Top POEMs of 2018: Infection

Top 20 POEMs of 2018

Short Courses of Antibiotics As Effective As Longer Courses for Outpatient Infections

Clinical question
Are short courses of antibiotics as effective as longer courses for common outpatient infections?

Bottom line
Just about every time someone asks "Can I get away with a shorter course of antibiotics," the answer is "Yes, you can." Shorter courses reduce cost, and may reduce the likelihood of adverse events. (LOE = 1a)(www.essentialevidenceplus.com)

Reference
Dawson-Hahn EE, Mickan S, Onakpoya I, et al. Short-course versus long-course oral antibiotic treatment for infections treated in outpatient settings: a review of systematic reviews. Fam Pract 2017;34(5):511-519.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Government

Setting: Various (meta-analysis)

Synopsis
This is a relatively new kind of study: a systematic review of systematic reviews, also called a systematic overview. The authors searched 5 databases and identified 9 systematic reviews that compared the duration of antibiotic therapies for a common outpatient infection. The reviews included between 2 studies and 17 studies, with a total of between 395 and 5763 patients. The best studied conditions were urinary tract infection (UTI), sinusitis, and community-acquired pneumonia (CAP). The authors found that, in children, 5 to 7 days was as good as 10 days for strep pharyngitis; 3 days was as good as 5 days for CAP; more than 2 days was as good as 7 or more days for otitis media, and 2 to 4 days was as good as 7 to 14 days for UTI. In adults, 3 to 7 days was as good as 6 to 10 days for acute bacterial sinusitis, 3 days was as good as 5 or more days for uncomplicated UTI in nonpregnant women, and 7 to 14 days was as good as 14 to 42 days for acute pyelonephritis. The authors also found that 7 or fewer days was as good as more than 7 days for CAP, and 3 to 6 days was as effective as 7 to 14 days for UTI in older women. There was some evidence that shorter courses resulted in fewer adverse events when treating acute otitis media in children and acute sinusitis in adults.

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

Nothing Works for Cough Associated with the Common Cold

Clinical question
Which treatments are safe and effective for cough associated with the common cold?

Bottom line
Suck it up: you have a cold, it'll get better. That seems to be the bottom line from this expert panel report, which found little evidence of benefit for most commonly used medications for the self-limited condition of the common cold. Ultimately, physicians must often act in the absence of good evidence, and it is reasonable to recommend safe options for the treatment of cough even if the optimal evidence is not available. These treatments include honey, dextromethorphan, and possibly zinc for patients with cough. (LOE = 1a-)(www.essentialevidenceplus.com)

Reference
Malesker MA, Callahan-Lyon P, Ireland B, Irwin RS, CHEST Expert Cough Panel. Pharmacologic and nonpharmacologic treatment for acute cough associated with the common cold: CHEST Expert Panel Report. Chest 2017;152(5):1021-1037.

Study design: Systematic review

Funding source: Other

Setting: Other

Synopsis
Although billed as an "expert panel report," this was really a hybrid of a systematic review, an "umbrella review" of published systematic reviews, and a guideline. The authors did a careful literature search, identifying randomized controlled trials (RCTs), as well as previous systematic reviews, and updated the searches of the published systematic reviews. They included any randomized trial of any treatment for acute cough in patients with an upper respiratory tract infection or the common cold. Although the authors said they looked for studies of herbal supplements, and included a few of them, the Cochrane Review of pelargonium sidioides was not included.The studies were assessed for quality using the Cochrane Risk of Bias tool for RCTs and a similar tool for systematic reviews, and excluded any studies at high risk of bias. The expert panel reviewed the evidence, then made 4 key recommendations. They concluded that there was insufficient evidence to make a recommendation for acetylcysteine or carbocysteine, and they recommend against the use of over-the-counter cold medications available in the United States to treat cough. They also recommend against the use of nonsteroidal anti-inflammatory drugs, given their lack of proven efficacy and, of course, their potential harms. Honey gets some love: The authors conclude that for children older than 1 year and adolescents with cough, honey is probably better than placebo or diphenhydramine, but not any better than dextromethorphan (…which they just told us not to use). Zinc had mixed evidence, and some of the benefit was attributed to underlying zinc deficiency in some countries, as well as the difficulty in masking patients to the treatment. In the end, the panel did not recommend the use of zinc. They also found no good evidence supporting or refuting the benefits of over-the-counter antitussives, expectorants, mucolytics, antihistamines, or combinations of any of them. Finally, the panel recommends against using codeine-containing medications in children.

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

Subacute Cough Treatments: Limited Data, Unclear Benefits

Clinical question

Which treatments for subacute cough are effective?

Bottom line
The available evidence for treating patients with subacute cough is limited and fails to demonstrate meaningful improvements. (LOE = 1a-)

Reference
Speich B, Thomer A, Aghlmandi S, Ewald H, Zeller A, Hemkens LG. Treatments for subacute cough in primary care: systematic review and meta-analyses of randomised clinical trials. Br J Gen Pract 2018;68(675):e694-e702.

