CITW 15: The Red Ear

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI/ROS: 5 year old female with a history of recurrent otitis media who presents to the ED with right ear pain. Per the parents, she developed acute onset right ear pain and “redness” one week ago that was associated with fevers (Tm 103.2). She saw her pediatrician who started a course of Augmentin for otitis media, however, after three days of no improvement, she received IM antibiotics (unknown type) with only minimal improvement in symptoms. On the day of ED presentation, her ear redness had worsened and she had developed limited range of motion of the head and neck. Associated symptoms included headache, hearing loss, and sore throat. No congestion, runny nose, conjunctivitis, visual changes, numbness, weakness, discoordination, cough, dyspnea, wheezing, abdominal pain, vomiting, diarrhea, or rash. No sick contacts or recent travel. Shots are up to date.

Vital Signs: T 102.3, HR 156, RR 22, BP 118/72, SpO2 99% on RA

Pertinent physical exam: Patient found sitting on her mother’s lap, not playful or interactive. Right TM is erythematous and bulging. There is edema and erythema noted behind the right auricle with tenderness to palpation. Shotty cervical chain adenopathy appreciated. No ear discharge. Left TM is clear. Oropharynx is clear with moist mucous membranes. No focal or gross neurological deficits. No meningismus. Neck is supple. Heart is tachycardic. Abdomen soft, non-tender. Lungs clear to auscultation. No rashes. No other pertinent exam findings.

CT imaging was obtained:

Mastoiditis 1
Image 1: CT brain, axial cuts in bone window.
Mastoiditis 2
Image 2: CT brain, coronal cuts in bone window.

What’s the diagnosis?

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Should We Reconsider Antipyretics For Fever?

What is Fever?

Although often used interchangeably, the terms fever and hyperthermia refer to different processes, and the distinction is key. In fever the thermoregulatory set-point is elevated, and the body actively raises its temperature with chills and rigors to reach the new set-point. In hyperthermia the body’s temperature exceeds the set-point, due to increased heat production (eg hypermetabolic state) or decreased dissipation (eg high humidity or ambient temperature).1

Fever is generally defined as temperature ≥38°C (100.4°F) and results from a complex mechanism. The body produces pyrogens (specific cytokines) that act on the thermoregulatory center in the hypothalamus to increase the set-point. This is thought to occur by increased prostaglandin synthesis, and antipyretic drugs lower the set-point likely by inhibiting prostaglandin synthesis.2 There are also numerous endogenous antipyretics (cryogens).

Increased temperatures enhance immune function in many ways, including improved neutrophil migration and secretion of antibacterial substances, increased interferon, and increased T cell proliferation.1

2

Fever Anxiety

A 1980 study titled “Fever phobia: misconceptions of parents about fever” surveyed parents, and found 94% thought fever may have harmful effects, 18% thought brain damage or serious harm could result from fever <38.9°C (102°F), and 16% thought fever could rise up to 48.9°C (120°F) if untreated.3 A 2001 study re-examined similar questions, and found 76% believed serious harm could occur at ≤40°C (104°F).3

This phobia also exists among healthcare workers. A 1992 survey by the American Academy of Pediatrics in Massachusetts showed 65% of pediatricians thought fever alone is potentially dangerous, 72% “always or often” prescribed antipyretics for fever, and 89% recommended antipyretics for fever of 101-102°F.4 A 2000 study of pediatric emergency department nurses, with a median experience of 8 years, found 11% were unsure what temperature constituted fever, 29% thought permanent brain injury or death could occur from high fever, and 18% believed it is dangerous for children to be discharged from the emergency department if still febrile.5

Is Fever Harmful?

Some providers have concerns that the increased temperature or metabolic demand from fever will harm patients. Humans generally tolerate temperatures below 41°C (105.8F) without harm. In contrast to hyperthermia, it is extremely rare for fever as a host defense against infection to reach dangerous temperatures in neurologically normal patients, since the body is actively adjusting both the set-point and actual temperature.3 A 2011 American Academy of Pediatrics policy paper states “There is no evidence that fever itself worsens the course of an illness or that it causes long-term neurologic complications.” 6 Continue reading

CITW 13: Itch, itch, itch

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI/ROS: 37 year old male with no significant past medical history presents to the ED with a rash. He states that it began one month ago and has been getting worse. Associated symptom is intense pruritus. It is not painful and nothing of note has made it better or worse. He’s never had a rash like this before. He denies any fevers, chills, shortness of breath, chest pain, myalgia/arthralgias, abdominal pain, nausea, vomiting, diarrhea, or urinary symptoms. He denies any recent exposures (environmental or chemical), medication changes, recent infections, or sick contacts.

