The edition · Emergency & Critical Care
Cephalosporin generation showed no difference in outpatient pyelonephritis
First-generation oral cephalosporins did as well as later generations for pyelonephritis discharged from the ED, cuff and arterial line pressures often disagree on vasopressors, arginine failed in sickle cell crises, and open ICU visiting and delirium.
The edition in brief
The edition closes on DOGMA-ED, a retrospective study of 1147 adults discharged from 11 US emergency departments on an oral cephalosporin for pyelonephritis. Fourteen-day treatment failure was about 18% to 20% whether patients received a first-, second- or third-generation agent, mostly cephalexin, cefuroxime or cefdinir. It is observational and from a low-resistance setting, so local resistance, particularly ESBL rates in India, should still drive the choice. In 13 Polish ICUs, almost one in five patients on vasoactive drugs had a brachial cuff mean pressure more than 11 mmHg away from the radial arterial line, linked to higher noradrenaline doses and higher mortality. The phase 3 STArT trial of intravenous arginine for sickle cell pain crises in 271 children and young adults stopped for futility, with no change in time to crisis resolution or opioid use. A meta-analysis of 13 randomised trials found open or flexible ICU visiting was associated with about half the rate of delirium (RR 0.48) without more infection, at low certainty. The pearl covers euglycaemic ketoacidosis in patients taking SGLT2 inhibitors.
Cuff and arterial line pressures often disagreed on vasopressors
When vasopressor doses are high, check the radial arterial reading against a cuff pressure before escalating further.
Intravenous arginine did not shorten sickle cell pain crises
Arginine did not help sickle cell pain crises; focus on prompt analgesia and watching for acute chest syndrome.
Open ICU visiting was linked to less delirium
Consider open or flexible ICU visiting; it was associated with less delirium without more infection.
Ketoacidosis with a normal glucose in SGLT2 inhibitor users
In an unwell patient on an SGLT2 inhibitor, check ketones even when glucose is normal.
First-generation cephalosporins did as well as later ones for outpatient pyelonephritis
For outpatient pyelonephritis, the cephalosporin generation mattered less than susceptibility; culture first and choose by local resistance.
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