Early-Goal Directed Therapy in Sepsis

The results of a multi-center trial from the UK, the ProMISe trial, were just released and it confirms what two prior studies (i.e., ProCESS and ARISE) have already shown; there does not appear to be any difference in mortality when septic patients are treated with a strategy of early-goal directed therapy as compared to usual care.

Patients were included in the ProMISe trial if they were in septic shock and were then randomized to either the EGDT group (630 patients) or the usual care group (630 patients); a total of 1,260.

The primary end-point was all cause mortality at 90 days and there was no difference shown in the primary outcome. There were no differences found in the measured secondary outcomes (e.g., serious adverse events)

This trial adds to the evidence that septic patients may not benefit from protocolized (i.e., EGDT) care versus usual care. One explaination why, is that our “usual care” in 2015 has significantly changed since the introduction of EGDT in 2001.

Noon Conference: Complications of Cirrhosis

If you missed it, you should definitely check it out! Dr. Mufti gave a great talk on the complications of cirrhosis. I promise, despite how much experience we have with cirrhosis, you will learn a lot from this review! You can listen to his lecture on the resident website as well.

(A note to email subscribers, you may not be able to see the slides from the email, to view, go to the full site by clicking the link above)

Answer to CC #10

Case Challenge #10 presented a 32 year old with SLE who presented with petechiae, pancytopenia, very elevated ferritin, transaminitis, etc.

We asked which of the following would be the most likely diagnosis?

The correct answer is: Hemophagocytic Lymphohistiocytosis (HLH)

  • Multisystem disorder of excess immune activation due to either genetic cause (primary) or triggered by secondary causes
  • Triggers: Infections (EBV, CMV, HIV, Histo, TB), heme malignancy, autoimmune disease (AOSD, SLE, RA)
  • Latter is termed macrophage activation syndrome
  • Presentation: Fevers, HSM à MODS, ARDS, shock from cytokine storm.
  • Labs findings: Pancytopenia, DIC, abnormal LFTs. Marked elevation in ferritin and triglycerides. Hemophagocytosis on BM or liver biopsy.
  • Treatment: Steroids +/- chemo, Rx triggering condition, supportive care

Tips for Using Antibiotics Wisely

We will conclude this week with a helpful list of tips from our own ID stewardship experts. Thanks to Dr. Lee, Dr. Cutrell and Dr. Bhavan!

Antibiotics are a precious but finite resource in medicine.  The best way to preserve them for future patients is optimizing antibiotic utilization now.

Ways to use antibiotics wisely include:

  • Avoid antibiotics when not needed
  • Use the narrowest agent possible
  • Ensure the right dose and right route of administration
  • Use the shortest duration of therapy needed
  • Promote antibiotic best practices including an “antibiotic timeout”

Key questions to ask when starting or reassessing antibiotics:

  1. Does my patient really have an infection?
    • Don’t forget to consider non-infectious causes of fever or elevated WBC.
  1. Can I target my therapy for a particular pathogen?
    • Use narrow spectrum agents to target positive culture results.
    • If no culture data available, the lack of patient risk factors for drug-resistant pathogens (like MRSA or Pseudomonas) may allow safe de-escalation to narrower agents.
  1. Are there patient factors that impact antibiotic dosing?
    • Changes in renal or hepatic function
    • Drug-drug interactions, esp. with oral abx that may impair absorption
    • Don’t hesitate to contact your pharmacist or stewardship team for help!
  1. How long do I need to treat this infection?

As always, the Antimicrobial Stewardship Programs at each hospital are available to help with these questions, so please contact us at any time.

Kavita Bhavan- Parkland

Brad Cutrell- VA

Francesca Lee- UTSW