If this feels like déjà vu, it might be because it is.
This short research letter in JAMA Internal Medicine describes patterns of antibiotic prescribing for three common conditions: otitis media, sinusitis, and pharyngitis. In all of these cases – in the infrequent occasion antibiotics are necessary – the appropriate first-line antibiotic is amoxicillin/penicillin. These authors estimate, based on treatment failures, allergies, and complicated disease, approximately 80% of antibiotic prescriptions for these conditions should be the first-line agents.
How did we do? Well, better in pediatrics than adults, but first-line prescribing ranged from a low of 37% to a high of 67%. The most commonly used inappropriate antibiotics were macrolides (invariably azithromycin) and fluoroquinolones. Macrolides are usually inappropriate due to high levels of resistance among common pathogens, and fluroquinolones are simply too broad-spectrum to be appropriate.
The catch, unfortunately, is the data source: the National Ambulatory Medical Care Survey, warts and all, from 2010 to 2011. The authors state they expect practice patterns have not changed much in the last five years, but it’s still a little challenging to generalize this to current practice.
Finally, as a nice corollary, this Medical Letter article was featured in JAMA regarding fluoroquinolones and their increasingly detected serious adverse effects. When antibiotics are truly necessary, physicians should try and choose one of the many alternatives presented in the article.
What? A 45-year-old female presented to the ED with a sharp central chest pain radiating slightly through to her back. It had started yesterday whilst leaning forward and reaching for a heavy object whilst gardening. Clinical examination was normal apart from a reproducible pain when the patient twisted her thorax. At rest she was pain →
This is the seventh lecture in our Research Lecture Series.
In this lecture, Annuradha Persaud discussesthe uses of REDCap (Research Electronic Data Capture). REDCap is a browser-based, metadata-driven EDC software solution and workflow methodology for designing clinical and transnational research databases.
Annuradha Persaud graduated with a Bachelor’s of Science degree in Psychology from the University of Louisville. From there she continued on to the University of Louisville for graduate school, pursing a Master’s degree in Public Health. Upon graduation, she accepted a position at the University of Louisville School of Medicine Division of Infectious Diseases. Primary foci on pneumonia, quality improvement in healthcare and support projects for the faculty and fellows of the University.
Some items in this lecture may have come from the lecturer’s personal academic files or have been cited in-line or at the end of the lecture. For more information, see our citation page.
In patients with symptoms of pulmonary embolism (PE), we often turn to vital signs, including heart rate, respiratory rate and pulse oximetry, as part of our initial impression of the patient. Before even considering further testing, such as d-dimer or CTPA, we look first at the vital signs to form our gestalt impression of the patient. Read More
Balcofen withdrawal is a life-threatening syndrome and patients should be admitted to the ICU while arranging for definitive management
Pump or catheter malfunction typically requires neurosurgical intervention in the operating room
If an empty reservoir is identified and refilled, the patient may be able to be discharged if all signs and symptoms resolve
Take Home Points
Baclofen withdrawal from an intrathecal pump presents with hemodynamic instability, increased spasticity, fever and altered mental status. Consider the diagnosis in any patient with an intrathecal pump and the above symptoms.
Oral baclofen replacement is unlikely to treat the disorder as it does not achieve adequate CSF levels.
The optimal treatment for intrathecal baclofen withdrawal is administration of baclofen into the CSF but this can be technically difficult.
Treat baclofen withdrawal with escalating doses of benzodiazepines and consider propofol infusion for patients who continue to decline.
Rao R.B. (2015). Special Considerations. In Hoffman R.S., Howland M, Lewin N.A., Nelson L.S., Goldfrank L.R. (Eds), Goldfrank’s Toxicologic Emergencies, 10e. Link
Chidester S, Smith S. Baclofen pump complications. The NYS Poison Centers Toxicology Letter 2011; 16(4): 1-12. Link
Hamilton R.J. (2015). Withdrawal Principles. In Hoffman R.S., Howland M, Lewin N.A., Nelson L.S., Goldfrank L.R. (Eds), Goldfrank’s Toxicologic Emergencies, 10e. Link
Stetkarova I et al. Procedure- and device-related complications of intrathecal baclofen administration for management of adult muscle hypertonia: a review. Neurorehabil Neural Repair. 2010;24(7):609-619. PMID: 20233964
Shirley KW et al. Intrathecal baclofen overdose and withdrawal. Pediatr Emerg Care. 2006;22(4):258-261. PMID: 16651918
Ross J et al. Acute Intrathecal Baclofen Withdrawal: A Brief Review of Treatment Options. Neurocrit Care. 2011;14(1):103-108. PMID: 20717751
Post Peer Reviewed By: Salim Rezaie (Twitter: @srrezaie)