Antibiotic Resistance – National Action Plan

On the heels of recent concern for carbapenem-resistant enterobacteriaceae, President Obama announced the National Action Plan to reduce antibiotic resistance by 2020. The plan hopes to accomplish this goal through the following means:

National Strategy on Combating Antibiotic-Resistant Bacteria 

The National Strategy provides detailed actions for five interrelated national goals to be achieved by 2020 in collaboration with partners in healthcare, public health, veterinary medicine, agriculture, and food safety, as well as in academic, Federal, and industrial research and development.  The goals are:

  1. Slow the emergence and prevent the spread of resistant bacteria.
  2. Strengthen National efforts to identify and report cases of antibiotic resistance.
  3. Advance the development and use of rapid diagnostic tests for the identification and characterization of antibiotic-resistant bacteria.
  4. Accelerate basic and applied research and development for new antibiotics as well as other therapeutics and vaccines.
  5. Improve international collaboration, capacities for antibiotic-resistance prevention, surveillance, control, and antibiotic research and development.

(Fact Sheet: Obama Administration Takes Actions to Combat Antibiotic-Resistant Bacteria. http://www.whitehouse.gov, accessed March, 2015)

Through an executive order, the plan calls for collaboration between physicians, hospitals, and the federal government to establish a task force for combating multi-drug resistant (MDR) bacteria, improve antibiotic stewardship, strengthen national surveillance efforts for resistant bacteria, promote the development of new and next-generation antibiotics and diagnostics, and strengthen international cooperation.  Interestingly, similar efforts have been adopted in India and China, with some degree of success. Finally, the administration hopes to launch of a $20 million prize for new, rapid, point-of-care diagnostic tests.

 

 

Digoxin Toxicity – A Practical Review

CLINICAL FEATURES

  • Acute digoxin toxicity
    • Time course: initial toxic effects of nausea and vomiting occur at 2-4 hours, peak serum levels at 6 hours and life-threatening cardiovascular complications  at 8-12h
    • GI: anorexia, nausea, vomiting, diarrhoea, abdominal pain
    • Metabolic: hyperkalaemia (early sign of significant toxicity)
    • CVS: enhanced automaticity (atrial tachycardias (e.g. flutter, AF) with AV block, VF, VT, ventricular ectopic beats), bradyarrhythmias (Conduction delays / blocks, slow or regularised AF), hypotension, shock
    • CNS: lethargy, confusion
  • Chronic digoxin toxicity
    • Typically occurs  in the context of intercurrent illness, especially with impaired renal function
    • Clinical features are a combination of toxicity and the intercurrent illness
    • Symptoms may have an insidious onset over days to weeks
    • Features include those of acute digoxin toxicity as well as visual disturbances (e.g. reduced acuity, yellow halos (xanthopsia) and altered color perception (chromatopsia))

DIAGNOSIS

  • Urgent K level, creatinine
  • Serum digoxin level –  a steady state level 6 or more hours after the last dose; levels can be misleading as levels near the therapeutic range (0.6-1.3 nmol/L) correlate poorly with severity of intoxication
  • ECG

MANAGEMENT

  • ACUTE DIGOXIN TOXICITY
    • Digoxin-induced cardiotoxicity is refractory to standard measures
      • Bradyarrhythmias
        • Digibind is the definitive treatment
        • Atropine
        • Epinephrine (but may aggravate cardiac irritability)
        • Pacing (rarely effective)
      • Tachyarrhythmias
        • Digibind is the definitive treatment
        • MgSO4as an adjunctive measure
        • Often refractory to cardioversion
    • Hyperkalemia: Insulin and glucose, bicarbonate Calciumis traditionally contra-indicated due to the risk of precipitating a ‘stone heart’.
    • Activated charcoal if the patient presents <1h post-ingestion and not vomiting (unlikely to prevent severe toxicity in large ingestions)
  • CHRONIC DIGOXIN TOXICITY
    • Resuscitation as for acute digoxin toxicity
    • Renal replacement therapy may be indicated in the context of renal failure and hyperkalemia
    • Digibind!