William D. Binder

Clinical Trial: Comparative Effectiveness of Cephalexin Plus Trimethoprim-Sulfamethoxazole Versus Cephalexin Alone for Treatment of Uncomplicated Cellulitis: A Randomized Controlled Trial

BACKGROUND Community-associated methicillin-resistant S. aureus (CA-MRSA) is the most common organism isolated from purulent skin infections. Antibiotics are usually not beneficial for skin abscess, and national guidelines do not recommend CA-MRSA coverage for cellulitis, except purulent cellulitis, which is uncommon. Despite this, antibiotics targeting CA-MRSA are prescribed commonly and increasingly for skin infections, perhaps due, in part, to lack of experimental evidence among cellulitis patients. We test the hypothesis that antibiotics targeting CA-MRSA are beneficial in the treatment of cellulitis. METHODS We performed a randomized, multicenter, double-blind, placebo-controlled trial from 2007 to 2011. We enrolled patients with cellulitis, no abscesses, symptoms for <1 week, and no diabetes, immunosuppression, peripheral vascular disease, or hospitalization (clinicaltrials.gov NCT00676130). All participants received cephalexin. Additionally, each was randomized to trimethoprim-sulfamethoxazole or placebo. We provided 14 days of antibiotics and instructed participants to continue therapy for ≥1 week, then stop 3 days after they felt the infection to be cured. Our main outcome measure was the risk difference for treatment success, determined in person at 2 weeks, with telephone and medical record confirmation at 1 month. RESULTS We enrolled 153 participants, and 146 had outcome data for intent-to-treat analysis. Median age was 29, range 3-74. Of intervention participants, 62/73 (85%) were cured versus 60/73 controls (82%), a risk difference of 2.7% (95% confidence interval, -9.3% to 15%; P = .66). No covariates predicted treatment response, including nasal MRSA colonization and purulence at enrollment. CONCLUSIONS Among patients diagnosed with cellulitis without abscess, the addition of trimethoprim-sulfamethoxazole to cephalexin did not improve outcomes overall or by subgroup. CLINICAL TRIALS REGISTRATION NCT00676130.

Assessment of a Clinical Performance Evaluation Tool for Use in a Simulator-based Testing Environment: A Pilot Study

Purpose. This study assessed a clinical performance evaluation tool for use in a simulator-based testing environment. Method. Twenty-three subjects were evaluated during five standardized encounters using a patient simulator (six emergency medicine students, seven house officers, ten chief resident-fellows). Performance in each 15-minute session was compared with performance on an identical number of oral objective-structured clinical examination (OSCE) sessions used as controls. Each was scored by a faculty rater using a scoring system previously validated for oral certification examinations in emergency medicine (eight skills rated 1–8; passing = 5.75). Results. On both simulator exams and oral controls, chief resident-fellows earned (mean) “passing” scores [sim = 6.4 (95% CI: 6.0–6.8), oral = 6.4 (95% CI: 6.1–6.7)]; house officers earned “borderline” scores [sim = 5.6 (95% CI: 5.2–5.9), oral = 5.5 (95% CI: 5.0–5.9)]; and students earned “failing” scores [sim = 4.3 (95% CI: 3.8–4.7), oral = 4.5 (95% CI: 3.8–5.1)]. There were significant differences among mean scores for the three cohorts, for both oral and simulator test arms (p < .01). Conclusions. In this pilot, a standardized oral OSCE scoring system performed equally well in a simulator-based testing environment.

Changes in cytokine levels and NK cell activation associated with influenza.

Several studies have highlighted the important role played by murine natural killer (NK) cells in the control of influenza infection. However, human NK cell responses in acute influenza infection, including infection with the 2009 pandemic H1N1 influenza virus, are poorly documented. Here, we examined changes in NK cell phenotype and function and plasma cytokine levels associated with influenza infection and vaccination. We show that absolute numbers of peripheral blood NK cells, and particularly those of CD56bright NK cells, decreased upon acute influenza infection while this NK cell subset expanded following intramuscular influenza vaccination. NK cells exposed to influenza antigens were activated, with higher proportions of NK cells expressing CD69 in study subjects infected with seasonal influenza strains. Vaccination led to increased levels of CD25+ NK cells, and notably CD56bright CD25+ NK cells, whereas decreased amounts of this subset were present in the peripheral blood of influenza infected individuals, and predominantly in study subjects infected with the 2009 pandemic H1N1 influenza virus. Finally, acute influenza infection was associated with low plasma concentrations of inflammatory cytokines, including IFN-γ, MIP-1β, IL-2 and IL-15, and high levels of the anti-inflammatory cytokines IL-10 and IL-1ra. Altogether, these data suggest a role for the CD56bright NK cell subset in the response to influenza, potentially involving their recruitment to infected tissues and a local production and/or uptake of inflammatory cytokines.

