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Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours
Release Date: April 22, 2015
Expiration Date: April 22, 2016
Estimated Completion Time: 15 minutes
There is no fee for this activity.
To Receive Credit
In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon above.
Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.
Alan Ehrlich, MD
Assistant Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Executive Deputy Editor, DynaMed, Ipswich, Massachusetts, USA
Michael Fleming, MD, FAAFP
Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company
Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.
No commercial support has been received for this activity.
ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint providership of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.
AAFP: This enduring material activity, DynaMed EBM Focus Volume 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AANP: This program is approved for 0.25 contact hour(s) of continuing education by the American Association of Nurse Practitioners. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards. Program ID: 1405237X2
Last week 501 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 170 articles were added to DynaMed content.
Based on criteria for selecting "articles most likely to inform clinical practice," one article was selected by the DynaMed Editorial Team.
Adjunctive Corticosteroids May Improve Outcomes in Adults Hospitalized with Community-Acquired Pneumonia
References: JAMA 2015 Feb 17;313(7):677, Lancet 2015 Apr 18;385(9977):1511 (level 2 [mid-level] evidence)
Community-acquired pneumonia is a major public health concern leading to millions of primary care and hospital visits each year in the United States alone. The Infectious Disease Society of America and American Thoracic Society (IDSA/ATS) 2007 guidelines recommend empiric antibiotic for treatment of community-acquired pneumonia (Clin Infect Dis 2007 Mar 1;44 Suppl 2:S27). Adjunctive corticosteroids are not currently recommended, but a growing body of evidence suggests they may provide clinical benefit. Two randomized trials published in 2015 compared adjunctive corticosteroids vs. placebo in adults hospitalized with community-acquired pneumonia.
The first trial from Torres et al. published in February (JAMA 2015 Feb 17;313(7):677) examined the effect of corticosteroid treatment on treatment failure and in-hospital mortality in adults with severe community acquired pneumonia. Treatment failure was evaluated as a composite outcome, with early treatment failure defined as shock, new need for invasive mechanical ventilation, or death within 3 days and late treatment failure defined as radiographic progression, persistent severe respiratory failure, shock, new need for invasive mechanical ventilation, or death between 3 and 5 days. In this trial, 120 adults (mean age 65 years) with severe community-acquired pneumonia were randomized to methylprednisolone (0.5 mg/kg per 12 hours IV bolus) vs. placebo for 5 days in addition to antibiotic treatment. All patients had a high inflammatory response at admission, defined as C-reactive protein levels > 150 mg/L . Septic shock was present in 17% of patients randomized to methylprednisolone and 31% of patients randomized to placebo (no p value reported). While there was no difference between groups in early treatment failure (10% per group), methylprednisolone was associated with a significantly decreased risk of late treatment failure compared to placebo (3% vs. 25%, p = 0.001, NNT 5). There were also no significant differences in in-hospital mortality, length of hospital or intensive care unit stay, time to clinical stability, or adverse events.
The second trial by Blum et al. recently published in The Lancet (Lancet 2015 Apr 18;385(9977):1511) evaluated oral corticosteroids in a larger population of adults hospitalized with pneumonia of any severity. The primary outcome of this trial was time to clinical stability, a composite outcome defined as time until vital signs were stable for ≥ 24 hours. Here, 802 adults (mean age 74 years) were randomized to prednisone (50 mg daily) vs. placebo for 7 days in addition to antibiotic treatment. Patients presented with a number of comorbidities, including renal insufficiency in 32%, antibiotic pretreatment in 23%, diabetes mellitus in 20%, heart failure in 18%, chronic obstructive pulmonary disease in 17%, and coinfection in 12%. Comparing prednisone to placebo, time to clinical stability was 3 days vs. 4.4 days (p < 0.0001) and length of hospital stay was 6 days vs. 7 days (p = 0.012). Consistent results were reported in subgroup analyses by age, median C-reactive protein concentration, history of chronic obstructive pulmonary disease, severity of pneumonia, or blood culture positivity. There were no significant differences in recurrent pneumonia, hospital readmission, or pneumonia-associated mortality.
Together, the results of these trials suggest that the addition of corticosteroids to antibiotic treatment may improve the clinical course of disease in patients hospitalized with pneumonia, regardless of disease severity. These trials have several limitations, however. Neither trial considered patients with community-acquired pneumonia treated in an outpatient setting. The trial by Torres et al. evaluated corticosteroids in a very specific population of patients with severe pneumonia plus high inflammatory responses, therefore these results may not be generalizable. Also, the decreased rate of late treatment failure observed in the methylprednisolone group in this trial may have been influenced by the lower percentage of patients with septic shock at baseline randomized to this treatment. While the trial by Blum et al. evaluated the use of adjunctive corticosteroids in a broader patient population, the individual components of the time to clinical stability composite outcome were not reported. One component of this outcome is a temperature of 37.8⁰C (100⁰F) or lower. Treatment with corticosteroids can result in a decrease in fever and a change in body temperature alone cannot be ruled out. Absence of fever is also a common component of discharge criteria, questioning the effect of corticosteroids on decreasing the length of hospital stay as well. The results of these trials show potential benefit for adjunctive corticosteroid use in hospitalized patients with community-acquired pneumonia, but further analysis is required to determine at what dose and in which patient populations they are truly effective.
For more information, see the Community-acquired pneumonia in adults topic in DynaMed.
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Critical Appraisal of the Medical Literature: A Simplified Approach
July 8 – 9, 2015 – Portland State University - Portland, Oregon.
Join DynaMed Editorial Board members Sheri Strite and Michael Stuart MD for a workshop to improve your critical appraisal skills. Sheri and Michael aim to make critical appraisal of the medical literature meaningful, useful, simple, and doable. This program will be particularly helpful to those who routinely evaluate the medical literature.
Visit their Seminar page for more details.
The DynaMed editorial team is seeking specialist editors in the following fields: Gastroenterology, Nephrology, Oncology (especially Breast cancer and Pancreatic cancer), Ophthalmology, and Pediatric Neurology.
If interested, please send a recent copy of your CV to Rachel Brady at email@example.com.
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