Are Antibiotics Useful for Small Skin Abscesses? (NEJM Journal Watch)

NEJM Journal Watch:
Are Antibiotics Useful for Small Skin Abscesses? Now There’s an Answer

Comments from Dr. Paolo:

Some initial thoughts on this study:

  1. Even taken at face value this is one study in a vast sea of
    literature that has found no distinction between antibiotic therapy versus
    simple incision and drainage.  If we are to assume the 7% difference in
    rate of cure as defined in the article (more to come) then difference in
    cure rate is a solitary data point that will be summated within the larger
    body of literature currently demonstrating no significant first pass cure
    rate (rates of subsequent skin and soft tissue infections aside).  This may
    move the summated needle and change the end point of the combined
    literature but it is not, in and of itself against a backdrop of negative
    studies, compelling on its own.
  2. Primary outcome was defined by a clinical test of cure assessment at
    7-14 days via a non-validated internally developed outcome measure.  This
    instrument has never been studied, externally validated, or assessed to
    determine the secondary generalizability and inter-rater reliability of the
    assessment tool.  Though the study mentions a “good inter-rater
    reliability” there is no external means to assess this instrument and it is
    the (very) subjective crux upon which the whole study rests.
  3. 34 of the total cohort was lost to follow-up and not included in an
    intention to treat analysis.  69 individuals were never assessed at the
    test of cure visit (or were excluded prior to the test of cure visit) and
    were included in the mITT-2 population.
  4. The secondary outcomes are nonsense and there are 12 of them and they
    should be dismissed out of hand and ignored.  There is no reason to include
    multiple uncontrolled, nonsensical secondary outcomes that cannot possibly
    be controlled for and will, defintionally, have significant differences
    discovered simply by the volume of the parsing of the initial dataset.
  5. The point estimate of this study offers a NNT of 14 to (and this is
    important) demonstrate clinical cure as assessed by a non-validated
    instrument at 7-10 days post incision and drainage (with no standardization
    of the I&D techniques).  This means that at best 13 people will receive no
    benefit whatsoever from the exposure to high dose antibiotics and will
    demonstrate no changes in a (non-validated) clinical assessment
    instrument.  Further if the lower bound of the confidence interval were
    true this would yield an NNT of 50 in order to achieve a benefit on the
    (non-validated) clinical assessment instrument.   There were no harms found
    in this study (NNH) to counterbalance the NNT for us to determine the
    likelihood of harm from the prescription of antimicrobials.  I am not sure
    why this occurred but we are aware of high rates of allergic reactions,
    c-diff, antimicrobial resistance, and diarrhea to counterbalance to alleged
    benefit of antimicrobial prescriptions.
  6. There were no distinctions between invasive disease between each group
    or other severe outcomes that would bias towards the treatment with
    antimicrobials.  If you believe this study and the point estimated
    difference then this study does not (as it alleges using a non-validated
    instrument) argue for treatment of all comers to the ED with initial
    antimicrobials rather than I&D alone (which cured the vast majority of
    patients)—in fact it argues that the initial treatment SHOULD be I&D alone
    followed by a return visit (or PCP follow-up) in 7-10 days for
    reassessment.  At the return visit antimicrobial therapy can be added to
    the small and select group who are deemed treatment failures rather than
    the wanton and inappropriate prescription of antibiotics to all comers
    (based upon this study and its non-validated clinical assessment

10/14/2015 – Wilderness Medicine Conference


8a ~ Drinking Water ~ Thomas Welch

Premise by which we are taught to treat potable water… Hx?

Giardiasis? AT & all over the country… 1976 Journal of Tropical Medicine & Hygiene, case report. Dietary fiber & changes on the trail can contribute to noninfectious diarrhea…

Food poisoning toxins common cause… intestinal infection actually rare.

By far most common infectious agents viral such as noro/rotavirus, Protozoa include Giardia,  while bacteria such as Salmonella, Shigella, Vibrio much less common here.

All of these come from ingestion of fecal matter transmission…

Typhoid Mary… contaminated surfaces in addition to contaminated food & water…

John Snow & the broad street pump, birth of epidemiology… 19th century London

1972 “Unita Mountain Event” ~ 65% of students in this group acquired Giardiasis!

