HCAP

Q: Health care-associated pneumonia (HCAP) is a critical concept for any clinician to be aware of, as it helps start antibiotics before cultures are available, saves lives, and decreases overall use of inappropriate antibiotics.

A) True

B) False

Answer: B

The category/idea/concept of health care-associated pneumonia (HCAP) has been removed from the 2016 and 2019 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines, as well as the combined 2017 European and Latin American Hospital-acquired pneumonia (HAP) (nosocomial) guidelines.

Previously, HCAP was defined as pneumonia acquired in health care facilities such as Long-Term Acute Care (LTAC), nursing homes, rehab centers, hemodialysis centers, or outpatient clinics, or within 90 days of a hospitalization. The whole purpose was to treat with antibiotics at the early stage of infection, particularly multidrug-resistant (MDR) infections. 

Later studies and evidence have shown that this was not a very prudent approach, as it led to increased, more inappropriate use of broad-spectrum antibiotics. The use of 'big guns' antibiotics was very high in comparison to the risk for MDR pathogens. This negates the concept of 'antibiotics stewardship'.

A new approach returns to the previous practice of treating HCAP as community-acquired pneumonia (CAP), and decides whether to consider MDR pathogens on a case-by-case basis based on prior exposures, risk factors, severity of illness, prior antimicrobial use, comorbidities, and functional status.

#ID

References:

1. Kalil AC, Metersky ML, Klompas M, et al. Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis 2016; 63:e61.

2. Metlay JP, Waterer GW, Long AC, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019; 200:e45.

3. Torres A, Niederman MS, Chastre J, et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia: Guidelines for the management of hospital-acquired pneumonia (HAP)/ventilator-associated pneumonia (VAP) of the European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Asociación Latinoamericana del Tórax (ALAT). Eur Respir J 2017; 50.

4. Kollef MH. Health care-associated pneumonia: perception versus reality. Clin Infect Dis 2009; 49:1875.

5. Chalmers JD, Rother C, Salih W, Ewig S. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis. Clin Infect Dis 2014; 58:330.

substernal goiter

Q; 52 years old female from Denmark* presented to ED with sudden enlargement of her known substernal goiter associated with pain. A bedside ultrasound followed by a CT scan confirmed hemorrhage into a goiter. Substernal goiter enlargement tends to do more of what? - select one

A) dysphagia 

B) stridor

Answer: B

Dysphagia is less common in substernal goiter because the esophagus is posteriorly located. An obstructive cervical or substernal goiter can enlarge and press on the trachea; when the tracheal lumen is less than 5 mm, stridor or wheezing at rest is expected. It would be prudent to secure the airway before relieving compression in acute cases. An experienced anesthesiologist should be called, as the margin of error is small.

Other symptoms which may occur are compression of a recurrent laryngeal nerve causing transient or permanent vocal cord palsy, manifesting as hoarseness, phrenic nerve paralysis, Horner's syndrome due to compression of the cervical sympathetic chain, and, in a few cases, jugular vein compression or thrombosis, cerebrovascular steal syndromes, or the superior vena cava syndrome.

#ENT

#endocrinology

#procedures

#surgical-critical-care

References:

1. O’Connor, Eoin, Looney, Michael, Lennon, Emma - Massive retrosternal goitre causing stridor and respiratory distress—a case report - Journal of Emergency and Critical Care Medicine - Vol 9 (March 30, 2025) /, https://jeccm.amegroups.org/article/view/8867

2. Al-Bazzaz F, Grillo H, Kazemi H. Response to exercise in upper airway obstruction. Am Rev Respir Dis 1975; 111:631.

3. Aragón Valera C, Antón Bravo T, Sanchón Rodríguez R, Martínez Bermejo E, Paniagua Ruiz A, Alvarez Santirso R. Dyspnea and stridor due to multinodular goiter in an obese woman. Endocrinol Nutr. 2008 May;55(5):234-6. English, Spanish. doi: 10.1016/S1575-0922(08)70674-0. Epub 2008 Oct 15. PMID: 22967919.

*Denmark epidemiology is consistent with mild-to-moderate iodine-deficient goiter.

IG and HG

Q: What's the difference between immune globulin (IG) and hyperimmune globulin (HG)?

