Podcast # 392: Maggot Therapy

Author: Jared Scott, MD

Educational Pearls:

  • Interest started as it was noticed soldiers who had wounds infected with maggots had better outcomes than those without maggots
  • Studies have shown that wound care with maggots is essentially equivalent to traditional therapy with oxygen, antibiotics, and debridement
  • Maggots debride the wound with proteolytic enzymes, sterilize the wound, and stimulate wound healing

References:

Sherman RA. Maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century. J Diabetes Sci Technol. 2009 Mar 1;3(2):336-44. Review. PubMed PMID: 20144365; PubMed Central PMCID: PMC2771513.

Baer WS. The treatment of chronic osteomyelitis with the maggot (larva of the blow fly) J Bone & Joint Surg. 1931;13:438–475.  DOI: 10.1007/s11999-010-1416-3

 

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

 

Podcast # 391: Necrotizing Fasciitis

Author: Peter Bakes, MD

Educational Pearls:

  • Necrotizing fasciitis is an infection of the deep soft tissues with destruction of the muscle fascia and overlying fat
  • Think of it if pain is out of proportion to your exam
  • Polymicrobial and Clostridium species typically cause condition in susceptible individuals (immunocompromised, diabetics, obese, penetrating injury)
  • Group A strep typically is less specific and can cause necrotizing infections in otherwise healthy individuals
  • Treatment is typically rapid surgical debridement in addition to broad spectrum antibiotics in addition to clindamycin

References:

Breyre A, Frazee BW. Skin and Soft Tissue Infections in the Emergency Department. Emerg Med Clin North Am. 2018 Nov;36(4):723-750. doi: 10.1016/j.emc.2018.06.005. Review. PubMed PMID: 30297001.

Stevens DL, Bryant AE. Necrotizing Soft-Tissue Infections. N Engl J Med. 2017 Dec 7;377(23):2253-2265. doi: 10.1056/NEJMra1600673. Review. PubMed PMID: 29211672.

 

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

Podcast #387: Fluoroquinolones are Perfectly Safe?

Author:  Don Stader, MD

Educational Pearls:

  • Fluoroquinolones can cause connective tissue disruption leading not only to tendon rupture but also aortic dissection.
  • Retrospective study from Taiwan showed over a 2x higher rate of dissection when exposed to fluoroquinolones (1.6% vs 0.6%).
  • Remember to think about aortic dissection when you have a patient with chest pain that travels and/or involves neurologic symptoms.
  • Try to use fluoroquinolones when no other appropriate antibiotic exists as they have significant other side effects as well.

 

Editor’s note:  In July 2018, the FDA required strengthening of warning labels on fluoroquinolones about the risks of mental health effects and hypoglycemia

References:

Lee CC, Lee MG, Hsieh R, Porta L, Lee WC, Lee SH, Chang SS. Oral Fluoroquinolone and the Risk of Aortic Dissection. J Am Coll Cardiol. 2018 Sep 18;72(12):1369-1378. doi: 10.1016/j.jacc.2018.06.067. PubMed PMID: 30213330.

Khaliq Y, Zhanel GG. Fluoroquinolone-associated tendinopathy: a critical review of the literature. Clin Infect Dis. 2003 Jun 1;36(11):1404-10. Epub 2003 May 20. Review. PubMed PMID: 12766835.

https://www.fda.gov/downloads/Drugs/DrugSafety/UCM612834.pdf

 

Summary by Travis Barlock, MS4    |   Edited by Erik Verzemnieks, MD

Podcast #379: Patient Perspectives of the Flu

Author:  Sam Killian, MD

Educational Pearls:

  • Patients may have certain fears or expectations about the flu based on hearsay and other less reliable sources
  • Taking extra time explaining the risks of the flu may help base these expectations more in reality
  • This includes providing good return precautions and acknowledging that the disease can still be unpredictable

 

Podcast #377: Endocarditis

Author:  Nick Tsipis, MD

Educational Pearls:

  • Persistent fever or positive blood cultures should raise suspicion for endocarditis
  • Patients with recent dental procedures, recent cardiac surgeries are at risk, or who inject drugs are at higher risk
  • Physical exam findings may include fever with a new murmur, Janeway lesions, Osler nodes, and/or splinter hemorrhages

 

References:

Long B, Koyfman A. Infectious endocarditis: An update for emergency clinicians. Am J Emerg Med. 2018 Sep;36(9):1686-1692. doi: 10.1016/j.ajem.2018.06.074. Epub 2018 Jul 2. Review. PubMed PMID: 30001813.