…no identifiable dose~response pattern, & no other groups there were affected?!

Food-borne infection was assumed improbable, but in retrospect, most likely foodborne hand-to-mouth transmission.  Giardia actually uncommon & difficult to contract.

Should treat water when single source used persistently over extended period of time, sites of heavy human use, & canyons relatively high risk.

Decision to treat should consider fecal vector of other infectious etiologies than just Giardia…

*Flocculation c “Alum” suspension looks pretty but not very useful.

*Boiling vs heating over 60*C…

*Filtration does not much with viruses, which are much more common…

*chemical Tx, Io, Cl… “Polar Pure” one of the easiest, best, cheapest…

*UV light?

1/3 of hikers have fecal matter on hands, according to 2004 article (Kellogg)

Exertional hyponatremia has caused deaths both in marathons & hiking!…

850a ~ Parasitic Worms ~ Josh Mularella

Tumbu fly (Africa) vs Botfly (South/Central)

*Worms App ~ Taenia solium/saginata ~ Pork & Cow tapeworms, cysticercosis

Echinococcus (hydatid dsx) also looks similar microscopically

beef tapeworm can become ~ 3m long!

Neurocysticercosis ~ can come from contaminated water/stool… treated c praziquantel but Tx can cause harm when cysts die….

*Trematodes ~ all go through snails. Lung flukes go through crabs, liver flukes (GB) through fish & watercress…

*Bilharzia & Schistosomiasis (Mansoni, Japonicum, Haematobium) ~ swimmer’s itch not bad in U.S. bc noninfectious spp.  Praziquantel ppx?!

*Hookworm ~ Necator & Ancylostoma ~ Filaria through soil & human feet… Albendazole Tx.

Dog & Cat hookworms can cause larvae cutanea migrans, itchy rash.

*Whipworm causes rectal prolapse?! Tx c reduction & albendazole

Ascaris Worms can cause obstruction/pseudo obstruction…

Albendzole ppx?! ~ 1x dose…

950a ~ Wilderness Articles ~ Sanjay Gupta (LIJ)

Drowning Prevention ~ worldwide public health issue ~ WHO 372K ppl est/yr deaths!

Most <25yo! M:F > 2:1?!

Tetanus… most common in neonates dt umbilical contamination!

Non~neonatal cases, unremitting spasms, risus sardonicus, Tx c Mag…

Getting tetanus does not convey immunity to C.tetani!

Super Glue/dermabond for Remote medical care?! (dermabond less exothermic)

Hemostatic (i.e.varicose veins), may reduce need for moleskin, bandages, tegaderm…

*Efficacy for Cold Packs in cooling of hyperthermic patients… more effective when cold packs applied to glabrous skin (palms, soles, cheeks) vs traditional (neck, groin, axillae)

*2009 Rattlesnake Exposures vs prevention measures? Larger snakes more aggressive, longer bites, more venom?!?! Denim somewhat protective?!

*Exsanguinating Trauma ~ permissive hypotension (while perfusing) may actually be helpful to minimize bleeding & blood dilution… Massive Transfusion Protocols just introduced in 2006?!

2015 PROPPR study 1:1:1 vs other ratios… multicenter trial c endpoints of 24hr & 30 day mortality… ratios not significantly different on primary outcomes, but post hoc analysis maybe favors 1:1:1…

*Tough mudder injuries?…

*US evaluation of volume status in Acute Mountain Sickness…

*Rectal fluid through foley in GI bleed?!

1035a ~ Ski Patrol ~ Rob Winter

National Ski Patrol Organization: Candidate, Patroller, Senior, Certified, Pro…

~23K Volunteer, ~4K paid

Physician Patrollers, & Medical Associates (typically wilderness physicians)

Most mountains have their own quality control, not typically DOH directed until EMS transport.

National Organization based in Colorado.  Every patrol at least BLS certified.

