Good points overall but the discussants made one recommendation I have a problem with. They recommended the combo of azithro and doxy several times which is not supported by guidelines. Azithro plus doxy combo also adds little to CAP pathogen coverage. The 2019 ATS CAP guidelines for outpatient adults do not recommend any combo of azithro with doxy (they only recommend amox/clav or cephalosporin PLUS doxy or azithro for higher risk outpatients). Azithro plus doxy merely would duplicate atypical coverage w somewhat better H flu and staph coverage by doxy and maybe or maybe not additional strep pneumonia coverage vs azithro alone w real added risks of more adverse effects,
As an aside, it would be a good future pharmacology episode to cover loading doses of Doxycycline and why we don't dose it once daily as the half life is 16-20 hours (we probably should do both)
Jack - good point. i have seen folks do azithro + doxy with the hopes of better strep coverage but, not what’s recommended. Amox + doxy would be a better combo or amox + azithro. The Shownotes have the correct recs and, we’ll address in a mailbag. Thanks!
In that presentation tachycardia fever noises on auscultation age group -how often is Chest XRAY negative ? Why wait an hour and return without antibiotics -if there is a surge of patients he could wait hours .
Appreciate Jack B's comments. What about amoxicillin monotherapy for this apparently rather healthy patient?
IDSA now has a handy free app for the IDSA/ATS CAP guidelines (https://www.idsociety.org/practice-guideline/IDSA-practice-guidelines-app/ ). IDSA recommends amoxicillin or doxycycline monotherapy for outpatients without significant comorbidities. Dave Glaser summarized these guidelines very nicely on February 2021 EMRAP. I checked my hospital's antibiogram here in the Southeast and 93% of Strep pneumo should be sensitive to penicillins. I'd be interested to hear if the resistance patterns are different in your neck of the woods. -Joe Reardon, MD Greenville, SC
Further with regard to Chest X-ray vs Local Ultrasound consider age and comorbidities also . In a thin 72 year old female with cough fever and increased respiratory rate who was a smoker for many years a Chest X-ray will reveal pneumonic consolidation and in how many lobes COPD heart failure and vertebral bone osteoporosis and fractures . The Chest ray can give more general information.
Alcoholic Ketoacidosis Brit Long and Anand Swaminathan Mentions non - ethanol alcohols causing lactic acidosis. You sure? Also, thiamine deficiency can result in the failure of pyruvate to enter the tricarboxylic acid cycle, thus preventing aerobic metabolism, which may lead to profound lactic acidosis. I think this is worth pointing out.
From Corependium re: Lactate: "Serum lactate levels may be falsely elevated by ethylene glycol metabolites or truly elevated due to inadequate perfusion."
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jack B. - September 1, 2022 9:27 PM
Good points overall but the discussants made one recommendation I have a problem with. They recommended the combo of azithro and doxy several times which is not supported by guidelines. Azithro plus doxy combo also adds little to CAP pathogen coverage. The 2019 ATS CAP guidelines for outpatient adults do not recommend any combo of azithro with doxy (they only recommend amox/clav or cephalosporin PLUS doxy or azithro for higher risk outpatients). Azithro plus doxy merely would duplicate atypical coverage w somewhat better H flu and staph coverage by doxy and maybe or maybe not additional strep pneumonia coverage vs azithro alone w real added risks of more adverse effects,
As an aside, it would be a good future pharmacology episode to cover loading doses of Doxycycline and why we don't dose it once daily as the half life is 16-20 hours (we probably should do both)
Anand S. - September 2, 2022 1:15 AM
Jack - good point. i have seen folks do azithro + doxy with the hopes of better strep coverage but, not what’s recommended. Amox + doxy would be a better combo or amox + azithro. The Shownotes have the correct recs and, we’ll address in a mailbag. Thanks!
Ian L. - September 1, 2022 10:45 PM
In that presentation tachycardia fever noises on auscultation age group -how often is Chest XRAY negative ? Why wait an hour and return without antibiotics -if there is a surge of patients he could wait hours .
Anand S. - September 2, 2022 1:16 AM
Agreed and we note that in the discussion, x-ray less than perfect
Joe Reardon - September 2, 2022 10:06 AM
Appreciate Jack B's comments. What about amoxicillin monotherapy for this apparently rather healthy patient?
IDSA now has a handy free app for the IDSA/ATS CAP guidelines (https://www.idsociety.org/practice-guideline/IDSA-practice-guidelines-app/ ). IDSA recommends amoxicillin or doxycycline monotherapy for outpatients without significant comorbidities. Dave Glaser summarized these guidelines very nicely on February 2021 EMRAP. I checked my hospital's antibiogram here in the Southeast and 93% of Strep pneumo should be sensitive to penicillins. I'd be interested to hear if the resistance patterns are different in your neck of the woods.
-Joe Reardon, MD
Greenville, SC
Ian L. - September 2, 2022 4:14 PM
Further with regard to Chest X-ray vs Local Ultrasound consider age and comorbidities also .
In a thin 72 year old female with cough fever and increased respiratory rate who was a smoker for many years a Chest X-ray will reveal pneumonic consolidation and in how many lobes COPD heart failure and vertebral bone osteoporosis and fractures .
The Chest ray can give more general information.
Richard H. - April 30, 2023 8:00 AM
Alcoholic Ketoacidosis
Brit Long and Anand Swaminathan
Mentions non - ethanol alcohols causing lactic acidosis. You sure?
Also, thiamine deficiency can result in the failure of pyruvate to enter the tricarboxylic acid cycle, thus preventing aerobic metabolism, which may lead to profound lactic acidosis. I think this is worth pointing out.
Anand S. - April 30, 2023 8:09 AM
From Corependium re: Lactate: "Serum lactate levels may be falsely elevated by ethylene glycol metabolites or truly elevated due to inadequate perfusion."