Rodrigo Costa

ID physician at Hospital CardioPulmonar - Rede D'Or / Salvador-BA 🇧🇷
#AntimicrobialStewardship

[Elliot Tapper @ebtapper]

There are too many studies in the medical literature comparing AI models
It doesn’t add anything meaningful and these models are often obsolete or replaced by the time of publication

[Anil Makam @AnilMakam]

SSC has done more harm than good

Yet, they learn nothing over time

We need guidelines based in evidence, led with hubris, and written by folks with appraisal skills

[Brad Spellberg @BradSpellberg]

@phil_c89 @MoarSahitoPTI Unfortunately that urban legend still persists despite years of trying to combat it. Lou Rice first pointed out it was bunk as far back as '08. But I still regularly hear people recite it reflexively. We need to keep messaging about this. The correct mantra is: Shorter Is Better.

[Josh Farkas MD 💊 @PulmCrit]

as a general rule, IGRA (interferon gamma release assay) should NOT be used as a test for active pulmonary TB

if you're worried about active pulmonary TB --> isolate & get induced sputa

yes, this is effort-intensive, but it's the correct way to do it

[Josh Farkas MD 💊 @PulmCrit]

again for the people in the back:

urinary tract infection is an EXCEEDINGLY rare cause of nosocomial fever or sepsis.

most such “cases” are probably misdiagnoses.

cystitis happens, for sure, but isolated cystitis doesn’t cause fever or sepsis.

[Brad Spellberg @BradSpellberg]

@emedfocus @ABsteward I think you’ve missed the point. I’ve been doing inpatient medicine for 27 years. I’ve never seen a hospital onset pyelonephritis. No one else i know has either. What you’re talking doesn’t happen. You are being fooled by urine and missing the actual source.

[Brad Spellberg @BradSpellberg]

@ABsteward @DrToddLee You know them all…

1) Shorter Is Better
2) Oral Is the New IV
3) Static/Cidal: Not a Thing
4) Antibiotics are the most potent anxiolytics in the pharmacopeia
5) Resistance is inevitable
6) ESR/CRP: Stop the Zombie Tests
7) Todd’s quote: The urine is innocent until proven guilty

[Antibiotic Steward Bassam Ghanem 🅱️C🆔🅿️🌟 @ABsteward]

"If you’re going to give antibiotics to patients who don’t need them, at least do the courtesy of giving them for a brief period of time." @BradSpellberg #IDQuotes 🌟 #IDXposts #shorterisbetter

[Antibiotic Steward Bassam Ghanem 🅱️C🆔🅿️🌟 @ABsteward]

"Empyema needs a surgeon and 3 inches of cold steel, instead of a fool of a physician.” , Sir William Osler (1849–1919) #idxposts #idquotes

[Vitor Borin P. de Souza @vitorborin_]

Essa dúvida é muito frequente, então vale elaborar um pouco.

Não precisa parar em 5L. Em princípio, pode-se retirar o volume necessário para aliviar o paciente. O ponto é que, quanto maior o volume retirado, maior a preocupação com algo que chamamos de disfunção circulatória pós-paracentese, que pode levar a alterações hemodinâmicas.

É nesse contexto que entra a discussão sobre albumina.

Existem alguns trabalhos, com evidências ainda bem incertas — principalmente porque não mostram benefício convincente em desfechos clínicos importantes para o paciente — sugerindo potencial benefício da infusão de albumina em paracenteses nas quais retiramos mais de 5L em pacientes cirróticos. Isso é importante: não estamos falando de qualquer ascite.

Nesses casos, quando julgamos que faz sentido prescrever, a reposição pode ser feita após o término do procedimento.

A partir disso, três interpretações acabam aparecendo com frequência:

1) “Não pode tirar mais que 5L.”
Pode sim. 5L não é um teto absoluto nem uma dose máxima de paracentese.

2) “Não pode tirar mais que 5L se não tiver albumina para repor.”
Também não é bem assim. A recomendação de albumina após paracentese de grande volume em cirróticos é mais frágil do que costuma parecer.

O que os estudos mostram de forma mais consistente é redução da chamada disfunção circulatória pós-paracentese. Mas esse desfecho foi classicamente definido por aumento da atividade de renina plasmática — um marcador neuro-hormonal, não um desfecho clínico diretamente importante para o paciente, e muito menos um desfecho substituto validado para morte, injúria renal clinicamente relevante, diálise, readmissão ou qualidade de vida.

