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Top POEMs of 2017: Infections

Top 20 POEMs of 2017

Use of Nonsterile Gloves Does Not Increase Risk of Infection for Outpatient Skin Procedures

Clinical question
Does the use of sterile gloves when performing minor outpatient cutaneous surgeries reduce the risk of infection?

Bottom line
It is fine to use nonsterile gloves for common outpatient skin procedures, such as laceration repair and lesion excision. (LOE = 1a)(www.essentialevidenceplus.com)

Reference
Brewer JD, Gonzalez AB, Baum CL, et al. Comparison of sterile vs nonsterile gloves in cutaneous surgery and common outpatient dental procedures a systematic review and meta-analysis. JAMA Dermatol 2016;152(9):1008-1014.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Unknown/not stated

Setting: Various (guideline)

Synopsis
These authors searched multiple databases (PubMed, EMBASE, Cochrane, and others) to identify observational studies and randomized trials of patients who had minor outpatient cutaneous surgical procedures in which the physician used either sterile or nonsterile gloves. The procedures included excisions, Mohs surgery, laceration repairs, and tooth extractions. They identified both observational studies and randomized controlled trials. The 8 trials randomized 1381 patients to nonsterile gloves and 1360 to sterile gloves. There was excellent homogeneity (I2 = 0%), and the relative risk showed no difference in the likelihood of infection between groups (relative risk 0.95; 95% CI 0.65 - 1.40). The observational studies included a total of 8330 patients and found similar results.

Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA

Empiric Treatment of Onychomycosis with Terbinafine is Most Cost-Effective Strategy

Clinical question
Is confirmatory diagnostic testing cost-effective for the management of clinically suspected onychomycosis?

Bottom line
The most cost-effective approach to the patient with clinically suspected onychomycosis is empiric therapy with oral terbinafine. The chance of liver injury is estimated to be only 1 in 50,000 to 1 in 120,000, so testing to confirm the diagnosis would cost tens of millions of dollars per case of liver injury avoided. If you plan to prescribe the much more expensive topical solution efinaconazole 10% (Jublia), then confirmatory testing with periodic acid-Schiff (PAS) reduces costs (LOE = 2a)(www.essentialevidenceplus.com)

Reference
Mikailov A, Cohen J, Joyce C, Mostaghimi A. Cost-effectiveness of confirmatory testing before treatment of onychomycosis. JAMA Dermatol 2016;152(3):276-281.

Study design: Decision analysis

Funding source: Unknown/not stated

Setting: Outpatient (any)

Synopsis
An annoyance of clinical practice is the requirement by many insurance companies to perform confirmatory diagnostic testing prior to initiating treatment for patients with clinically suspected onychomycosis. This was based on analyses done 15 years ago, when terbinafine was significantly more expensive. Terbinafine is now affordable (approximately $10 for a full 12-week course), but the topical solution efinaconazole 10% provides a new, more expensive option (more than $500 for each 4-mL bottle in the United States). These authors performed a decision analysis that compared 3 strategies: (1) treat all patients empirically; (2) if in-office potassium hydroxide testing result is positive, treat; if negative, order PAS stain and treat if positive; or (3) order PAS stain on all patients and treat only if positive. They assumed, on the basis of previous studies, that between 65% and 95% of patients presenting with clinical nail dystrophy have a fungal infection, and that the cost of a course of treatment was $2307 for efinaconazole and $53 for terbinafine (including monitoring liver function). They concluded that if you are going to prescribe terbinafine, empiric therapy without confirmatory testing is the preferred strategy (and the least expensive overall) with a very low risk of serious adverse effects. If you are going to prescribe efinaconazole, then confirmatory testing with PAS is preferred. However, this is a much more expensive treatment option.

Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA

POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com(www.essentialevidenceplus.com).

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