LEPTOSPIROSIS IN AN URBAN SETTING: CASE REPORT AND REVIEW OF AN EMERGING INFECTIOUS DISEASE

Leptospiosis is a common zoonosis affecting most mammals. Leptospirosis has protean manifestations ranging from a flu-like illness to fulminant hepatic and renal failure culminating in death. Although the diagnosis is often not considered upon presentation, the literature suggests that leptospirosis is a reemerging infectious disease in urban centers throughout the industrialized world. It will be incumbent upon Emergency Physicians to include this spirochetal disease in the differential diagnosis of febrile patients with appropriate risk factors and symptomatology. We present the case of a 36 year-old woman who presented to the Emergency Department with fever and hypotension. We review the literature on leptospirosis with specific focus on risk factors and pathogenesis, clinical manifestations, diagnosis, treatment, and outcome.

Case 37-2010: A 16-Year-Old Girl with Confusion, Anemia, and Thrombocytopenia

Dr. Michele S. Duke (Pediatrics): A 16-year-old girl was seen in the emergency department of this hospital because of confusion, anemia, and thrombocytopenia. The patient had lupus nephritis but had been well until approximately 7 days before admission, when malaise developed, associated with frontal headaches, light-headedness when rising, fatigue, palpitations, and shortness of breath. Episodes of nausea and vomiting occurred that prompted her to leave school early. Two days before admission, she saw her primary care physician; the examination was reportedly normal, and no laboratory tests were performed. The symptoms were attributed to a recent tapering of prednisone and stress associated with school. At approximately 9:30 p.m. on the night of admission, right-sided weakness and numbness involving the face, limbs, and abdomen suddenly developed. The patient’s parents took her to the emergency room at another hospital, arriving at 11 p.m. On examination, the patient was awake and appeared in distress, moaning. She reported abdominal pain. The temperature was 38.4°C, the blood pressure 109/56 mm Hg, the pulse 98 beats per minute, the respiratory rate 18 breaths per minute, and the oxygen saturation 100% while she was breathing ambient air. The oral mucous membranes were dry. Strength in the right arm was reportedly decreased, and the gait was unsteady; the examination was otherwise normal. Serum levels of creatine kinase, creatine kinase isoenzymes, and troponin I were normal; other results are shown in Table 1. Urinalysis showed 1+ protein. An electrocardiogram was normal. Computed tomography (CT) of the head without the administration of contrast material was normal. Hydromorphone, metoclopramide, ondansetron, and normal saline were administered intravenously. During the next 2 hours, the patient reported that numbness extended to involve the left side, and increasing confusion and agitation developed. Approximately 2.5 hours after arrival, she was transferred to the emergency department at this hospital, arriving 40 minutes later. The patient had not had fevers, chills, diarrhea, rash, cough, or nasal congestion or discharge. A diagnosis of lupus nephritis had been made 3 years earlier, when hypertension and proteinuria (1.8 g of protein per 24 hours) developed after Case 37-2010: A 16-Year-Old Girl with Confusion, Anemia, and Thrombocytopenia

Are cervical spine radiograph examinations useful in patients with low clinical suspicion of cervical spine fracture? An experience with 254 cases

Trauma patients with low clinical suspicion of cervical spine fracture are often examined with a plain X-ray cervical spine series rather than with cervical spine computed tomography (CT). The authors have been concerned by the absence of fractures in the group of patients examined with plain X-ray. The objective of this investigation was to determine the usefulness of plain X-ray examinations in suspected cases of cervical spine fracture compared to CT. A retrospective review was performed of all trauma patients undergoing imaging for suspected cervical spine fracture in our Emergency Department over a one-year period (January 1, 2007 to December 31, 2007). During the study period, 254 cervical spine plain X-ray and 3,080 cervical spine CT examinations were performed. Of the 254 plain X-ray examinations, 237 were interpreted as negative for fracture, 11 were suboptimal examinations, and six were interpreted as possible fractures (later ruled out by further imaging). Of the 3,080 CT examinations, 2,884 were interpreted as negative for fracture and 196 as positive. The overall positivity rates for acute cervical spine fracture were 0.0% in plain X-ray and 6.4% in CT examinations. These data confirm the authors’ concern that plain X-ray imaging for patients with low clinical suspicion for cervical spine trauma in our hospital may have too low a yield to justify its use. However, the 6.4% positivity rate in the group of patients selected for CT examination justifies its use in this group.