Vital Signs: T 98.6, HR 88, RR 14, BP 156/72, SpO2 99% on RA

Pertinent physical exam: Diffuse, papular rash along upper and lower extremities including trunk and back. The neck and face are spared. It is non-blanching, non-weeping, and there are no open sores. It spares the face, lower back, and calves. Patient appears well otherwise. No other pertinent exam findings.

One

TwoWhat’s the diagnosis?

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Coming Down the Pike: Zika Virus

8x11-ZikaENG
From the Pan American Health Organization Zika virus website: http://www.paho.org/zikavirus

What is Zika Virus?
A single-stranded RNA virus of the Flavivirdae family, genus Flavivirus. The virus was first identified in 1947 in a rhesus monkey in the Zika Forest, Uganda.

What are the signs and symptoms?
Only about 1 in 4 people infected with Zika develop signs or symptoms, which include fever, maculopapular rash, arthralgias and conjunctivitis. Additionally, Zika causes headaches, myalgias, retro-orbital pain and vomiting.

How is it transmitted?
Zika Virus is primarily transmitted through the Aedes mosquito, which also transmits Dengue and Chikungunya. Transmission is also believed to take place vertically between mother and child, and through sexual contact.

Where has it been found?
As of the January 9, 2016, the following Pan American countries have seen confirmed cases of Zika virus: Brazil, Chile, Colombia, El Salvador, French Guiana, Guatemala, Honduras, Martinique, Mexico, Panama, Puerto Rico, Paraguay, Suriname, and Venezuela. 

Countries with confirmed Zika virus outside of the Americas include: Central African Republic, Egypt, French Polynesia, Gabon, India, Indonesia, Malaysia, Nigeria, The Philippines, Sierra Leone, Tanzania, Thailand, Uganda, and Vietnam

Why is it in the news?
Zika virus made national headlines in the United States in late December 2015 when Brazillian health officials advised would-be parents to delay pregnancy over concerns that Zika virus is contributing to a spike in microcephaly. The Brazil Ministry of Health reports a twenty-fold increase in the incidence of microcephaly over the past year in areas that have had confirmed Zika virus transmission (2,782 cases in 2015 versus 147 cases in 2014). The connection was made in November 2015 when Brazilian health officials found traces of Zika virus in a deceased newborn born with microcephaly.
zika_microcephaly
From the Pan American Health Organization Zika virus website, Epidemiological Alert, December 1, 2015

Additionally, Brazil has reported an increase in neurological syndromes in patients infected with Zika virus, most notably Guillain-Barré syndrome.

What is the treatment?
Supportive care: rest, fluids, antipyretics, and analgesics. Hold aspirin or NSAIDs until Dengue has been ruled out to reduce the risk of hemorrhage.

Sources:
Pan American Health Organization Zika virus website: http://www.paho.org/zikavirus

Brazil warns against pregnancy due to spreading virus, CNN, December 23, 2015
http://www.cnn.com/2015/12/23/health/brazil-zika-pregnancy-warning/

Foy BD, Kobylinski KC, Foy JLC, Blitvich BJ, Travassos da Rosa A, Haddow AD, et al. Probable non–vector-borne transmission of Zika virus, Colorado, USA. Emerg Infect Dis. 2011 May; http://www.ncbi.nlm.nih.gov/pubmed/21529401

Pan American Health Organization Epidemiological Alert: Neurological syndrome, congenital malformations, and Zika virus infection. Implications for public health in the Americas; December 1, 2015. PDF Direct Link

A new mosquito-borne threat to pregnancy women in Brazil, The Lancet, published online December 23, 2015. http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(15)00548-4/abstract

Just another cellulitis, or not?

This is part of a recurring series examining landmark articles in Emergency Medicine, based on ALiEM’s 52 Articles.

Discussing: Wong, C. Khin, L. Kien-Seng, H. Kok-Chai, T. Cheng-Ooi, L. “The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: A tool for distinguishing necrotizing fasciitis from other soft tissue infections.” Crit Care Med, 2004, Vol 32(7). 1535-1541.

