Tuesday, May 30, 2017

CA-MRSA coverage is unnecessary for uncomplicated cellulitis

- Kenny Lin, MD, MPH

Cephalexin has long been my oral antibiotic of choice for a patient with uncomplicated cellulitis and no cephalosporin allergy. However, the increasing prevalence of skin and soft tissue infections (SSTIs) caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), often mistaken by patients and clinicians for spider bites, has raised the question of whether it makes sense to also prescribe an antibiotic such as trimethoprim/sulfamethoxazole for empiric CA-MRSA coverage for immunocompetent patients with cellulitis that is not purulent or severe enough for inpatient therapy.

A 2009 case-control study found that children with SSTIs who received empiric monotherapy with trimethoprim/sulfamethoxazole had higher rates of treatment failure than those who received beta-lactam antibiotics. Although helpful, this study did not measure outcomes in adults or in children who were prescribed more than one antibiotic. Despite the lack of evidence of benefit, national data suggest that up to 3 in 4 patients presenting to the emergency department with skin infections are prescribed antibiotics active against CA-MRSA. Potential downsides of "double coverage" include higher rates of adverse effects, cost, and increasing antibiotic resistance.

In a recent paper in JAMA, Dr. Gregory Moran and colleagues reported the results of a multicenter randomized, controlled trial of 500 adolescents and adults with diagnosed in the emergency department with cellulitis and no wound, purulent drainage, or abscess (verified by soft tissue ultrasound) who received 7 days of therapy with either cephalexin plus trimethoprim/sulfamethoxazole or cephalexin plus placebo. They found no differences in clinical cure rates in either the modified intention-to-treat or per-protocol analyses.

Based on this study's results, I will continue to restrict my use of trimethoprim/sulfamethoxazole to patients whose cellulitis fails to respond to cephalexin and patients with purulent infections. Of note, the American College of Emergency Physicians recommends against sending wound cultures or prescribing antibiotics in persons who undergo successful incision and drainage of skin and soft tissue abscesses and who have adequate medical follow-up. A 2015 AFP article provides more information on the management of SSTIs, including inpatient treatment and other special considerations.

Monday, May 22, 2017

2017 Family Medicine Day of Action #staywellsoon

- Jennifer Middleton, MD, MPH

AFP provides content on a variety of issues that may compel a larger call to social justice. Articles on caring for the homeless, victims of intimate partner violence, and ethnic minorities demonstrate our specialty's mission to care for all. Promoting breastfeedinggun safety, and oral health can help patients avoid potentially catastrophic outcomes. Our generalist's perspective can provide expertise on issues such as debated cancer screenings (breast, prostate, and lung) and unnecessary interventions (antibiotics, imaging). We are also well-suited to comment on public health issues such as obesity, opioid misuse, and even global warming.

We may recognize, however, that knowing these medical facts is only the first step to meeting our patients' and communities' needs. Sharing our perspective as family physicians is another important way that we can care for our communities.

Every year, the AAFP's Family Medicine Advocacy Summit takes a group of interested family physicians, trains them in political advocacy, and takes them to Capitol Hill to meet with their elected officials. This opportunity is undoubtedly valuable for those able to participate, but family physicians unable to make this trip now have other ways to get involved. Joining the Family Physician Action Network is a great first step; signing up will provide you with resources to be an effective advocate for your patients. An overview is available on the Family Physician Action Center website, including a primer on the legislative process and tips to maximize your engagement over social media as well as conduct an effective telephone or in-person conversation with your elected officials. Speaking up doesn't have to take a lot of time, and it can have a powerful impact. AFP's Graham Center One-Pagers Department Collection provides succinct talking points on a variety of topics.

The AAFP has also decreed tomorrow the first "Family Medicine Day of Action." You can post a "Stay Well Soon" e-postcard to your Facebook, Twitter, and/or Tumblr contacts by clicking here. AAFP's goal is to have 1000 people post with a goal of 1,000,000 views. It's an easy way to promote Family Medicine and all we have to offer our patients and communities.