Yearly skills tests & toboggan handling.  Ski patrol training done publicly, not bad for marketing…

Model 100 Toboggan now standard & uses belay 2man method.  Lift evacuations…

Off season summer events now including bike patrols.  Paper PCR to EMR transitioning…

Local Toggenburg…

1110a ~ Aerospace Medicine ~ Rebecca Blue

Essentially wilderness medicine, far far away.  Relatively healthy people in an environment trying to kill them.  Compression/decompression complications… Humans in remote environments also have behavioral/psychiatric concerns.  “Flight Surgeons”

Acceleration/Deceleration injuries… vertebral compression frx…

Cold & Heat injuries… Launches & Landings in Kazakhstan.

Physicians have psychological role in medical care of family & friends in fatality events.

Apollo XIII ~ explosion complications as well as medical sickness

Apollo 1 Fire… Accidents happen when we push the schedule.

What are the most likely threats? What do you put in your backpack?

Flight Surgeon helps determine risks as well as evaluation for evacuation. Making the call…

Human Factors (cooperation, coordinations, stress & SI/HI?!)

Commercial Space Flight… Now opening to “everyone”?! ~ But most are very limited duration.

Remote Launch sites ~ New Mexico ~ hazards.  Lots of desert. Heat/Cold/Water/Food/Animals

Coordination of ground response, research c centrifuges…

1pm ~ NYS Police Search & Rescue ~ Troopers Bender & Mandin & Connors

Missing Persons Search… Bears & Moose Country

Type 3 Grid Search… K9 Search… Helicopter Extrication

Communications Vital in Extrication!  Air Access zone…

120p ~ Nepal Earthquake MCI 2015 ~ Renee Salas

HRA (Himalayan Rescue Association) Pheriche & Everest Base Camp,

MGH Wilderness Medicine Fellowship, Kathmandu

Khumbu Valley, Nepal, Lukla Airport (one of the most dangerous airports in the world)

5 day hike up to Pheriche, climate adjustments…

2 days up to Everest base camp, 1 day hike down…

Everest Base Camp ER… April 25th 2015:  7.8 Magnitude Earthquake, several thousand fatalities!  Happened at noon & lucky most people outside, aftershocks, slept in sunroom, sat phone communications…

70+pts for 3 docs… Recruitment of resources, patient labeling & organization…

Name, injuries, meds, vitals… Ultrasound & limited resources…

If you are going to do a diagnostic test, make it have utility… ro PTX or tamponade…

…but intraperitoneal bleeds would have to wait for Trauma SG at further hospital…

Mi-17 helicopter was requested & delivered for pt extraction…

Prioritizing helicopter transport… Probably ~150 Volunteers.

MGH International Medical Corps in Gorkha, Nepal.

2nd Earthquake 7.3 Mag, & helicopter damaged prior to evac…

NEJM Media driven, telling the story & raising awareness…

Communications, communications, communications…

Risk Assessment… Know potential dangers, disasters, have tools & skill sets at least roughly appropriate to scenario. Judicious use of pain medicine & transport capabilities.

Identification as Physicians? …now there are vests…

Remote medicine can emphasize the humanism in medicine.

Teamwork! & Role of Media?…

2p ~ Doctor on Board? Airplane Emergencies ~ Ryan Bodkin

Know the risks, know the tools, know the skills…

Cabin Altitude & Pressure ~ pressurized above 5K to 8K feet… decreased pressure causes decreased saturation, esp in COPD/CHF, immobility, nebs, Sz meds…

12,000 calls for emergency assistance on flight; 69% had MD/NP/PA, & 1/600 flights have a call.  N/V > CP…

Should you respond? Aviation Medical Assistance Act ~ 1998 has vague wording.  NOT required to act!  No standard of care, do the best you can.  No cases so far assigned liability.

Rules apply to where aircraft lands, not departs.

1) You must be asked to help.  Flight crews should ask.  Consent.

2) You must verify your credentials.  ground medical control available as needed, & in charge.

3) Good samaritan law normally prohibits compensation; Aviation Act states gifts do not disqualify from good samaritan status in this circumstance. …but no direct $$.