Ou seja: a albumina pode fazer sentido fisiopatologicamente, mas isso não é a mesma coisa que ter demonstrado benefício clínico convincente. A falta de albumina não transforma 5L em um limite absoluto, ela só tem que entrar no julgamento clínico. Se, ainda assim, fizer sentido retirar mais volume pensando no conforto e na qualidade de vida do paciente, podemos monitorá-lo e considerar expansão volêmica alternativa conforme o contexto.

3) “Vale para qualquer ascite.”
Não vale. O racional fisiopatológico e o que foi estudado se aplicam principalmente à ascite por cirrose/hipertensão portal. Não dá para extrapolar automaticamente para ascite neoplásica, cardíaca, pancreática ou outras etiologias. Portanto, essa indicação de albumina não deve ser extrapolada automaticamente para esses outros cenários.

[Josh Farkas MD 💊 @PulmCrit]

in ICU, the white coat is just a big walking fomite

ideally, every piece of external clothing should be industrially laundered daily by the hospital (e.g. scrubs, green hospital-issued warm-up jackets)

part of primum non nocere is not walking around covered in Cdiff spores

[FireFighterDev @fire_starter457]

“Atheists will never get to Heaven!”

Most of us know this. We also know we won’t get to Oz, Middle-earth, Narnia, or Valhalla. But we can still choose to be decent people anyway, right?

[Zain Shah @zan2434]

Imagine every pixel on your screen, streamed live directly from a model. No HTML, no layout engine, no code. Just exactly what you want to see.

@eddiejiao_obj, @drewocarr and I built a prototype to see how this could actually work, and set out to make it real. We're calling it Flipbook. (1/5)

[Apu Akkad @ApuAkkad1]

@transplantID Anyone can start abx. It takes an expert to stop them.

[Brad Spellberg @BradSpellberg]

@ABsteward @DrToddLee Here’s the thing. This is a burden of proof paradox issue. Cefazolin is easier (3x per day not 6), cheaper, safer (fewer AEs). It actually doesn’t have to be more effective to be preferred. It’s the other way around

[Brad Spellberg @BradSpellberg]

@ABsteward @DrToddLee But at the end of the day, this isn’t about data. We’ve lived through this with short vs long abx. Static vs cidal. Oral vs iv. ESR/crp vs not. This is how 🌍 people are. You just have to wear them out with persistence.

“Just…keep…swimming!”

[Josh Farkas MD 💊 @PulmCrit]

new, larger RCT on selective decontamination of the digestive tract in NEJM shows that its ineffective

SDD would eventually lead to drug-resistant organisms (beyond the timeframe of RCTs)

SDD is an intellectual wasteland that ignores the whole field of antimicrobial stewardship

[Antibiotic Steward Bassam Ghanem 🅱️C🆔🅿️🌟 @ABsteward]

Antibiotics in patients with CAP and a positive respiratory viral test:
Our "hypothetical" WikiGuidelines recommendation:
A Procalcitonin negative: Clear Recommendation
Multiple concordant randomized controlled trials in patients with lower
respiratory tract infections demonstrate that antibiotics can be safely discontinued based on procalcitonin results. Therefore, in patients with
CAP with a positive respiratory viral test, we recommend stopping antibiotics if the procalcitonin result supports cessation using a published algorithm.
@sarubactam

[Brad Spellberg @BradSpellberg]

Our @wikiguidelines letter to the editor regarding the controversy between IDSA and ATS on CAP guidelines is now published. Time for societies to modernize their approach to guidelines to STOP creating care standards based on opinions. @ABsteward @DrToddLee @AnilMakam @medrants

[Antibiotic Steward Bassam Ghanem 🅱️C🆔🅿️🌟 @ABsteward]

Words matter!
It’s very frustrating that I’m still encountering the term “oral step-down” in major ID journals.
Let’s replace it with stewardship-aligned terms:
IV to oral switch
Oral transition
Streamlining
“Step-down” implies inferiority of oral antibiotics.
Time to stop using this term in ID journals—authors, editors, reviewers. #IDXposts