Main Points:

  1. Developed in a 2004 retrospective observational study, the LRINEC score uses routine laboratory studies alone (CBC, BMP, CRP) to stratify patients with soft tissue infections into high-, moderate-, and low-risk for necrotizing fasciitis.
  1. Using a cut-off value of 6, the PPV was 92% and NPV was 96%; though approximately 10% of patients with necrotizing fasciitis still had a LRINEC score < 6, stressing that this is only a diagnostic adjunct for what is ultimately a clinical diagnosis.

Background:

Necrotizing fasciitis is a rare, rapidly progressive soft tissue infection that is potentially limb and life threatening. Delayed recognition correlates with a higher mortality rate, though early in its course, the disease may be difficult to distinguish from cellulitis or abscess. The purpose of this study was to develop a diagnostic scoring system to differentiate necrotizing fasciitis from other soft tissue infections.

Details:

This was a retrospective observational study divided into a developmental cohort of 314 patients and validation cohort of 140 patients at two teaching tertiary care hospitals in Singapore. The developmental cohort consisted of 89 consecutive patients admitted for necrotizing fasciitis and 225 control patients randomly selected from patients admitted with severe cellulitis or abscess during that same period.

The definitive diagnosis of necrotizing fasciitis was based on characteristics during operative exploration: the presence of grayish necrotic fascia, demonstration of a lack of resistance of normally adherent muscular fascia to blunt dissection, lack of bleeding of the fascia during dissection, and the presence of foul-smelling “dishwater” pus. The diagnosis of severe cellulitis or abscess was based on clinical impression of severe infection in documentation, the use of parenteral antibiotics for > 48 hours, and abscess (when present) requiring surgical debridement.

Thirteen variables from biochemical and hematologic tests done on admission were analyzed, including age, gender, total WBC, hemoglobin, platelet count, serum sodium, potassium, chloride, glucose, urea, creatinine, CRP, and ESR. To construct a diagnostic scoring system, these factors were entered as categorical variables. Six criteria – total WBC, sodium, glucose, serum creatinine, and CRP – were found to be independently predictive of necrotizing fasciitis, each worth 0, 1, 2, or 4 points for a total of 13 points.

This score was then retrospectively “externally validated” on a separate cohort of 56 consecutive patients with necrotizing fasciitis and 84 control patients with severe cellulitis or abscess seen at a separate hospital during a similar time period.

Patients were classified into three groups: low (LRINEC < or = 5), moderate (LRINEC 6-7), or high (LRINEC > or = 8) risk. These risk groups corresponded to a probability of developing necrotizing soft tissue infections of <50%, 50-75%, and >75%, respectively. A LRINEC score greater than or equal to 6 yielded a PPV of 92% and NPV of 96%. Eighty-nine and 92.9% of patients with necrotizing fasciitis had a LRINEC score of 6 or greater in the developmental and validation cohorts, respectively; whereas only 3.1% and 8.4% of control patients in the corresponding cohorts had a score of 6 or greater. The authors concluded that patients above this cutoff of 6 should be carefully evaluated for the presence of necrotizing fasciitis.

Commentary:

The advantage of the LRINEC score, as the authors mention, is that the variables used are routinely obtained when assessing severe soft tissue infections (CBC, BMP, CRP). Another cited advantage is the potential to detect clinically early cases of necrotizing fasciitis.

There are several limitations. Approximately 15% of the data sets were incomplete with respect to the CRP, and yet in the final model, CRP is the most heavily weighted (four points, with no other variable being weighted more than two points). Other potentially useful laboratory markers, such as CK, were not included in the analysis.

While the LRINEC score may be useful in identifying patients at high risk for necrotizing fasciitis, it is less useful in ruling out the diagnosis. In this study, approximately 10% of patients with necrotizing fasciitis had a LRINEC score of less than 6. This highlights the importance of recognizing the clinical features (toxic-appearing patient, pain out of proportion to skin findings, crepitus, rapid progression, bullous lesions, skin necrosis) of a disease that is ultimately diagnosed only in the operating room.

Results from subsequent studies have been even less optimistic. Based on the cutoff of 6, a small retrospective study in 2009 by MJ Holland yielded a sensitivity of 80%, specificity of 67%, PPV 57%, NPV 86% for diagnosing necrotizing fasciitis. A larger retrospective study by Liao et al. in 2012 demonstrated a sensitivity of 59.2%, specificity of 83.8%, PPV 37.9%, and NPV 92.5%. Finally, there have been no prospective trials yet validating the LRINEC score or demonstrating implementation of the score leads to earlier diagnosis or improved outcomes.

