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Penicillin allergy delabelling of patients at risk of sexually transmitted infections in primary care

Author/s: 
Wittmer, R., Vincent-Boulay, O., Barrios, J. L.

KEY POINTS
Most patients who report a penicillin allergy do not have a serious allergy.

Penicillin allergy delabelling enables patients to receive penicillin and β-lactam antibiotics when indicated.

A simple algorithm allows for stratification of allergy risk for patients.

Patients at low risk of a serious allergic reaction can undergo an oral penicillin challenge in sexual health clinics and other primary care settings.

Keywords 
Penicillins Anti-Bacterial Agents primary health care sexually transmitted diseases hypersensitivity

Management of acute diverticulitis

Author/s: 
Zondervan, N., Snelgrove, R., Bradley, N.

1 Emergency department visits and hospital admissions for acute
diverticulitis have increased
Emergency department visits for acute diverticulitis increased by 26.8% to
113.9 visits per 100 000 from 2006 to 2013 in the United States.1
Hospital admissions for diverticulitis increased 7.5% annually from 190 per 100 000 in 2008 to
310 per 100 000 in 2015 in Europe; the increase occurred predominantly among
patients aged younger than 60 years.2 Insufficient consumption of dietary fibre
is associated with this rise.
2 Symptoms of diverticulitis may be driven by inflammation rather
than infection
Contemporary evidence shows that use of antibiotics in uncomplicated cases of
diverticulitis neither accelerates recovery nor improves outcomes.2
A recent
study has suggested that chronic inflammation secondary to environmental risk
factors and alterations of the gut microbiome are now favoured causes over
microperforation or bacterial translocation.3
3 Most patients with uncomplicated diverticulitis can be treated as
outpatients with nonopiate analgesia rather than antibiotics
Cross-sectional imaging that shows inflamed colonic diverticula without perforation or abscess defines uncomplicated diverticulitis. Two randomized controlled trials that compared antibiotic and nonantibiotic treatment reported
no difference in recovery time, treatment duration or rate of recurrence.4,5
Updated guidelines recommend reserving antibiotics for patients taking
immunosuppressive medications and those with sepsis.1,2 Treating symptoms
with nonopiate analgesics avoids worsening bowel function and contributing
to opiate dependence.
4 Evidence of complicated diverticulitis should prompt emergent
surgical assessment and antibiotic treatment
Complicated diverticulitis, defined as radiologic evidence of perforation or intraabdominal abscess, has a 30-day mortality rate of 8.7%.2
Antibiotic therapy is indicated, and many patients require admission to hospital.1
Percutaneous drainage
of large abscesses (> 3 cm) or emergency surgery may be required.2
5 Colonoscopy and elective colon resection are not routinely required
after resolution of uncomplicated diverticulitis
Only 8.7% of patients with uncomplicated diverticulitis will present to hospital
with a second episode.1
Elective surgery should be determined by frequency
and severity of symptoms, rather than prevention of future complications.2
Risk of malignant disease after uncomplicated left-sided diverticulitis is similar to that of the general population (1%), and standard colon cancer screening guidelines should be followed.1
Complicated diverticulitis warrants an
interval colonoscopy, typically 6 weeks after resolution.1

Keywords 
Colonoscopy abscess Anti-Bacterial Agents Bacterial translocation sepsis

Appropriate Use of Short-Course Antibiotics in Common Infections: Best Practice Advice From the American College of Physicians

Author/s: 
Lee, Rachael A., Centor, Robert M., Humphrey, Linda L., Jokela, Janet A., Andrews, Rebecca, Qaseem, Amir

Description: Antimicrobial overuse is a major health care issue that contributes to antibiotic resistance. Such overuse includes unnecessarily long durations of antibiotic therapy in patients with common bacterial infections, such as acute bronchitis with chronic obstructive pulmonary disease (COPD) exacerbation, community-acquired pneumonia (CAP), urinary tract infections (UTIs), and cellulitis. This article describes best practices for prescribing appropriate and short-duration antibiotic therapy for patients presenting with these infections.

Methods: The authors conducted a narrative literature review of published clinical guidelines, systematic reviews, and individual studies that addressed bronchitis with COPD exacerbations, CAP, UTIs, and cellulitis. This article is based on the best available evidence but was not a formal systematic review. Guidance was prioritized to the highest available level of synthesized evidence.

Best practice advice 1: Clinicians should limit antibiotic treatment duration to 5 days when managing patients with COPD exacerbations and acute uncomplicated bronchitis who have clinical signs of a bacterial infection (presence of increased sputum purulence in addition to increased dyspnea, and/or increased sputum volume).

Best practice advice 2: Clinicians should prescribe antibiotics for community-acquired pneumonia for a minimum of 5 days. Extension of therapy after 5 days of antibiotics should be guided by validated measures of clinical stability, which include resolution of vital sign abnormalities, ability to eat, and normal mentation.

Best practice advice 3: In women with uncomplicated bacterial cystitis, clinicians should prescribe short-course antibiotics with either nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole (TMP-SMZ) for 3 days, or fosfomycin as a single dose. In men and women with uncomplicated pyelonephritis, clinicians should prescribe short-course therapy either with fluoroquinolones (5 to 7 days) or TMP-SMZ (14 days) based on antibiotic susceptibility.

Best practice advice 4: In patients with nonpurulent cellulitis, clinicians should use a 5- to 6-day course of antibiotics active against streptococci, particularly for patients able to self-monitor and who have close follow-up with primary care.

Keywords 
pneumonia Cellulitis bacterial infections Anti-Bacterial Agents Best practive
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