Top POEMs of 2017 Consistent with the Principles of the Choosing Wisely Campaign: Infections

Top 20 POEMs of 2017 Consistent with the Principles of the Choosing Wisely Campaign

Oral Steroids Not Helpful for Acute Lower Respiratory Tract Infection in Nonasthmatic Adults

Clinical question
Are steroids useful in the treatment of acute lower respiratory tract infection in adults without asthma?

Bottom line
This study found no clinically significant benefit of steroids for the treatment of acute lower respiratory tract infection (LRTI) in adults without asthma, including those presenting with wheezing or shortness of breath. (LOE = 1b)(www.essentialevidenceplus.com)

Reference
Hay AD, Little P, Harnden A, et al. Effect of oral prednisolone on symptom duration and severity in nonasthmatic adults with acute lower respiratory tract infection. A randomized clinical trial. JAMA 2017;318(8):721-730.

Study design: Randomized controlled trial (double-blinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (primary care)

Synopsis
Because symptoms of acute LRTI can mimic those of exacerbated asthma, steroids are commonly prescribed with or without antibiotics. These investigators enrolled adults, 18 years or older, presenting with an acute cough (lasting 28 days or less) as the main symptom and at least 1 other lower respiratory tract symptom (eg, phlegm, chest pain, wheezing, or shortness of breath). Exclusion criteria included evidence of chronic pulmonary disease, having received any asthma medication in the previous 5 years, or requiring same day hospitalization or urgent antibiotic treatment. Patients (N = 401) randomly received (concealed allocation assignment) either 40 mg prednisolone daily for 5 days or matched placebo. Those patients also receiving a nonurgent antibiotic prescription were asked to delay filling the prescription for at least 48 hours. Patients assessed outcomes using symptom diaries and remained masked to their treatment group assignment. Symptoms were measured daily, including twice-daily peak expiratory flow, for 28 days or until symptom resolution. Complete follow-up occurred for 94% of patients at 28 days. Using intention-treat analysis, no clinically significant group differences occurred in the median duration of cough or severity of symptoms, symptom duration, antibiotic use, peak flow, or patient satisfaction. There were also no significant subgroup effect differences (ie, smoking, wheezing, chest pain, or shortness of breath).

David Slawson, MD
Professor and Vice Chair for Education and Scholarship
University of North Carolina Chapel Hill, Carolinas HealthCare System
Charlotte, NC

Tubes Ineffective for Treating Otitis Media in Children

Clinical question

In children with recurrent otitis media or chronic effusion, do tympanostomy tubes decrease further episodes, improve hearing, or improve language acquisition?

Bottom line
Tympanostomy tubes, with or without other interventions, do not produce sustained improved hearing as compared with no treatment, and has not been shown to improve language acquisition, cognitive development, or behavior measures. There might be a small reduction in the recurrence of acute otitis media, but there is little research in this area. Another study of tubes found no long-term (6 years to 9 years) benefit on development (N Engl J Med 2007;356:248-261). (LOE = 1a-)(www.essentialevidenceplus.com)

Reference
Steele DW, Adam GP, Di M, Halladay CW, Balk EM, Trikalinos TA. Effectiveness of tympanostomy tubes for otitis media: a meta-analysis. Pediatrics 2017;139(6):e20170125

Study design: Meta-analysis (other)

Funding source: Government

Setting: Various (meta-analysis)

Synopsis
These researchers searched 4 databases, including Cochrane CENTRAL, to find randomized controlled trials and other comparative research studies that evaluated the effectiveness of tympanostomy tubes. They included research written in any language. Citations were selected by 2 independent researchers. Study details were abstracted by one researcher and checked by a second researcher. In 16 randomized controlled trials of treating children with otitis media with effusion, the insertion of tubes with or without adenoidectomy decreased (improved) hearing threshold within the first 1 month to 3 months by an average 9.1 dB to 10.0 dB as compared with no treatment. However, there was no effect on hearing thresholds at 12 months to 24 months for tympanostomy alone or combined with adenoidectomy, prophylactic antibiotic treatment, or myringotomy as compared with no treatment. Overall, there was no effect on cognitive, language, and behavioral outcomes. In 3 small studies of children with recurrent acute otitis media the effect of tympanostomy tubes was inconsistent regarding recurrences. This analysis was a Bayesian network analysis, a statistical approach that still has some kinks in it, and the study report itself was somewhat incomplete, as is the evidence base for this common intervention.

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

No Benefit with Addition of TMP-SMX to Cephalexin for Nonpurulent Cellulitis

Clinical question
Does the addition of trimethoprim-sulfamethoxazole to cephalexin increase the rate of cure for uncomplicated cellulitis?

Bottom line
Compared with cephalexin alone, covering for methicillin-resistant Staphylococcus aureus (MRSA) and streptococci with cephalexin plus trimethoprim-sulfamethoxazole (TMP-SMX) does not improve rates of clinical cure when treating nonpurulent cellulitis. However, a trend favoring the combination regimen was found in a modified intention-to-treat population in this study so further research may be required. (LOE = 1b)(www.essentialevidenceplus.com)

Reference
Moran GJ, Krishnadasan A, Mower WR, et al. Effect of cephalexin plus trimethoprim-sulfamethoxazole vs cephalexin alone on clinical cure of uncomplicated cellulitis. JAMA 2017;317(20):2088-2096.

Study design: Randomized controlled trial (double-blinded)

Funding source: Government

Allocation: Concealed

Setting: Emergency department

Synopsis
Guidelines from the Infectious Diseases Society of America recommend treating nonpurulent cellulitis with an antibiotic that is active only against streptococci. However, in practice, clinicians often prescribe an antibiotic regimen that includes activity against MRSA. Using concealed allocation, these investigators randomized 500 patients who presented to the emergency department with nonpurulent, uncomplicated cellulitis to receive a 7-day course of either cephalexin plus TMP-SMX or cephalexin plus matching placebo. Bedside ultrasound was used to exclude patients with abscess. The primary outcome was clinical cure at 14 to 21 days in the per-protocol group (those who took at least 75% of the study drugs during the first 5 days and had an in-person follow up at 14 to 21 days, or those who took at least 75% of the study medication during the first 48 hours but had clinical failure). No significant difference was detected with approximately 85% clinical cure in both groups. In the modified intention-to-treat population of patients who took at least 1 dose of study drugs and were followed up at 14 to 21 days, there was a trend toward greater clinical cure in the cephalexin plus TMP-SMX group (76% vs 69%; difference 7.3%; 95% CI -1.0% to 15.5%; P = .07). Although this difference was not statistically significant, the 95% confidence interval includes the minimal clinically important difference of 10%, suggesting a possible benefit. Adverse events, reported as mild 90% of the time, were not different between the 2 groups.

Nita Shrikant Kulkarni, MD
Assistant Professor in Hospital Medicine
Northwestern University
Chicago, IL

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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