How do/will you use the LRINEC score?

Relevant articles:

Wilson, MP. Schneir, AB. “A case of necrotizing fasciitis with a LRINEC score of zero: clinical suspicion should trump scoring systems.” J Emerg Med. 2013 May; 44(5):928-31.

Liao, Chun-I. Lee, Yi-Kung. Su, Yung-Cheng. Chuang, Chin-Hsiang. Wong, Chun-Hing. “Validation of the laboratory risk indicator for necrotizing fasciitis (LRINEC) score for early diagnosis of necrotizing fasciitis.” Tzu Chi Medical Journal. 2012 24: 73-76.

Holland MJ. “Application of the Laboratory Risk Indicator in Necrotising Fasciitis (LRINEC) score to patients in a tropical tertiary referral centre.” Anaesth Intensive Care. 2009 Jul;37(4):588-92.

Chan, T. Yaghoubian, A. Rosing, D. Kaji, A. deVirgilio, C. “Low sensitivity of physical examination findings in necrotizing soft tissue infection is improved with laboratory values: a prospective study.” Am J Surg. 2008 Dec; 196(6):926-30.

 

Resident author: Roger Wu, MD
Faculty reviewer: Matthew Siket, MD, MS

Infections bite! Antibiotic prophylaxis for mammalian bites

This is part of a recurring series examining landmark articles in Emergency Medicine, in the style of ALiEM’s 52 Articles.

Discussing:  Medeiros, I, and H Saconato. “Antibiotic prophylaxis for mammalian bites.”  Cochrane database of systematic reviews Online 2 (2001) : CD001738.

Main Points:

  1. The use of antibiotic prophylaxis for hand bites reduces infections
  1. There is weak evidence supporting the use of antibiotic prophylaxis after human bites to reduce infections (based on one study)

Background:

Mammalian bites account for up to 1% of all ED visits and administration of prophylactic antibiotics is based on studies with insufficient power to determine true efficacy. In order to gather enough cases to sufficiently power a study, The Cochrane Collaboration did a meta-analysis of randomized trials considering the value of antibiotic prophylaxis in human and other mammalian bites. The goal of this analysis was to determine if the use of antibiotics in mammalian bites is effective in preventing bite wound infection.

Eligible studies were searched and retrieved based on inclusion criteria (see details) by two reviewers. Relevant data to answer the study question were extracted, risk of bias was assessed for included studies, and subgroup analysis was performed based on intention to treat of the eight final studies chosen.

For dog bites, there was no statistically significant reduction in infection rate after prophylactic antibiotics (4% (10/225)) versus control (5.5% (13/238)). Only one trial analyzed human bites and the infection rate was significantly lower in the antibiotic group (0/33) versus the control group (47% (7/15)) (OR 0.02, 95% CI 0.00 to 0.33). The infection rates for hand bites were significantly reduced by antibiotic administration (2% vs. 28% in control group) (OR 0.10, 95% CI0.01 to 0.86, NNT=4, 95% CI 2 to 50). There appeared to be no significant difference in infection rate with antibiotic prophylaxis for cat bites, when separating out wound type (laceration vs. puncture), or for bites on body parts other than the hand.

Pitfalls of this meta-analysis:

  1. The antibiotics chosen for prophylaxis were not consistent across studies, and no more than two studies used the same antibiotic. In some studies, the antibiotic used was inappropriate for coverage of mixed anaerobes and aerobes, which is common in many mammalian infections.
  2. The predominance of included patients suffered dog bites (463/522) compared to cats (11/522) or humans (48/522), so the results are skewed heavily toward one species of bite.
  3. Only five studies reported LTFU and three of these had rates over ten percent. Four studies did not even include LTFU numbers, and an intention to treat analysis could not be performed in these. This may bias the results toward no effect since those who did not go on to have an infection would likely not return to the ED.
  4. Only 25% of the studies used double-blinded methods with a placebo of identical appearance.

Details:

This was a meta-analysis study, with the following inclusion criteria:

  1. Study type: RCTs or quasi-RCTs
  2. Participants: patients with mammalian bites (including humans) if they presented within 24 hours and had no clinical signs of infection.
  3. Interventions: use of antibiotics within 24 hours of injury compared to placebo/no-intervention.
  4. Outcomes measured: proven bacterial infection (clinical signs of infection plus positive culture), presumed infection (clinical signs of infection with negative culture) or absence of infection (no clinical signs).