Murdoch DR, Corey GR, Hoen B et. al. International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) Investigators. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med. 2009 Mar 9;169(5):463-73. doi: 10.1001/archinternmed.2008.603

Podcast # 373: Legionnaires Disease

Author:  Gretchen Hinson, MD

Educational Pearls:

  • Legionnaires disease refers to a severe pneumonia caused by Legionella pneumophilia and occurs typically at the extremes of age
  • Associated gastrointestinal symptoms (nausea/vomiting/diarrhea) may be present
  • Hyponatremia is a common laboratory finding
  • Legionella urinary antigen can be a convenient test to identify the infection
  • Treatment is with fluoroquinolones, macrolides and/or tetracyclines

 

 

References

Pierre DM, Baron J, Yu VL, Stout JE. Diagnostic testing for Legionnaires’ disease. Annals of Clinical Microbiology and Antimicrobials. 2017;16:59. doi:10.1186/s12941-017-0229-6.

Cunha BA, Cunha CB. Legionnaire’s Disease and its Mimics: A Clinical Perspective. Infect Dis Clin North Am. 2017 Mar;31(1):95-109. doi: 10.1016/j.idc.2016.10.008. Review.

Podcast # 360: Epidural Abscess Screening

Author: Dylan Luyten, MD.

Educational Pearls:

  • Dangerous causes of back pain: AAA, cauda equina syndrome, epidural abscess.
  • Young person with back pain needs to be evaluated for injection drug use (major risk factor).
  • Patient with focal neurologic deficits (FND) require an MRI.  Patients without FND can be screened with ESR and CRP. An ESR < 20 & CRP < 1 can effectively rule out epidural abscess as it has a 90% sensitivity for epidural abscess.
  • Treatment is IV antibiotics and surgical debridement.

References

Davis DP et al. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain, Journal of Neurosurgery: Spine. 2011. 14:765-770.

Podcast #355: Syphilis

Author: Aaron Lessen, MD

Educational Pearls:

  • Re-emerging STI.
  • Progresses through distinct phases if untreated:
  • Primary syphilis: frequently overlooked because initial chancre is painless.
  • Secondary syphilis: viral syndrome, rash on trunk, palms, and soles.
  • Latent syphilis: asymptomatic period, lasting 5-20 years.
  • Tertiary syphilis: includes neurosyphilis (dementia, encephalitis, etc.) and cardiovascular syphilis (aortitis, etc).
  • Treatment penicillin G 2.4 million units once for primary or secondary treatment; once weekly for 3 weeks for latent/tertiary.

References

Mattei, P., Beachkofsky, T., Gilson, R., Wisco, O. Syphilis: A reemerging infection. 2012. American Family Physician., 86(5), 433-440.

Podcast # 353: Xofluza

Author: Sam Killian, MD

Educational Pearls:

  • Japan recently approved baloxavir marboxil (Xofluza), which may potentially “kill” Flu A/B within 24 hours
  • Recent RCT trial showed superiority over oseltamavir (Tamiflu) in cessation of viral shedding (24 vs 72 hours)
  • Compared to placebo, superior in time to symptom resolution (53.7 vs 80.7  hours)
  • Administered as single dose
  • Yet to be considered for FDA approval

References

Portsmouth S, Kawaguchi K, Arai M, Tsuchiya K, Uehara T. Cap-dependent Endonuclease Inhibitor S-033188 for the Treatment of Influenza: Results from a Phase 3, Randomized, Double-Blind, Placebo- and Active-Controlled Study in Otherwise Healthy Adolescents and Adults with Seasonal Influenza. Open Forum Infectious Diseases. 2017;4(Suppl 1):S734. doi:10.1093/ofid/ofx180.001.

Podcast # 345: Epidural Abscess

Author: Sue Chilton, MD

Educational Pearls:

  • IV drug use and spinal procedures are major risk factors.
  • Classic triad of back pain, focal neurological deficit and fever. However, presence of fever is highly variable. Neurologic deficits may not present until later, but then they can have a rapid progression of neurological decline.
  • MRSA is most common organism, but GNR and MSSA are also possible.

 

References

Chen WC, Wang JL, Wang JT, et al. (2008). Spinal epidural abscess due to Staphylococcus aureus: clinical manifestations and outcomes. Journal of Microbiology, Immunology and Infection. 41:215.

Danner RL, Hartman BJ. (1987).Update on spinal epidural abscess: 35 cases and review of the literature. Review of Infectious Disease. 9:265.

Pfister H-W, Klein M, Tunkel AR, Scheld WM. Epidural abscess. In: Infections of the Central Nervous System, Fourth Edition, Scheld WM, Whitley RJ, Marra CM (Eds), Wolters Kluwer Health, Philadelphia 2014. p.550.