Study design: Systematic review

Funding source: Foundation

Setting: Outpatient (any)

Synopsis

Subacute cough—defined as cough that lasts no more than 8 weeks, is not accompanied by radiographic evidence of pneumonia, and resolves on its own—is fairly common, especially following respiratory infections. These authors systematically searched PubMed and the Cochrane Central Register of Clinical Trials to identify randomized trials published in English that evaluated various treatments in patients at least 16 years old with subacute cough. The studies could have included drug and nondrug treatments, but excluded Chinese or Asian herbal remedies. They also hand-searched reference lists of included studies, relevant systematic reviews, and clinical practice guidelines. Two authors independently assessed the inclusion of studies and the risk of bias for each study. They used a third author to resolve disagreements. They were able to find only 6 trials with between 30 and 276 patients (median = 96). The studies included montelukast, inhaled albuterol (also called salbutamol) plus ipratropium, gelatin, inhaled corticosteroids (fluticasone propionate, budesonide), and opioids. Five of the studies compared treatment with placebo, one with usual care. Overall, the reporting of the studies made assessing their risk of bias difficult. The studies used a variety of cough severity scores. Although the authors identified statistically significant improvement of cough scores with some interventions, none were clinically important. Additionally, some interventions provided short-term improvement but none were sustained beyond 2 weeks. Five studies reported on adverse effects of treatment, which were mostly mild and ranged from 0% to 40% for active treatment and 0% to 27% for placebo or usual care.

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI

Five-Day Nitrofurantoin Superior to Single-Dose Fosfomycin for Women with Uncomplicated UTI

Clinical question
Is a 5-day course of nitrofurantoin as effective as single-dose fosfomycin in the treatment of women with uncomplicated lower urinary tract infection?

Bottom line
A 5-day course of nitrofurantoin is significantly more likely than single-dose fosfomycin to achieve both clinical and microbiologic resolution of uncomplicated lower urinary tract infections (UTIs) in otherwise healthy adult women. (LOE = 1b-)(www.essentialevidenceplus.com)

Reference
Huttner A, Kowalczyk A, Turjeman A, et al. Effect of 5-day nitrofurantoin vs single-dose fosfomycin on clinical resolution of uncomplicated lower urinary tract infection in women. A randomized clinical trial. JAMA 2018;319(17):1781-1789.

Study design: Randomized controlled trial (single-blinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (primary care)

Synopsis
These investigators identified women,18 years and older, who presented with at least 1 symptom of acute lower UTI, including dysuria, urgency, frequency, or suprapubic tenderness, and a urine dipstick result positive for either nitrites or leukocyte esterase. Exclusion criteria included pregnancy, lactation, suspected upper UTI, antibiotic treatment for a UTI in the previous 4 weeks, indwelling urinary catheter, or immunosuppression. The patients randomly received (concealed allocation assignment) either oral nitrofurantoin, 100 mg 3 times daily for 5 days, or a single 3-g dose of oral fosfomycin. Although patients were directly aware of treatment group assignment (open-label), individuals masked to treatment group assignment assessed all outcomes, including the primary outcome of clinical resolution of all symptoms and signs of UTI without prior failure. Complete follow-up occurred for 92% of patients at 28 days. Using both intention-to-treat and per-protocol analyses, significantly more patients in the nitrofurantoin group achieved clinical resolution than in the fosfomycin group (70% vs 58%; number needed to treat = 8.1; 95% CI 4.8 - 25.9). Similarly, microbiologic resolution based on a negative urine culture occurred significantly more often in patients treated with nitrofurantoin. No significant group differences occurred in the development of pyelonephritis or urosepsis. Adverse events were mild and occurred similarly in both treatment groups.

David C. Slawson, MD
Professor and Vice Chair of Family Medicine for Education and Scholarship
Atrium Health
Professor of Family Medicine, UNC Chapel Hill
Charlotte, NC

Increased Water Intake Decreases UTI Recurrence in Women

Clinical question
Does increased water intake decrease urinary tract infection recurrence in women?

Bottom line
Drinking an additional 1.5 liters per day of water halved the recurrence of urinary tract infection (UTI) in women with a history of at least 3 episodes per year. (LOE = 1b-)(www.essentialevidenceplus.com)

Reference
Hooton TM, Vecchio M, Iroz A, et al. Effect of increased daily water intake in premenopausal women with recurrent urinary tract infections. JAMA Intern Med 2018;178(11):1509-1515.

Study design:Randomized controlled trial (nonblinded)

Funding source: Industry

Allocation: Concealed

Setting: Outpatient (any)

Synopsis
These researchers enrolled 140 premenopausal women with 3 or more documented episodes of lower UTI but not pyelonephritis in the previous year. In this unblinded study (What is a suitable placebo for water?), the women were randomized, using concealed allocation, to continue their normal levels of water intake or to drink an additional 1.5 liters (3 bottles) of Evian-branded water daily for 12 months, which participants, on average, were able to maintain. Women in the extra water group had approximately half as many infections as the usual intake group, an average 1.7 documented UTIs over the year as compared with an average 3.2 infections in the usual intake group (P < .001). All that extra water resulted in an additional 2 more trips to the bathroom every day, on average, than the usual intake group.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Alex Schreiber, PhamD

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).