A guest post by Anand Swaminathan (@EMSwami) of EM Lyceum and Essentials of EM fame.
Over the last decade, researchers have sought to determine the usefulness, or lack there of, for systemic antibiotics in a number of infectious etiologies previously thought to require antibiotics for resolution. This includes strep throat, sinusitis, bronchitis and, more recently, diverticulitis. Acute otitis media (AOM) has long been a target for such studies and recently, the guidelines have changed. The American Academy of Pediatrics now endorses a “wait and see” approach for many children with AOM while also recommending a more stringent definition of the disease.
What about for patients with tympanostomy tubes who present with signs of AOM? These patients typically present with otorrhea (pus from the tympanostomy tube). Is the presence of drainage adequate to treat or should these patients be placed on oral or topical antibiotics? Small trials have shown good efficacy of topical antibiotics but Pediatricians and Emergency Physicians continue to prescribe oral antibiotics in the face of inadequate evidence.
The researchers here attempt to answer this question. They performed a fairly large study of 230 children who were randomized to either observation, oral antibiotics or topical antibiotic-glucocortocoid drops in an open-label fashion. The primary endpoint was resolution of otorrhea at 2 weeks. The results are surprising. Resolution was seen in 95% in the group given drops, 56% in the oral antibiotic group and 45% in the observation group. These numbers yield a miniscule NNT = 3 for resolution of otorrhea with topical antibiotics-glucocortocoids vs. oral antibiotics.
A couple of notes are important. All of the patients had otorrhea for up to 7 days prior to entering the study and the presence of a fever excluded them from the study. Additionally, tubes couldn’t be recently placed (< 2 weeks) there couldn’t be recent antibiotic use (< 2 weeks) or otorrhea (< 4 weeks).
As evidence mounts to the harms of inappropriate and unnecessary systemic antibiotic use, it’s important to tailor therapy based on the available literature. Many patients with tympanostomy tubes that develop otorrhea will resolve with simple observation. However, treatment with topical antibiotic-glucocortocoid drops should be the first line treatment as they are superior to oral antibiotics with fewer side effects.
"A trial of treatment for acute otorrhea in children with tympanostomy tubes."
Making an even three consecutive posts on opiate abuse makes a week of it; this ought to be the last, unless further profound insights are hot-off-the-presses.
This study – actually a minor Research Letter in JAMA Internal Medicine – evaluates self-reported behavioral patterns in nonmedical drug use in the United States. This accompanies another study
looking at the risk factors for unintentional opiate-related deaths, which, helpfully, adds a little context.
This survey extrapolates out to approximately 12 million nonmedical opiate users aged greater than 12 years in the United States. A slight majority of users were male, and most had annual incomes less than USD$50,000. Most interesting, however, is Table 2, which describes how the source of opiates varies with increasing frequency of use. Individuals who reported nonmedical use of opiates fewer than 30 days out of the year received their opiates predominantly for free from a friend or relative. As frequency of use increased, opiates were less frequently received from a friend for free – and more likely to be received from a physician or purchased from friends, family, or drug dealers. As the accompanying study notes, increasing prescription and increasing mean daily use of opiates were associated with increased risk of death – so it would appear the population at highest risk of death also has the greatest extent of physician contact for opiates.
But, just as important as it may be to evaluate an individual risk for opiate misuse when prescribing, it is also important to note the majority of nonmedical use was obtained via diversion activities. Every opiate prescribed enters an ecosystem of illicit exchange – presumably under-recognized by physicians, else I would expect far fewer prescriptions. Judicious – and sparing – use of opiates is far more likely to benefit society than harm.
“Sources of Prescription Opioid Pain Relievers by Frequency of Past-Year Nonmedical Use: United States, 2008-2011”http://archinte.jamanetwork.com/article.aspx?articleid=1840031
The title says it all.
This is an observational cohort analysis of linked medical and pharmacy records for commercially insured patients across 14 health plans. Patients were identified by age 13-17 with, allegedly, new-onset atraumatic headache from claims database abstraction – limited, of course, by the nature of querying such a database. 8,373 patients were identified from their two year study period as meeting these criteria.
And 46% were prescribed opiates.
52% of those received more than one prescription for opiates, including 11% who received 5 or more prescriptions for opiates during the study period.
This study came about because the insurer contacted the American Academy of Pediatrics with a query regarding the appropriate frequency of use of opiates for headache. The answer ought to be a tiny fraction, as third-line or rescue therapy
Considering all the problems this country has with prescription opiate abuse, it is maddening to see physicians inoculating such a vulnerable population with medication whose harms almost certainly outweigh the benefits.
“Opioid Use Among Adolescent Patients Treated for Headache”http://www.jahonline.org/article/S1054-139X(13)00834-3/abstract
It is well-known the elderly are at higher risk for medication adverse effects. It is, likewise, recognized opiates are one of the most dangerous prescription medications in use. Therefore, the prudent thing to do would be avoid opiate use in the elderly – and, certainly, not be irresponsible regarding multiple, concurrent prescriptions for opiates.
However, as this 20% random sample of Medicare beneficiaries demonstrates, an estimated 5.2M Americans covered by this insurance source received opiates – with approximately 85% of this cohort aged greater than 55. Most patients who received opiates filled more than one prescription – including a full 7% who received >4 prescriptions, from >4 different providers. This last group received a mean number 15 opiate prescriptions in a single calendar year. Unsurprisingly, increased opiate prescriptions were associated with increased subsequent hospitalizations. While there is no mortality data in this report, I don't think it's a stretch to speculate the illness-adjusted outcomes would be much poorer.
The use of opiates for pain control for acute and chronic illness is a necessary evil, particularly in the elderly. This study, given its limitations, cannot precisely elucidate whether the opiates provided represented irresponsible prescribing – but it supports much of what we anecdotally observe regarding the fragmented healthcare process. Whether the magnitude of the problem is as great as these authors seem to suggest, there should be no argument we have plenty of room for improvement in treating some of our most vulnerable patients.
“Opioid prescribing by multiple providers in Medicare: retrospective observational study of insurance claims”http://www.bmj.com/content/348/bmj.g1393
The ABCD2 score for the prediction of stroke after TIA was initially touted as a possible risk-stratification tool geared towards determining which patients could undergo delayed evaluation for modifiable risk factors. Unfortunately, the “low risk” cohort generated by the ABCD2 score still has an unacceptably high risk of stroke at 7 days, with poor predictive and discriminative power.
These authors try to take it to the next level – the ABCD3 score and the ABCD3-I score. Derived retrospectively from the Kyoto Stroke Registry, the third element of D3 is “Dual TIA” – which is having had another TIA within the prior 7 days. Then, the “I” is dependent upon having a positive MRI DWI lesion associated with concurrent ipsilateral carotid artery stenosis.
In their retrospective application of ABCD2, ABCD3, and ABCD3-I, as expected, the ABCD2 score showed minimal utility for the outcome of interest for the Emergency Department – the 7 day risk of stroke in the low-risk cohort was ~6%. The low-risk ABCD3 and ABCD3-I cohort, however, had a ~1 to 2% risk at 7 days. If verified prospectively, this begins to approach reliable utility for discharge decision-making in the ED. Given the ABCD2 score’s checkered past, I would certainly wait for the next bit of evidence.
“ABCD3 and ABCD3-I Scores Are Superior to ABCD2 Score in the Prediction of Short- and Long-Term Risks of Stroke After Transient Ischemic Attack”http://stroke.ahajournals.org/content/45/2/418.full