Whether it's attending the Advocacy Summit, getting involved in the Action Network, or posting a #staywellsoon e-postcard, all of us can find a way to speak up. What will yours be?

Tuesday, May 16, 2017

Should patients with first syncopal episodes be evaluated for PE?

- Kenny Lin, MD, MPH

The evaluation of patients with syncope has changed minimally over the years, with considerable continuity between recommendations in American Family Physician reviews published in 2005, 2011, and most recently, in the March 1, 2017 issue. But the field received an unexpected jolt last October, when Dr. Paolo Prandoni and colleagues published a cross-sectional study in the New England Journal of Medicine that calculated a surprisingly high prevalence of pulmonary embolism (PE) of 17.3% in patients hospitalized for a first episode of syncope. In this study, 230 of 560 patients at 11 Italian hospitals who did not have a low pretest probability of PE by the Wells rule and negative D-dimer assay underwent computed tomographic pulmonary angiography (CTPA) or ventilation-perfusion lung scans. 97 of these patients had evidence of PE. Overall, the investigators identified PE in 25% of patients with no alternative explanation for syncope and 13% of patients with an alternative explanation.

Standard algorithms for syncope evaluation focus on identifying cardiac and neurally mediated causes and do not include routine testing for PE. The question raised by the Italian study is if all inpatients with syncope warrant an evaluation, since nearly 1 in 6 patients may have PE. There are good reasons to think twice about doing so. First, we don't know if the prevalence of PE in this study was representative of the general population of adults hospitalized for syncope, as it only included patients admitted from emergency departments (and not patients initially evaluated in primary care settings). Second, the study did not determine if PE was the etiology of syncope, as opposed to an incidental finding. This is important because evidence suggests that the enhanced sensitivity of CTPA for detecting small, subsegmental PE is increasing overdiagnosis and overtreatment of clinically insignificant clots. Finally, the absence of a comparison group means that it is not known if the systematic workup for PE affected the patients' prognosis, if at all.

A retrospective cross-sectional study in JAMA Internal Medicine recently addressed the generalizability question by using clinical and administrative data from 4 hospitals in Toronto to estimate the prevalence of PE in 1305 patients with a first episode of syncope who were not receiving anticoagulation at the time of admission. 120 of these patients received CTPA, ventilation-perfusion scan, and/or compression ultrasonography, resulting in the diagnosis of PE in 18 patients. As opposed to the Italian study, where all persons received at least a D-dimer test, the decision to evaluate for PE was driven by clinical judgment. Nonetheless, of 146 patients in the Toronto study who received any test for PE (presumably those with the highest pretest probability), only 12% were positive, and the overall prevalence of PE was a mere 1.4%. The authors concluded that "there is little, if any, justification for routine testing for [venous thromboembolism] in all patients hospitalized for a first episode of syncope."

Based on both studies, I agree that evidence does not support routine testing in patients with syncope. In those with signs or symptoms of PE, another clinical decision rule may be used to confidently rule out the diagnosis without resorting to the less sensitive Wells rule or less specific D-dimer test, where a positive result often leads to unnecessary CTPA.

Monday, May 8, 2017

Counseling postmenopausal women on exercise

- Jennifer Middleton, MD, MPH

Exercise has many benefits for older women. In the current issue of AFP, "Health Maintenance in Postmenopausal Women" describes exercise's benefits regarding cardiovascular disease prevention and fall prevention. Exercise may also reduce the risk of cognitive decline in older women; one meta-analysis found that both aerobic and resistance training may help preserve executive function in women to a greater degree than either exercise modality does in men. Unfortunately, many older women do not regularly exercise, and knowledge of both common barriers and some strategies to overcome them may improve the effectiveness of our counseling.

