Journal Feed Weekly Wrap-Up
- Jan 9th, 2021
- Clay Smith
- categories:
#1: New Regimen for Gonorrhea and Chlamydia
Spoon Feed
The new regimen for treating gonorrhea is ceftriaxone 500mg IM, and in patients with unknown chlamydia status, add doxycycline 100mg po bid x 7 days. Azithromycin is out.
Why does this matter?
Since 2010, the CDC has recommended treatment of uncomplicated gonorrhea of the cervix, urethra, or rectum with ceftriaxone 250mg IM, and if chlamydia status is unknown (which it often is), azithromycin 1g po is added. But changes are needed. Here’s why.
STI Dx and Tx UTD
N. gonorrhea is increasingly resistant to azithromycin. Not only was azithromycin considered important in empirically treating possible co-infection with chlamydia, it was thought that having dual agents working by a different mechanism may have been important in reducing N. gonorrhea resistance to ceftriaxone. Now, that is no longer an effective strategy. Also, there is increasing resistance of Mycoplasma genitalium to azithromycin and concern about the efficacy of treating chlamydia, especially rectal disease, with azithromycin. Now, instead of azithromycin, doxycycline 100mg po bid x 7 days is recommended. Finally, to achieve higher MICs and optimize effectiveness, especially with gonococcal disease of the pharynx, ceftriaxone 500mg IM as a single dose is now recommended.
Source
Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep. 2020 Dec 18;69(50):1911-1916. doi: 10.15585/mmwr.mm6950a6.
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From the CDC.
#2: HEAR or HEART Pathway – Can We Drop Troponin?
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Patients with a HEAR score of 0 or 1 were at very low risk of MACE within 30 days. We need a larger study to confirm this before putting it into practice.
Why does this matter?
We have covered numerous articles on use of the HEART pathway to risk stratify chest pain patients. What if we dropped the troponin? The HEART pathway consists of history, ECG, age, risk factors, and serial troponins. HEAR would drop the troponin. Could we use HEAR for ACS like we use PERC for PE?
Did you HEAR this?
This was a secondary analysis of a HEART pathway implementation study with 4,979 patients. In patients with very low HEAR score of 0 or 1 (9%; 447/4979), the risk of MACE (composite: death, MI, and PCI) at 30 days was 0.9%. Troponin measurement would have reclassified two patients. One was a cocaine user with chronic troponin elevation who had no change in management. One had clean coronaries and was diagnosed with Takotsubo. Of the two patients who died, both were from existing cancer, not heart disease. Sensitivity was 97.8% (95%CI 94.5% to 99.4%) and NPV 99.1% (95%CI 97.7% to 99.8%). The result of 0.9% falls, “under the 1% benchmark that is generally considered the threshold of acceptability.” However, this study was not designed to measure this outcome, and the 95% confidence interval ranges from 0.2% to 2.3%. We need a larger study to clarify this outcome before we implement the HEAR score in practice.
Source
Identification of very low-risk acute chest pain patients without troponin testing. Emerg Med J. 2020 Nov;37(11):690-695. doi: 10.1136/emermed-2020-209698. Epub 2020 Aug 4.
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#3: Prednisone to Reduce Cluster Headaches
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Prednisone, given while up-titrating verapamil, was effective at reducing the frequency of cluster headache attacks.
Why does this matter?
Prednisone is often used for cluster headache, but its effectiveness hasn’t been proven in a RCT. Even one less cluster headache could impact quality of life. Does prednisone reduce cluster headache attacks?
Cluster bomb, cluster headache, cluster B…the only good cluster I know is a Goo Goo Cluster (…pecan is the best).
This was a multicenter, double blinded, placebo controlled RCT with 116 patients who received prednisone 100mg x 5 days, with a taper by 20mg every three days (17 days total) or placebo while up-titrating verapamil for prophylaxis (40mg tid up to 120mg tid over 19 days). Mean number of attacks in the first week were fewer in the prednisone group vs placebo: 7.1 vs 9.5, respectively (-2.4 headache attacks, 95%CI -4.8 to -0.03). Also, 35% of the prednisone group vs. 7% (p=0.0006) of placebo patients had complete cessation of attacks in the first 7 days. There was no increase in serious adverse events in the treatment arm. There were a number of exclusions you should be aware of and consider, such as diabetes, hypertension, gastric ulcers, along with many others. They had to stop the trial early because it was difficult to enroll patients, and they ran out of funding. Almost all patients enrolled were German, which may impact generalizability. Overall, this is an evidence based treatment that could help patients suffering with this awful condition.
Source
Safety and efficacy of prednisone versus placebo in short-term prevention of episodic cluster headache: a multicentre, double-blind, randomised controlled trial. Lancet Neurol. 2021 Jan;20(1):29-37. doi: 10.1016/S1474-4422(20)30363-X. Epub 2020 Nov 24.
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