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Chills during hemodialysis: prediction and prevalence of bacterial infections
446 achieve each time interval improvement. The integrated network also resulted in greater improvement in 90th percentile response time. However, the integrated network model did result in one rural region having no drone bases, and subsequently not experiencing a significant improvement in its median response time. The authors concluded that drone delivery of AEDs has the potential to improve response times for OHCA and, in theory, could improve OHCA survival. [Avi Baehr, MD Denver Health Medical Center, Denver, CO] Comment: This is the first study to use actual OHCA data to model and test a drone network for AED delivery. By modeling different response time improvement goals as well as a regional versus integrated drone network, the authors highlight some of the important costs and benefits that will need to be considered prior to implementation of a drone network. More resources would be needed to achieve greater response time improvements. An integrated rather than regional approach has the potential to reduce resource requirements; however, it does so at the cost of some rural regions being effectively left out of the drone network. , CHILLS DURING HEMODIALYSIS: PREDICTION AND PREVALENCE OF BACTERIAL INFECTIONS. Shepshelovich D, Yelin D, Bach LO, et al. Am J of Medicine 2017;130(4):477-481 Infections are a leading cause of death in hemodialysis patients, and accordingly, hemodialysis patients presenting with chills are frequently treated with broad-spectrum antibiotics. However, the predictive value of chills for bacterial infection had not been previously characterized. The authors performed a retrospective analysis to determine risk factors for bacterial infections in patients who are admitted for chills during or shortly after a hemodialysis session. All adult chronic hemodialysis patients at a single medical center who were hospitalized for chills during or immediately after dialysis from 2004 – 2015 were included in the study. Patients who reported chills or fever before dialysis were excluded. Repeat patient presentations were also excluded. Patient level data was abstracted from the medical record, and survival data was obtained using a national database. An infectious disease specialist classified infections based on either culture data or clinical diagnosis. Sixty percent of the 269 patients with chills were diagnosed with an infection: 90 patients (33.5%) had bacteremia and 72 (26.8%) had a clinically documented infection. Significant predictors of bacteremia on multivariate analysis included tunneled/central catheters as dialysis access (odds ratio (OR) 6.2; 95% CI 3.2-12.0) and fever (OR 1.6; 95% CI 1.1-2.3). Nearly half (130/269) of the patients with chills presented with a temperature lower than 38.5 C. Bacteremia was found in 26.2% of these patients and any infection was found in 54.6% of these patients, Significant predictors of any infection in afebrile patients included leukocytosis and hypoalbuminemia. The authors developed a prediction model where fever, central access, abnormal white blood cells, and hypoalbuminemia were each assigned one point. Excluding the patients with
Abstracts clinically rather than culture-diagnosed infection, this model was used to predict bacteremia with an area under the curve of 0.697. Of patients with no fever, no central access, normal leukocyte count and normal albumin, the incidence of bacteremia was 6%. Overall mortality for hemodialysis patients with chills was low, at 4.8%, and no cases of mortality were documented in patients with either 0 or 1 of the 4 risk factors. The authors conclude that bacterial infection rates are high among hemodialysis patients with chills, and they define statistically significant risk factors for infection including fever, central access, leukocytosis and hypoalbuminemia. They suggest that in patients with none of these risk factors and without a history suggestive of infection, antibiotics might be withheld. [Avi Baehr, MD Denver Health Medical Center, Denver, CO] Comment: This study highlights that hemodialysis patients presenting with chills have a very high incidence of bacterial infection and bacteremia and therefore should be taken seriously by emergency department (ED) providers. The authors highlight risk factors for bacterial infection and describe a risk stratification tool to identify ‘‘low-risk’’ patients, which may have limited utility in the ED setting given the 6% incidence of bacteremia even among this low-risk cohort. It must be noted that this is a single-center, retrospective study, and as such, its generalizability may be limited. , EFFECT OF ORAL DEXAMETHASONE WITHOUT