Case 37-2010

Dr. Michele S. Duke (Pediatrics): A 16-year-old girl was seen in the emergency department of this hospital because of confusion, anemia, and thrombocytopenia. The patient had lupus nephritis but had been well until approximately 7 days before admission, when malaise developed, associated with frontal headaches, light-headedness when rising, fatigue, palpitations, and shortness of breath. Episodes of nausea and vomiting occurred that prompted her to leave school early. Two days before admission, she saw her primary care physician; the examination was reportedly normal, and no laboratory tests were performed. The symptoms were attributed to a recent tapering of prednisone and stress associated with school. At approximately 9:30 p.m. on the night of admission, right-sided weakness and numbness involving the face, limbs, and abdomen suddenly developed. The patient’s parents took her to the emergency room at another hospital, arriving at 11 p.m. On examination, the patient was awake and appeared in distress, moaning. She reported abdominal pain. The temperature was 38.4°C, the blood pressure 109/56 mm Hg, the pulse 98 beats per minute, the respiratory rate 18 breaths per minute, and the oxygen saturation 100% while she was breathing ambient air. The oral mucous membranes were dry. Strength in the right arm was reportedly decreased, and the gait was unsteady; the examination was otherwise normal. Serum levels of creatine kinase, creatine kinase isoenzymes, and troponin I were normal; other results are shown in Table 1. Urinalysis showed 1+ protein. An electrocardiogram was normal. Computed tomography (CT) of the head without the administration of contrast material was normal. Hydromorphone, metoclopramide, ondansetron, and normal saline were administered intravenously. During the next 2 hours, the patient reported that numbness extended to involve the left side, and increasing confusion and agitation developed. Approximately 2.5 hours after arrival, she was transferred to the emergency department at this hospital, arriving 40 minutes later. The patient had not had fevers, chills, diarrhea, rash, cough, or nasal congestion or discharge. A diagnosis of lupus nephritis had been made 3 years earlier, when hypertension and proteinuria (1.8 g of protein per 24 hours) developed after Case 37-2010: A 16-Year-Old Girl with Confusion, Anemia, and Thrombocytopenia

Dexamethasone in adults with bacterial meningitis [2] (multiple letters)

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African Tick-Bite Fever in a Returning Traveler

BACKGROUND African tick bite fever (ATBF) is an emerging infection endemic to sub-Saharan Africa and increasingly noted in travelers to the region. CASE REPORT We present a case of ATBF in a 63-year-old man who presented with complaints of a rash and fever to the emergency department. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Rickettsial diseases are increasingly common and are seen on every continent except Antarctica. Many factors are contributing to their prevalence, and they have become the second most common cause of fever behind malaria in the traveler returning from Africa. Due to the global distribution of rickettsial diseases, as well as increasing international travel, emergency physicians might encounter ill and febrile travelers. A careful travel history and examination will enable the emergency physician to consider spotted fever group rickettsial diseases in their differential diagnosis for single and multiple eschars.

Serial procalcitonin as a predictor of bacteremia and need for ICU care in adults with pneumonia, including those with highest severity: a prospective cohort study

Abstract Background Procalcitonin (PCT) is a prohormone that rises in bacterial pneumonia and has promise in reducing antibiotic use. Despite these attributes, there are inconclusive data on its use for clinical prognostication. We hypothesize that serial PCT measurements can predict mortality, intensive care unit (ICU) admission, and bacteremia. Methods A prospective cohort study of inpatients diagnosed with pneumonia was performed at a large tertiary care center in Boston, Massachusetts. Procalcitonin was measured on days 1 through 4. The primary endpoint was a composite adverse outcome defined as all-cause mortality, ICU admission, and bacteremia. Regression models were calculated with area under the receiver operating characteristic curve (AUC) as a measure of discrimination. Results Of 505 patients, 317 patients had a final diagnosis of community-acquired pneumonia (CAP) or healthcare-associated pneumonia (HCAP). Procalcitonin was significantly higher for CAP and HCAP patients meeting the composite primary endpoint, bacteremia, and ICU admission, but not mortality. Incorporation of serial PCT levels into a statistical model including the Pneumonia Severity Index (PSI) improved the prognostic performance of the PSI with respect to the primary composite endpoint (AUC from 0.61 to 0.66), bacteremia (AUC from 0.67 to 0.85), and need for ICU-level care (AUC from 0.58 to 0.64). For patients in the highest risk class PSI >130, PCT was capable of further risk stratification for prediction of adverse outcomes. Conclusion Serial PCT measurement in patients with pneumonia shows promise for predicting adverse clinical outcomes, including in those at highest mortality risk.