Nine studies met all inclusion criteria but one study did not separate infection rates for each mammalian species.

Level of evidence:

ACEP Level I for Meta-analysis

Source article: Medeiros, I, and H Saconato. “Antibiotic prophylaxis for mammalian bites.” Cochrane database of systematic reviews Online 2 (2001) : CD001738.

 

You Put a Catheter Where? The Groin May Not be as Dirty as Previously Reported

This is part of a recurring series examining landmark articles in Emergency Medicine, in the style of ALiEM’s 52 Articles.

Discussing:  Marik, P. Flemmer, M. Harrison, W. “The Risk of Cathether-Related Bloodstream Infections with Femoral Venous Catheters As Compared to Subclavian and Internal Jugular Venous Cathethers: A Systematic Review of the Literature and Meta-Analysis.” Critical Care Medicine, 2012, Vol 40(8). 2479-2485

Main Points:

  1. This 2012 meta-analysis demonstrated that catheter-related blood stream infection (CRBI) risk is no different between internal jugular, subclavian, and femoral catheter insertion. The authors demonstrated that previous level 1A guidelines regarding femoral catheter infectious risk were in error.
  2. The overall risk of CRBI is declining over the recent years and likely due to the combination of more precautions at the time of insertion as well as vigilant management of the catheter once placed.

Background:

There is significant morbidity and mortality associated with CRBI. In the United States alone, an estimated 30-60 thousand patient deaths occur annually secondary to this infectious process. In 2011 a clinical recommendation from respected organizations including the CDC’s Healthcare Infection Control Practices Advisory Committee as well as the Infectious Disease Society of America issued a class 1A recommendation to “avoid using the femoral vein for central access in adult patients.” This recommendation would suggest that there is strong supporting data including at least one well performed RCT. The purpose of this meta-analysis by Marik and his colleagues was to call into question the validity of such an absolute statement. Marik and his partner Flemmer performed an exhaustive literature search and were able to find 2 RCTs and 8 cohort trials to include in their meta-analysis. This literature review was more comprehensive then the citations provided by the societies issuing the level 1A recommendations. There study, however, focused solely on the question of CRBI and did not address concerns other concerns associated with central venous access such as injury to nearby structures, DVT, or bleeding.

Details:

This study reviewed more data than the 1A recommendation from the CDC and IDSA and could not find compelling evidence that the femoral vein should be avoided for concerns of CRBI. Furthermore, it appears that the universal precautions that are being used currently have likely led to an overall decrease in CRBI compared to the years past. For example, the rate of CRBI in the United States in 1998 was 5.32/1,000 catheter days and has subsequently dropped to 2.05/1,000 in recent data. The Welsh Healthcare Associated Infection Program which is the largest collection of data and noted that in over 55 thousand catheter days in 2009 and 2010 there were only 0.61/1,000 catheter day infectious risk with no difference between insertion sites. Marik and his colleagues therefore note that the site of preference should “depend on the expertise and skill of the operator and the risks associated with placement.” The authors recommend against using femoral vein catheters in renal transplant patients, patients who would benefit from early mobilization as well as the massively obese due to a subgroup analysis in the Parienti study that noted worse outcomes in these individuals.

The average CRBI density in the compilation of trials was noted to be 2.5 +/- 1.9 per 1,000 catheter days (range 0.6-7.2). In compiling the data it was noted that two of the cohort trials, Lorente and Nagashima, appeared as statistical outliers increasing the heterogeneity of the meta-analysis significantly. It is unclear why these two trials demonstrated a more than two-fold increased risk of CRBI with femoral catheter insertion. If these trials were removed from the data the authors noted that there appeared to be no heterogeneity within the study (RR 1.02, 95% CI 0.64-1.65, p = 0.92, I² = 0%). This study also performed a meta-regression that appeared to demonstrate a significant interaction between the risk of infection and the year of publication (p = 0.01).

Level of Evidence:

Based on the design of this study, including RCTs and cohort trials, with a few limitations this study was graded a level III based on the ACEP Clinical Policy Grading Scheme for meta-analyses.

Surprises:

In many aspects of medicine it is curious to see how wide practice variation can be, especially when considering geographic and healthcare system influences. This notion is highlighted by reviewing the different guidelines within this meta analysis by various public health/safety committees across the United States and United Kingdom.