IMMEDIATE ANTIBIOTICS VS PLACEBO ON ACUTE SORE THROAT IN ADULTS. Hayward GN, Hay AD, Moore MV, et al. JAMA 2017;317(15):1535-1543 Sore throats are a common symptom among patients presenting to primary care and emergency departments. These patient visits are associated with a high burden of unnecessary antibiotic prescription, and there is a need for alternative treatment strategies. Corticosteroids may accelerate symptomatic relief, but their effect on symptom resolution in the absence of antibiotics had not previously been studied. The goal of this study was to determine whether a single dose of oral dexamethasone provided symptomatic relief to adult patients presenting to primary care with acute sore throat. The authors conducted a randomized, double-blind, placebocontrolled trial at 42 primary care sites in England. Adult patients presenting within 7 days of symptom onset and judged to not require immediate antibiotics were recruited. Patients were excluded if they had used corticosteroids in the past month or used antibiotics in the past two weeks. Participants were given either a 10mg tablet of dexamethasone or an identical tablet of placebo; participants, clinicians and researchers were blinded to the allocation. Outcome data were collected through phone or text message interviews, patient symptom diaries, and review of the electronic medical records, with the primary outcome being the proportion of patients with complete symptom resolution at 24hrs, and secondary outcomes including symptom resolution at 48hrs. Subgroup analyses were performed based on whether the patient received a delayed antibiotic prescription.
Abstracts clinically rather than culture-diagnosed infection, this model was used to predict bacteremia with an area under the curve of 0.697. Of patients with no fever, no central access, normal leukocyte count and normal albumin, the incidence of bacteremia was 6%. Overall mortality for hemodialysis patients with chills was low, at 4.8%, and no cases of mortality were documented in patients with either 0 or 1 of the 4 risk factors. The authors conclude that bacterial infection rates are high among hemodialysis patients with chills, and they define statistically significant risk factors for infection including fever, central access, leukocytosis and hypoalbuminemia. They suggest that in patients with none of these risk factors and without a history suggestive of infection, antibiotics might be withheld. [Avi Baehr, MD Denver Health Medical Center, Denver, CO] Comment: This study highlights that hemodialysis patients presenting with chills have a very high incidence of bacterial infection and bacteremia and therefore should be taken seriously by emergency department (ED) providers. The authors highlight risk factors for bacterial infection and describe a risk stratification tool to identify ‘‘low-risk’’ patients, which may have limited utility in the ED setting given the 6% incidence of bacteremia even among this low-risk cohort. It must be noted that this is a single-center, retrospective study, and as such, its generalizability may be limited. , EFFECT OF ORAL DEXAMETHASONE WITHOUT IMMEDIATE ANTIBIOTICS VS PLACEBO ON ACUTE SORE THROAT IN ADULTS. Hayward GN, Hay AD, Moore MV, et al. JAMA 2017;317(15):1535-1543 Sore throats are a common symptom among patients presenting to primary care and emergency departments. These patient visits are associated with a high burden of unnecessary antibiotic prescription, and there is a need for alternative treatment strategies. Corticosteroids may accelerate symptomatic relief, but their effect on symptom resolution in the absence of antibiotics had not previously been studied. The goal of this study was to determine whether a single dose of oral dexamethasone provided symptomatic relief to adult patients presenting to primary care with acute sore throat. The authors conducted a randomized, double-blind, placebocontrolled trial at 42 primary care sites in England. Adult patients presenting within 7 days of symptom onset and judged to not require immediate antibiotics were recruited. Patients were excluded if they had used corticosteroids in the past month or used antibiotics in the past two weeks. Participants were given either a 10mg tablet of dexamethasone or an identical tablet of placebo; participants, clinicians and researchers were blinded to the allocation. Outcome data were collected through phone or text message interviews, patient symptom diaries, and review of the electronic medical records, with the primary outcome being the proportion of patients with complete symptom resolution at 24hrs, and secondary outcomes including symptom resolution at 48hrs. Subgroup analyses were performed based on whether the patient received a delayed antibiotic prescription.