Algorithmic treatment of staphylococcal bacteremia
There is considerable variability in the clinical approach to treatment of staphylococcal bacteremia; standardizing management may be useful to optimize duration of antibiotic therapy. In a randomized trial including more than 500 patients with staphylococcal bacteremia, use of algorithm-based therapy (compared with usual practice) was associated with a nearly two-day reduction in antibiotic duration overall, including a three-day reduction for uncomplicated coagulase-negative staphylococcal bacteremia*. The rate of clinical success between the groups was comparable. These findings are promising for reducing unnecessary antibiotic use; further study defining optimal duration of antibiotic therapy is needed.
* Holland TL, Raad I, Boucher HW, Anderson DJ, Cosgrove SE, Aycock PS, et al.Staphylococcal Bacteremia Investigators. Effect of Algorithm-Based Therapy vs Usual Care on Clinical Success and Serious Adverse Events in Patients with Staphylococcal Bacteremia: A Randomized Clinical Trial. JAMA. 2018 Sep 25;320(12):1249-1258.
Water intake and recurrent cystitis
Increased fluid intake has long been thought to reduce the risk of recurrent cystitis but had not previously been evaluated in a controlled study. In a randomized trial of 140 premenopausal women with recurrent cystitis and low-volume fluid intake at baseline, drinking an additional 1.5 L of water daily reduced the incidence of cystitis by about 50 percent compared with continued baseline intake (mean 1.7 versus 3.2 episodes over 12 months) *. These findings support our suggestion that women with recurrent cystitis target a fluid intake of 2 to 3 L daily.
* Hooton TM, Vecchio M, Iroz A, Tack I, Dornic Q, Seksek I, Lotan Y. Effect of Increased Daily Water Intake in Premenopausal Women With Recurrent Urinary Tract Infections: A Randomized Clinical Trial. JAMA Intern Med. 2018 Nov 1;178(11):1509-1515.
Updated recommendations for prevention of hepatitis A infection
The United States Advisory Committee on Immunization Practices (ACIP) issued updated recommendations for prevention of hepatitis A virus (HAV) infection in November 2018*. It now recommends preexposure prophylaxis with HAV vaccination for infant travelers aged 6 to 11 months. The new guidelines also recommend postexposure prophylaxis for individuals >40 years with HAV vaccine (with or without immune globulin [IG]) rather than IG alone, given diminished IG potency. In addition, homelessness is a new indication for HAV vaccination, given the recent increase in infection rates in this group**.
* Nelson NP, Link-Gelles R, Hofmeister MG, Romero JR, Moore KL, Ward JW,
Schillie SF. Update: Recommendations of the Advisory Committee on Immunization Practices for Use of Hepatitis A Vaccine for Postexposure Prophylaxis and for Preexposure Prophylaxis for International Travel. MMWR Morb Mortal Wkly Rep. 2018 Nov 2;67(43):1216-1220.
** Foster M, Ramachandran S, Myatt K, Donovan D, Bohm S, Fiedler J, et al. Hepatitis A Virus Outbreaks Associated with Drug Use and Homelessness – California, Kentucky, Michigan, and Utah, 2017. MMWR Morb Mortal Wkly Rep. 2018 Nov 2;67(43):1208-1210.
No benefit of oral and digestive tract decontamination when antibiotic resistance is prevalent
Modest mortality benefits have been demonstrated among intensive care unit (ICU) patients treated with orally applied or ingested non-absorbable antimicrobials (selective oropharyngeal and digestive decontamination [SOD and SDD]) in trials from the Netherlands, a region with low baseline antimicrobial resistance. However, in a trial among European ICUs with a moderate to high prevalence of antibiotic resistance, chlorhexidine mouthwash, SOD, and SDD were not associated with reductions in mortality or in ICU-acquired multidrug-resistant gram-negative bacteremia compared with baseline care*. These findings support the current practice of ICUs with a moderate to high prevalence of antibiotic resistance to forgo SOD and SDD.
* Wittekamp BH, Plantinga NL, Cooper BS, Lopez-Contreras J, Coll P, Mancebo J, et al. Decontamination Strategies and Bloodstream Infections With Antibiotic-Resistant Microorganisms in Ventilated Patients: A Randomized Clinical Trial. JAMA. 2018 Oct 22.
Efficacy and approval of baloxavir for influenza (September 2018, Modified November 2018)
Baloxavir is a novel oral antiviral agent that blocks influenza proliferation by inhibiting the initiation of mRNA synthesis. In a phase III randomized trial of healthy patients aged 12 to 64 years with uncomplicated influenza, a single weight-based dose of baloxavir reduced median time to symptom alleviation compared with placebo (54 versus 80 hours) and was similar to five days of oseltamivir*. Baloxavir was associated with a shorter median duration of virus detection than placebo or oseltamivir. Adverse events attributable to baloxavir were uncommon. Baloxavir was approved for the treatment of uncomplicated influenza in adults and children ≥12 years of age in Japan in February 2018 and in the United States in October 2018**.
* Hayden FG, Sugaya N, Hirotsu N, Lee N, de Jong MD, Hurt AC,et al. Baloxavir Marboxil Investigators Group. Baloxavir Marboxil for Uncomplicated Influenza in Adults and Adolescents. N Engl J Med. 2018 Sep 6;379(10):913-923.
** Shionogi press release. XOFLUZA (Baloxavir marboxil) tablets 10 mg/20 mg for the treatment of influenza types A and B launched in Japan. http://www.shionogi.co.jp/en/company/news/2018/pmrltj0000003oid-att/e180314.pdf (Accessed on October 24, 2018).
Timing of renal replacement therapy in patients with acute kidney injury and septic shock
The optimal timing of initiating renal replacement therapy (RRT) for patients with sepsis and severe acute kidney injury (AKI) is unclear. A randomized trial of nearly 500 patients compared earlier (within 12 hours of AKI diagnosis) versus delayed (development of an emergent indication for RRT or at 48 hours after AKI diagnosis) initiation of RRT in patients with early septic shock and severe AKI*. There was no difference in mortality at 90 days between the groups, although the trial was stopped early for futility. These findings support recommendation not to electively initiate RRT in patients with severe AKI without an urgent indication, such as clinically significant uremic symptoms, severe electrolyte abnormalities, or volume overload.
*Barbar SD, Clere-Jehl R, Bourredjem A, Hernu R, Montini F, Bruyère R, et al.IDEAL-ICU Trial Investigators and the CRICS TRIGGERSEP Network. Timing of Renal-Replacement Therapy in Patients with Acute Kidney Injury and Sepsis. N Engl J Med. 2018 Oct 11;379(15):1431-1442.
Source: Uptodate, November 2018.