Part 1: The Pneumococcal meningitis story
Part 2: Understanding the effect of different antibiotics on inflammation
Part 3: Best antibiotics for severe CAP?
Part 4: Patients with risk factors for MRSA or Pseudomonas
Part 5: Steroid therapy for CAP
Synthesizing data on steroid
- Patients with contraindications to steroid were excluded from RCTs.
- Steroid might not be beneficial when combined with fluoroquinolone. This combination has not been investigated adequately, with a signal of possible harm within Snijders 2010.
- CAP is a collection of different diseases. Retrospective observational studies have found that steroid use correlates with increased mortality in influenza (Yang 2015). For patients presenting during flu season with a clinical syndrome of influenza pneumonia (especially suggested by a diffuse infiltrates on chest radiograph and lack of significant consolidation on ultrasound) it may be sensible to avoid steroid. Radiologic and ultrasonographic patterns of CAP were explored last week.
- Treatment of pneumococcus with ceftriaxone increases inflammation, whereas azithromycin and fluoroquinolones have some anti-inflammatory properties.
- For patients without risk factors for MRSA or pseudomonas, the best antibiotic selection may be the combination of azithromycin plus a reasonably broad-spectrum beta-lactam (e.g. ceftriaxone or ampicillin-sulbactam).
- Multiple large RCTs have demonstrated benefit of adjunctive steroid. The most robust finding is reduced hospital length of stay, with additional evidence that steroid reduces the need for intubation.
- For patients with severe CAP who look like they might deteriorate and require intubation, a maximally aggressive approach may consist of immediate quadruple therapy with ceftriaxone, azithromycin, steroid, and high-flow nasal cannula oxygen.
- Radiographic and ultrasonographic patterns of CAP.
- Myth-busting: Azithromycin does not cause torsade de pointes or increase mortality.
- Treating infection is about more than killing bacteria: Management of toxic shock syndrome.
- Understanding steroid in critical illness: Stress dose steroid in sepsis.
- High-flow nasal cannula for pneumonia (FLORALI study).
- Debunking double coverage of pseudomonas with a fluoroquinolone.