  We’ve already talked about fluids and how much to give.  Just a reminder that a history of CHF doesn’t preclude proper fluid resuscitation.  I think broad spectrum antibiotics for relatively well patients is a big controversy.  Our national rates of antibiotic resistance are terrible, and yet we’re using more antibiotics all the time.  There are very few if any antibiotics coming down the pharma pipeline and we’re going to have to face the music eventually.  Finally, we need national metrics that mirror clinical evidnece.  Protocols should be a tool and not a crutch.  You know what’s best for the patient in front of you, so don’t let metrics or protocols make you do things you think are not in your patient’s best interest. Nachi: So how do you escape the hospital protocols and CMS and do what’s best for your patient without “getting in trouble”? Jeremy: Here’s how I deal with it as the one who reads and QI’s all of our sepsis charts. I tell my colleagues to do what’s right, and if you need to deviate from the protocol tell me why.  As long as you can explain your decision, I’ll support it.  Explaining your thinking is good clinical practice and is good medico-legal practice. CMS has been unable to link these metric  to payment, simply because no hospital can meet them with any regularity.  It’s important that we advocate for our patients or nothing will change. Make them respect you for the highly educated professional that you are, and your patients will ultimately benefit. Jeff: Preach!! And before we close out with disposition, there are a few new therapies and trials on the horizon to keep a lookout for. The RACE trail examined the role of L-carinitine.  The VICTAS trial is looking at vitamin C, thiamine, and steroids in sepsis.  The CLOVERS trial is looking at early vasopressors vs a crystalloid liberal strategy.  And lastly, IL-7 is also being investigated.  All really cool stuff that could change how we manage sepsis in the future.. Nachi  A few quick notes on disposition before we close this episode out.  Certainly not all patients meeting SIRS require admission, but many do.  Those with qSOFA of 2 or higher represent a sick population and an ICU admission should be considered.   Even for those with a qSOFA of 1 but a lacate over 2 -- they have a mortality approaching that of patients with a qSOFA of 2.  Be careful just sending a patient who is on the fence to the floor because several studies have demonstrated that patients who are later upgraded have worse outcomes. Jeff: That’s in line with the general themes we’ve laid out today - definitely better to start early with aggressive care rather than play catch up later.  Jeremy - in 30 seconds or less, what are the most salient points in the management of sepsis that you would like our listeners to take with them from this episode. Jeremy:  Here are my take aways: qSOFA, RR, AMS SBP < 100 Norepi, not Dopamine - it doesn’t work! Be smart about fluids!! Be smarter about antibiotic use! You are the best advocate for your patient, despite what anyone else says! Jeff: Excellent, so that wraps up the October 2018 episode of Emplify. A big thanks to Jeremy Rose for joining us. Jeremy: Thank you for having me!!! It was great talking with you. Nachi: For our listeners -- additional materials are available on our website for Emergency Medicine Practice subscribers. If you’re not a subscriber, consider joining today. You can find out more at www.ebmedicine.net/subscribe. Subscribers get in-depth articles on hundreds of emergency medicine topics, concise summaries of the articles, calculators and risk scores, and CME credits. You’ll also get enhanced access to the podcast, including the images and tables mentioned. You can find everything you need to know at ebmedicine.net/subscribe. Jeff: And the address for this month’s credit is ebmedicine.net/E1018, so head over there to get your CME credit.  As always, the ding sound  you heard throughout the episode corresponds to the answers to the CME questions. Nachi: Lastly, be sure to find us on iTunes and rate us or leave comments there. You can also email us directly at emplify@ebmedicine.net with any comments or suggestions. Talk to you next month!

Swab/Urine Chlamydia: usually asymptomatic. Screen routinely. Can cause infertility/PID and Fitz-hugh-curtis. Treat with Azithro x1 Gonorrhea: often asymptomatic. Screen routinely. Can cause infertility/PID. Treat with Ceftriaxone and Azithromycin Trich: frothy/watery discharge. “Strawberry cervix” Can see trich moving on wet mount. Treat Flagyl 2g PO once. HPV: Cervical dysplasia/cancer and Genital warts. Topical treatments as needed. […]

Swab/Urine Chlamydia: usually asymptomatic. Screen routinely. Can cause infertility/PID and Fitz-hugh-curtis. Treat with Azithro x1 Gonorrhea: often asymptomatic. Screen routinely. Can cause infertility/PID. Treat with Ceftriaxone and Azithromycin Trich: frothy/watery discharge. “Strawberry cervix” Can see trich moving on wet mount. Treat Flagyl 2g PO once. HPV: Cervical dysplasia/cancer and Genital warts. Topical treatments as needed. […]

Commentary by Dr. Valentin Fuster

Background: A prospective observational study was undertaken in 2,481 patients undergoing elective colon resection in 114 German centers to identify optimal drug and dosing modalities and risk factors for postoperative infection. Methods: Patients were pair matched using six risk factors and divided into 672 pairs (ceftriaxone vs, other cephalosporins, group A) and 400 pairs (ceftriaxone vs. penicillins, group B). End points were local and systemic postoperative infection and cost effectiveness. Results: Local infection rates were 6.0 versus 6.5% (group A) and 4.0 versus 10.5% (group B); systemic infection rates in groups A and B were 4.9 versus 6.3% and 3.3 versus 10.5%, respectively. Ceftriaxone was more effective than penicillins overall (6.8 vs. 17.8%, p < 0.001). Length of postoperative hospital stay was 16.2 versus 16.9 days (group A) and 15.8 versus 17.6 days (group B). Of the six risk factors, age and concomitant disease were significant for systemic infection, and blood loss, rectum resection and immunosuppressive therapy were significant for local infection. Penicillin was a risk factor compared to ceftriaxone (p < 0.0001). Ceftriaxone saved Q160.7 versus other cephalosporins and O416.2 versus penicillins. Conclusion: Clinical and microbiological efficacy are responsible for the cost effectiveness of ceftriaxone for perioperative prophylaxis in colorectal surgery. Copyright (C) 2000 S. Karger AG, Basel.