Surotomycin (A Novel Cyclic Lipopeptide) vs. Vancomycin for the Treatment of Clostridioides difficile Infection: A Systematic Review and Meta-analysis.

BACKGROUND: Current guidelines recommend the use of vancomycin for the initial treatment of moderate to severe Clostridioides difficile Infection (CDI). Surotomycin, a novel antibiotic, has been utilized for the management of CDI with variable results. METHODS: A systematic literature search was performed using the following electronic databases [Medline, Embase, google scholar and Cochrane] for eligible studies. Randomized controlled trials comparing Surotomycin with Vancomycin for the CDI treatment were included. Demographic variables and outcomes (CDI resolution, CDI recurrence, B1/NAP1/027-specific strain treatment, B1/NAP1/027-strain recurrence, death not related to treatment) were analyzed. The primary outcome was clinical cure rate defined as the resolution of CDI at the end of the 10-day drug course. RESULTS: Three RCTs met the inclusion criteria with a total of 1280 patients with CDI who received either surotomycin 250 mg twice daily (642 patients) or vancomycin 125 mg four times daily (638 patients). Clinical cure rates after 10 days of treatment with either surotomycin or vancomycin were not significantly different (pooled OR: 0.89, 95% CI 0.66-1.18, p=0.41). Sustained clinical response at clinical follow-up and the overall recurrence of CDI were also not significantly different between the two groups - pooled OR 1.15 (95% CI 0.89-1.50, p=0.29) and pooled OR 0.74 (95%CI 0.52- 1.04, p=0.08), respectively. With regards to the NAP1/BI/027 strain, patients in the surotomycin group had significantly lower rates of recurrence compared to vancomycin (pooled OR 0.35, 95% CI 0.19-0.63, p<0.01). CONCLUSION: Surotomycin is non-inferior to vancomycin and offers a promising alternative for the treatment and prevention of C. diff infection.

A Nationwide Assessment of the “July Effect” and Predictors of Post-Endoscopic Retrograde Cholangiopancreatography Sepsis at Urban Teaching Hospitals in the United States

BACKGROUND/AIMS: To analyze the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) sepsis in the early (July to September) and later (October to June) academic months to assess the “July effect”. METHODS: The National Inpatient Sample (2010–2014) was used to identify ERCP-related adult hospitalizations at urban teaching hospitals by applying relevant procedure codes from the International Classification of Diseases, 9th revision, Clinical Modification. Post-ERCP outcomes were compared between the early and later academic months. A multivariate analysis was performed to evaluate the odds of post-ERCP sepsis and its predictors. RESULTS: Of 481,193 ERCP procedures carried out at urban teaching hospitals, 124,934 were performed during the early academic months. The demographics were comparable for ERCP procedures performed during the early and later academic months. A higher incidence (9.4% vs. 8.8%, p<0.001) and odds (odds ratio [OR], 1.07) of post-ERCP sepsis were observed in ERCP performed during the early academic months. The in-hospital mortality rate (7% vs. 7.5%, p=0.072), length of stay, and total hospital charges in patients with post-ERCP sepsis were also equivalent between the 2 time points. Pre-ERCP cholangitis (OR, 3.20) and post-ERCP complications such as cholangitis (OR, 6.27), perforation (OR, 3.93), and hemorrhage (OR, 1.42) were significant predictors of higher post-ERCP sepsis in procedures performed during the early academic months. CONCLUSIONS: The July effect was present in the incidence of post-ERCP sepsis, and academic programs should take into consideration the predictors of post-ERCP sepsis to lower health-care burden.

Evaluation of arterial stiffness in nondiabetic chronic kidney disease patients.

Chronic kidney disease (CKD) is a growing problem worldwide. Clinical and epidemiologic studies have shown that structural and functional changes that occur in major arteries are a major contributing factor to the high mortality in uremic patients. Recent studies have shown a stepwise increase of the carotid-femoral pulse wave velocity (cfPWV) from CKD Stage 1 to Stage 5. We evaluated the cfPWV and augmentation index (AIx), as indirect markers of arterial stiffness in patients with nondiabetic CKD and compared the values with normal population; we also evaluated the relationship between various stages of CKD and arterial stiffness markers. This cross-sectional study was carried out in the Department of Nephrology for a duration of two years from January 15, 2012, to January 14, 2014. Fifty patients with nondiabetic CKD were studied along with 50 healthy volunteers who did not have CKD, who served as controls. Assessment of arterial stiffness (blood pressure, PWV, heart rate, aortic augmentation pressure, and AIx) was performed using the PeriScope device. PWV positively correlated with systolic and diastolic blood pressure, mean aortic arterial pressure, serum creatinine, and serum uric acid and negatively correlated with estimated glomerular filtration rate. Arterial stiffness increased as CKD stage increased and was higher in nondiabetic CKD group than in the general population. Arterial stiffness progressed gradually from CKD Stage 2 to 5, and then abruptly, in dialysis patients. Measures to decrease the arterial stiffness and its influence on decreasing cardiovascular events need further evaluation.

Clinical profile and outcome of conservatively managed emphysematous pyelonephritis.

Emphysematous pyelonephritis (EPN) is a severe, necrotizing renal parenchymal infection characterized by production of intraparenchymal gas. EPN predominantly affects female diabetics and immunocompromised patients. In a three-year period 2008-2011, a total of 8 patients were admitted to our hospital. All of them were diabetics, and both males and females were equally affected. These patients showed vague symptoms at admission and frequently presented with fever, loin pain, dysuria, and pyuria necessitating urgent medical attention. EPN required radiological diagnosis. CT scan revealed bilateral EPN with urinary obstruction and hydronephrosis in 50% of patients. Escherichia coli was found to be the causative organism in all the patients. Treatment comprised of resuscitation, normalization of serum electrolytes and blood sugars, administration of parenteral antibiotics, and relieving ureteric obstruction if present. All the patients improved with conservative management without any mortality.

Severe loin pain following renal biopsy in a high-risk patient: a case report of a rare combination of pseudoaneurysm and arterio-venous fistula.

We report a 50-year-old male patient with diabetes mellitus and hypertension who presented with low-grade fever, anuria and renal failure. He had no prior history of nephropathy and retinopathy. Since anuria persisted, a renal biopsy was performed using automated gun, under ultrasound guidance. Two hours after the renal biopsy was performed, the patient developed severe left loin pain that required analgesics and sedatives. Ultrasound of the abdomen performed immediately, two hours and four hours after the biopsy, did not reveal any hematoma. The hemoglobin was stable when the patient developed loin pain, but after eight hours decreased to 9.1 g/dL, and computed tomography scan of the abdomen revealed a big peri-nephric hematoma around the left kidney. He was managed with blood transfusions and a selective angiogram was done. It revealed a pseudoaneurysm and arterio-venous fistula from the segmental artery of lower pole of the left kidney; both were closed by using microcoils and liquid embolic agent N-butyl-cyanoacrylate (NBCA). The only risk factor the patient had at the time of renal biopsy was severe renal failure. Our case suggests that severe loin pain immediately after renal biopsy in a patient with renal failure warrants careful follow-up of hemoglobin and imaging, even if initial imaging is normal. Further fall of hemoglobin necessitates early evaluation with angiogram, which helps in diagnosing the treatable, although rare, complications like pseudoaneurysm and arterio-venous fistula.