Thread by @AMTatara

Hi #IDTwitter and #MedTwitter! As we near the end of 1st year of ID fellowship @MGHBWHIDFellows , I wanted to reflect on 10 RCTs that I found useful on General ID. This is neither all-encompassing nor meant to get into the meat of study design/critique (#IDJournalClub). (1/12)

1. Staph aureus bacteremia (SAB) is our bread and butter! We are often asked about combination tx. DASH (pubmed.ncbi.nlm.nih.gov/29843781/) did not show benefit to adding daptomycin to beta-lactams for treatment of MSSA SAB. Duration of bacteremia was the primary endpoint. (2/12)

2. What about dreaded MRSA bacteremia? Likewise, CAMERA2 did not show benefit of combo tx w in MRSA SAB and had to be ended early due to AKI in the combo group (jamanetwork.com/journals/jama/…). Synergy with ceftaroline is an upcoming area (journals.asm.org/doi/full/10.11…) (3/12)

3. Duration of tx is another frequent consult question. I found myself frequently referring to the "Shorter is Better" @BradSpellberg (bradspellberg.com/shorter-is-bet…). STOP-IT is 1 example of an important RCT examining duration for intra-abdominal infxn (nejm.org/doi/full/10.10…). (4/12)

4. "Do we need a PICC?" Between line issues and toxicity from IV tx, I learned in 1st year that 6 wks of IV is no joke. OVIVA examined early transition to PO regimens compared to IV throughout for osteomyelitis and found PO to be non-inferior (nejm.org/doi/pdf/10.105…). (5/12)

5. Likewise, POET looked at early transition to PO abx compared to IV throughout for L-sided endocarditis (nejm.org/doi/full/10.10…) and found PO to be non-inferior in stable pts. Sparing folks prolonged IV antibiotics when possible is very powerful for the right pts. (6/12)

6. On the topic of abx selection, as a resident I was less comfortable with dapto and linezolid. The controversial ZEPHyR trial (pubmed.ncbi.nlm.nih.gov/22247123/) is a reason to get excited about non-vanc tx. In pts w/ MRSA PNA, linezolid had similar success and less AKI than vanc. (7/12)

7. More bread+butter- we are frequently asked to weigh in on cellulitis, especially in pts w/ freq recurrence. In PATCH I (nejm.org/doi/full/10.10…), it was shown that PCN prophylaxis can decrease recurrence. (8/12)

8. More recently, compression wraps were also shown to decrease cellulitis recurrence in a non-blinded RCT (nejm.org/doi/full/10.10…). How cool is a non-pharmacologic intervention?? (9/12)

9. We are also often called to discuss MDR infxn. In MERINO, pip/tazo was NOT non-inferior to carbapenems for ceftriaxone-R E coli and Klebsiella bacteremia (pubmed.ncbi.nlm.nih.gov/30208454/). Note that this was not designed to study specifically AmpC producers nor study cefepime. (10/12)

10. Lastly, who could forget that our 1st year coincided with a global pandemic? The RECOVERY trial (nejm.org/doi/full/10.10…) was a game-changer in how we dosed corticosteroids in critically ill pts w/ COVID-19. (11/12)

There is a whole world of HIV+Transplant ID that this thread does not cover, plus dozens of other Gen ID studies- perhaps next time! Dislike 1 of these studies? Feel there is a glaring omission? Let me know! Many thx to all my attendings and co-fellows throughout Year 1! (12/12)