Most studies examining barriers to regular exercise in older adults include both men and women; identified barriers include concerns about damaging joints, falling, and sustaining injuries. Older adults referred to aquatic therapy often feel uncomfortable wearing a bathing suit in public. Inclement weather is a commonly cited barrier, as is spending significant time caring for an ill partner. Some older women believe, too, that exercise is unnecessary at their age.

Older patients are often receptive to counseling about exercise, but physicians frequently don't initiate these conversations, possibly due to a lack of knowledge about how to do so. Exploring which of the above barriers might keep a patient from exercising is a good first step. Communicating the benefits of exercise to postmenopausal women and brainstorming how to incorporate it into their everyday lives can help with motivation and planning. Reassuring women that it can take some time to develop physical fitness, and that some initial muscle discomfort is normal, may help. Local exercise programs targeted to older adults may be more appealing to patients than attending classes with younger participants.

Providing an exercise prescription is another useful strategy. Last month's AFP article on "Exercise Prescriptions in Older Adults" reviews how to compose one: identify exercises and/or modalities of interest and provide specifics regarding frequency and intensity. A balanced exercise prescription should include aerobic, flexibility, and balance exercises. Including short- and long-term goals of an exercise program may increase patient engagement. This 2010 AFP article on "Physical Activity Guidelines for Older Adults" provides several examples of exercise modalities to consider along with a sample exercise prescription in Table 3. Cardiac stress testing is only needed for patients with established cardiovascular disease who wish to participate in vigorous activities. There are AFP By Topics on Geriatric Care (certainly not all postmenopausal women are geriatric, but some are) and Health Maintenance and Counseling if you'd like to read more.

Monday, May 1, 2017

Three ways AFP translates research for practice

- Kenny Lin, MD, MPH

The May 1 issue of American Family Physician features the latest installment of the "Top 20 Research Studies" series of articles that Drs. Mark Ebell and Roland Grad have been writing annually since 2012. What sets this particular set of study summaries apart from other journals' "best of the year" studies lists? Dr. Jay Siwek explains in his editor's note:

Medical journals occasionally publish an article summarizing the best studies in a certain field from the previous year; however, those articles are limited by being one person's idiosyncratic collection of a handful of studies. In contrast, this article by Drs. Ebell and Roland Grad is validated in two ways: (1) the source material (POEMs) was derived from a systematic review of thousands of articles using a rigorous criterion-based process, and (2) these “best of the best” summaries were rated by thousands of Canadian primary care physicians for relevance and benefits to practice.

The research studies from 2016 rated most primary care relevant, valid, patient-oriented, and practice changing include patient-oriented evidence that matters (POEMs) on hypertension; respiratory conditions; musculoskeletal conditions; diabetes mellitus and obesity; and miscellaneous items. The complete POEMs are available in AFP's Evidence-Based Medicine toolkit. Also, Canadian Medical Association members identified four important guidelines published in 2016: the U.S. Preventive Services Task Force (USPSTF) on screening for colorectal cancer and interventions for tobacco cessation in adults; the American College of Physicians on management of chronic insomnia; and the Centers for Disease Control and Prevention on opioid prescribing for chronic pain.

During Dr. Ebell's past membership on the USPSTF, the panel voted to recommend one-time screening for hepatitis C virus (HCV) in every adult born between 1945 and 1965 (also known as birth cohort screening). On the other hand, as a member of the Canadian Task Force on Preventive Health Care, Dr. Grad recently developed a recommendation against screening for HCV in asymptomatic adults without risk factors, including baby boomers. AFP previously presented both sides of this complicated debate in a pair of editorials that outlined the case for birth cohort screening and the case against it. You can find other Pro-Con editorials on controversial family medicine topics in this online collection.

Finally, readers should be aware that essential concepts from AFP Journal Club, a popular journal feature that analyzed key research studies from 2007 to 2015, have been incorporated into our EBM toolkit. This annotated collection of evidence-based medicine pointers provides useful information for clinicians, teachers, and learners at all levels.