4) The bigger the aircraft, the more stuff they have. AED on every flight. BVM, Epi, Lido, Diphen…

5) Focus on basic interventions.  Goal is stabilization & reassurance. Open the kit.  See the supplies.  Provide O2.  Lower altitude?  Confer c Ground Medical Control. ABCD.  Ask for glucometer?… Improvise nebulizer c O2 if needed.  ASA > NTG in remote context

*Paramedics likely covered, but EMTs, Med Students unlikely…

235p ~ Animal Bites & Injuries ~ Amy Biondich

In the U.S. Yellowstone: 43 bear injuries, bull elk & bison injuries… among 3million visitors/year

~20 Cougar deaths reported, ~14 dog bites, ~12 rattlesnake, ~40 bee stings…

*Exotic animals in U.S.!!! 650 Million imported animals between 2003-2007?!

1990-2011 300+ incidents c large captive cats?! Intoxication often associated…

Moose & deer most often injure ppl in cars.  We did have a camel bite in Syracuse.

1) Is the scene safe?! Evacuation plan!!! ABCs…

C Spine very important precautions esp c big cats.  Stop bleeding.  Get an IV if you can.  Clean wounds c clean water.  May be combination of both penetrating & blunt injury, often get TraumaSG involved, usually require thorough eval & Abx!!! Assess Neurovascular staus & be aware for compartment syndrome dt bite crush pressure!

PTSD screening early!!!  Esp: tiger, dog, croc, shark attacks!

No pressure irrigation or tight closure of wounds.  At least partial closure when the face is involved. Hands, Face, Genitals, Closure, Deep, Cats, Immune Compromised get Abx.

RABIES?! ~ Acute viral encephalitis, dangerous but incredibly rare.

Rabies is the closest we have to a zombie virus, transmitted by saliva & causes behavioral changes… carnivores more likely than other mammals to harbor rabies.  Brain Bxy necessary for definitive Dx & 10 day quarantine could be required… Rabies *Vaccine* vs Rabies IG…

Vaccine does not completely exclude infection.  Experimental “Milwaukee” Protocol, 5 have survived, vaccine probably better…

Cat bites… =Nasty Puncture Wounds! Pasteurella in 75% as well as mixed anaerobes.  Augmentin, Doxy, Bactrim… Dog Bites ~ 50% Pasteurella, so identical recommendations! …although crush injury more common

Monkey bites ~ Herpes B Virus??? Mortality up to 80% without Treatment… Acyclovir…

Sealpox ~ virus, only ~3 cases so far… no known human to human contact

Tularemia highly pathogenic, septicemia, mortality up to 30% in untreated, mostly via insect bites… multifocal necrosis… DCX or Cipro…

Hepatic Coccidiosis from eating rabbits…

Bear attacks ~ Approach to Black vs Brown/Grizzly very different.

Cougars attack runners & cyclists from behind.  Feed on kills for up to 2 weeks so high risk search & rescue! make yourself look large & pick up kids & pets, fight back.

AliEM AIR Series 2 HEENT

AIR Series: Head, Ear, Eye, Nose and Throat (HEENT)

“Welcome to the second ALiEM Approved Instructional Resources (AIR) Module! In an effort to reward our readers for the reading and learning they are already doing online, we have created an Individual Interactive Instruction (III) opportunity utilizing FOAM resources for US Emergency Medicine residents. For each module, the board curates and scores a list of blogs and podcasts. A quiz is available to complete after each module to obtain residency conference credit. Once completed, your name and institution will be logged into our private Google Drive database, which participating residency program directors can access to provide proof of completion.”

See Also: ALiEM Approved Instructional Resources (AIR)

ALiEM Approved Instructional Resources (AIR)

New AIR Series: ALiEM Approved Instructional Resources

On behalf of the AIR Executive Board, we are excited to introduce the Approved Instructional Resources (AIR) series! The AIR series was conceived to provide a credible method by which an U.S. Emergency Medicine resident can receive academic credit for using Free Open Access Meducation (FOAM) resources. The Executive Board will release a list of high-quality FOAM educational posts and podcasts specially selected by our Executive Board, in parallel with the CORD residency training curriculum. We will have an accompanying quiz for each list and track who completes it. EM residents who complete the quiz can hopefully receive credit for Individualized Interactive Instruction (III) from their EM residency for training purposes.AIR-Series-Thumbs-Up-Small

AIR Series: Infectious Disease, Hematology, Oncology 2014