Relevant articles:

Lorente, L. Henry, C. Martin, MM. et al. “Central Venous Catheter-Related Infection in a Prospective and Observational Study of 2, 595 Catheters.” Crit Care, 2005 9. R631-5

Nagashima, G. Kikuchi, T. Tsuyuzaki, H. et al. “To Reduce Catheter-Related Bloodstream Infections: Is the Subclavian Route Better than the Jugular Route for Central Venous Catheterization?” J Infec Chemother, 2006 12. 363-65

Parienti, JJ. Thirion, M. Megarbane, B. et al. “Members of the Cathedia Study Group: Femoral v. Jugular Venous Catheterization and Risk of Nosocomial Events in Adults Requiring Acute Renal Replacement Therapy: A Randomized Controlled Trial.” JAMA, 2008 299. 2413-22

Source Articles:

Marik, P. Flemmer, M. Harrison, W. “The Risk of Cathether-Related Bloodstream Infections with Femoral Venous Catheters As Compared to Subclavian and Internal Jugular Venous Cathethers: A Systematic Review of the Literature and Meta-Analysis.” Critical Care Medicine, 2012 Vol 40(8). 2479-2485

By

Anatoly Kazakin MD

Peds EM Follow Up 2015: Pediatric Osteomyelitis

2 Articles of Interest & An Excruciating, Detailed and Lengthy Guide to Diagnosis and Management

 

Dartnell J, Ramachandran M, Katchburian M. Haematogenous Acute and Subacute Paediatric Osteomyelitis: A Systematic Review of the Literature. J Bone Joint Surg Br. 2012 May;94(5):584-95.

  • A meta-analysis of 1854 papers, 132 of which were examined in detail
  • 40% of patients were afebrile
  • Tibia and femur were most common sites
  • Exam, labs, and imaging must be used in combination
  • S. aureus > Kingella > other
  • Typical treatment: start empiric IV abx, switch to PO when possible

Harris JC, et al. How Useful are Laboratory Investigations in the Emergency Department Evaluation of Possible Osteomyelitis? Emerg Med Australias. 2011 Jun;23(3):317-30. Epub 2011 Apr 4

  • A meta-analysis of 36 studies of adults and children
  • Recommended algorithm:
    • Adults and kids w/ low pretest probability: nL ESR and CRP<5 → done
    • Med/high pretest probability and puncture wounds: nL ESR and CRP<5 → LOW NPV
    • ESR >30 and/or CRP>10-30 → further investigation (imaging) required
    • WBC count is not especially helpful!

Osteo locations

 

PEDIATRIC OSTEOMYELITIS:

  • Definition: bacteria infecting bone
  • Usually hematogenous spread, but can be direct inoculation (surgery, open trauma, puncture, etc) or contiguous spread (skin, sinus, dental infections)

CLINICAL PRESENTATION

  • Constitutional symptoms, irritability, decreased PO
  • +/- fever
  • Localized pain, bony tenderness
  • Functional limitations, i.e. unwilling to crawl or walk
  • Time course: usually several days to >1 week
  • Risk factors: bacteremia, sepsis, immunocompromised, indwelling catheters/hardware, prematurity, skin infection, complicated delivery, GU abnormalities

Continue reading

I’m Pro Probiotic

We see a ton of people in the ED who visit us for their infectious “emergencies.” Ideally, we start them on the appropriate antibiotics and send them on their way, either out the door or upstairs as the case necessitates. Our best intentions can unfortunately give rise to unexpected side effects. It is well known that taking antibiotics opens you up to developing C. difficile infections which can lead to dehydration, malnourishment, hospitalization, and even death. It costs lots of time and money to care for and treat this untoward outcome. Due to a 2013 Cochrane review, I’ve gotten in the habit of giving an extra med for the folks needing antibiotic treatment – a probiotic.

The Cochrane group included 31 studies (including 24 RCTs) in the review which found that there was a significant reduction in C. difficile associated diarrhea (CDAD) in patients given probiotics. The incidence was 2% in the probiotic group vs 5.5% in the placebo/no treatment groups. The number needed to treat was found to be 29 patients to prevent a case of CDAD. There was also found to be a significantly lower rate of non-C. difficile antibiotic associated diarrhea as well as other adverse events (e.g. flatulence, abdominal cramping, nausea) in the group given probiotics.

Next time you are treating the little old lady with the UTI or the young lady who maybe had CMT, think about throwing on some probiotics to reduce the continuity of care in the ED. It’s pretty low risk with pretty high yield. I’ve been giving out Lactobacillus capsules myself. Feel free to check out the link.

Probiotic