Answer:

Immune globulin is derived from the plasma of random donors. It can be used for an array of disorders, including primary and secondary immune deficiency states, as well as many autoimmune and inflammatory disorders. It is mainly given intravenously (IVIG), but can also be given subcutaneously (SCIG) or intramuscularly (IMIG). Additives and stabilizers are usually added to the product.

Hyperimmune globulin refers to immune globulin obtained from the plasma of individuals with high titers of specific antibodies to certain pathogens, or from individuals immunized or naturally exposed to particular antigens. In some diseases, it can also be obtained from animals.

#immunology

References:

1. Schroeder HW Jr, Cavacini L. Structure and function of immunoglobulins. J Allergy Clin Immunol. 2010 Feb;125(2 Suppl 2):S41-52. doi: 10.1016/j.jaci.2009.09.046. PMID: 20176268; PMCID: PMC3670108.

2. Novaretti MC, Dinardo CL. Immunoglobulin: production, mechanisms of action and formulations. Rev Bras Hematol Hemoter. 2011;33(5):377-82. doi: 10.5581/1516-8484.20110102. PMID: 23049343; PMCID: PMC3415776.

3. Pati I, Cruciani M, Candura F, Massari MS, Piccinini V, Masiello F, Profili S, De Fulvio L, Pupella S, De Angelis V. Hyperimmune Globulins for the Management of Infectious Diseases. Viruses. 2023 Jul 13;15(7):1543. doi: 10.3390/v15071543. PMID: 37515229; PMCID: PMC10385259.

allopurinol and heart

Q: Allopurinol can be used as an anti-anginal drug.

A) True

B) False

Answer: A

There is weak evidence that Allopurinol, a xanthine oxidase inhibitor, may be beneficial in stable angina.

It significantly increased the median time to ST depression and the median total exercise time when compared to placebo.

The mechanism of action is proposed to be improved endothelium-dependent vasodilation and the abolition of oxidative stress. The suggested dose is 600 mg per day.

#cardiology

#pharmacology

References:

1. Noman A, Ang DS, Ogston S, et al. Effect of high-dose allopurinol on exercise in patients with chronic stable angina: a randomised, placebo controlled crossover trial. Lancet 2010; 375:2161.

2. Rajendra NS, Ireland S, George J, et al. Mechanistic insights into the therapeutic use of high-dose allopurinol in angina pectoris. J Am Coll Cardiol 2011; 58:820.

Urine Dipstick in the Rapid Diagnosis of Septic Arthritis

Q: What is the urine "dipstick" test, which can help in the diagnosis of septic arthritis?

Answer:

The two confirmatory (aka gold standard) tests for diagnosing a septic joint are synovial fluid culture or synovial biopsy. Said that many times: both are hard to obtain or require a wait for results.

Many adjuvant tests help to establish a probable diagnosis, along with clinical signs and other tests such as blood counts and blood cultures. Recently, nucleic acid amplification tests like polymerase chain reaction (PCR) and matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectometry have been used at advanced centers, particularly when routine cultures are negative but clinical suspicion is high. But these tests are time-consuming and not very cost-effective.

Interestingly, a simple, quick, and highly cost-effective urine "dipstick" test to measure synovial fluid leukocyte esterase can be used as an adjunct to diagnose septic arthritis (reference 1 for details).

#ID

#laboratory-medicine

#rheumatology

References:

1. Aslani H, Pasha Zanoosi MR, Navali AM. Urine Dipstick Leukocyte Esterase in the Rapid Diagnosis of Septic Arthritis. Arch Bone Jt Surg. 2022 Jan;10(1):38-44. doi: 10.22038/ABJS.2021.47573.2334. PMID: 35291247; PMCID: PMC8889425.

2. Dey M, Al-Attar M, Peruffo L, et al. Assessment and diagnosis of the acute hot joint: a systematic review and meta-analysis. Rheumatology (Oxford) 2023; 62:1740.

2. Sanpera I, Salom M, Alves C, Eastwood D. Diagnosis and management of septic arthritis: A current concepts review. J Child Orthop. 2025 Jan 2;19(1):14-19. doi: 10.1177/18632521241311302. PMID: 39758603; PMCID: PMC11694264.