Hi
Today we review a meta analysis evaluating the different treatment options available for Clostridium difficile infection (CDI). This meta analysis attempts to answer a few questions related to an emerging disease in the sub continent
Comparative efficacy of treatments for Clostridium difficile infection: a systematic review and network meta-analysis.
Beinortas et al 
Lancet Infect Dis 2018;18:  1035–44

This meta analysis could identify 24 comparative studies which evaluated two or more treatment options for CDI. A total of 5361 patients receiving 13 different treatment options were evaluated. The primary outcome measure was primary cure of diarrhea. Recurrence of infection was not an end point of interest for the meta analysis. Most of the studies included follow up of 28 days. Severity of the disease was not specified in 9 /24 studies. The most common therapy used was vancomycin followed by metronidazole and fidaxomicin. Most of the drugs were compared against Vancomycin. 17/24 studies included were industry sponsored. Teicoplanin and Fidaxomicin performed better than Vancomycin. Metronidazole performed inferiorly compared to most main line drugs. Tolevamer also did not perform well. Ridinilazole was significantly better than vancomycin in attaining a sustained symptomatic cure in patients with mild to moderate infections with C difficile and who were younger than 65 years. Teicoplanin, Ridinilazole and Fidaxomicin were the top three ranked drugs. However, the no of participants in the studies involving Teicoplanin were small and confidence intervals were wide. Ridinilazole appeared to be the best drug for prevention of recurrence in sub group analysis. The advantage of Teicoplanin seemed to decrease in the analysis when non blinded studies were excluded.
Therefore, fidaxomicin has the strongest evidence for being the most effective treatment
in providing a long-term cure against C difficile. Apart from affordability, there is little evidence to support use of metronidazole as a first-line treatment against infections with C difficile.
Early data for ridinilazole suggest that this treatment could potentially become a new, efficacious
treatment against infections with C difficile.

Drawbacks:
Majority of studies are industry sponsored
No stratification of severe infections

My view: Fidaxomicin seems to be the first choice. Teicoplanin can be used in mild to moderate cases. No overwhelming need to stick to Vancomycin. Metronidazole should be avoided.

A few interesting studies

1.Thomalla. MRI-Guided Thrombolysis for Stroke with Unknown Time of Onset. N Engl J Med 2018;379:611-622 
2.  Yu. Clinical outcomes of prolonged infusion (extended infusion or continuous infusion) versus intermittent bolus of meropenem in severe infection: A meta-analysis. PLoS One 2018;13(7):e0201667 
3. Lindgren. Endovascular coiling versus neurosurgical clipping for people with aneurysmal subarachnoid haemorrhage. Cochrane Database of Systematic Reviews 2018, Issue 8. Art. No.: CD003085
4. Devlin. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med 2018;46(9):e825-e873

A few good reviews as well
Finfer. Intravenous fluid therapy in critically ill adults. Nature Reviews Nephrology 2018;14:541–557

Bussard. Angiotensin II: a new therapeutic option for vasodilatory shock. Ther Clin Risk Manag 2018;14:1287–1298


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Good Morning

Happy to be back on the blog

This week, we introspect about two meta analyses which analysed the outcomes associated with the use of saline versus balanced crystalloids. Balanced crystalloids are being projected and used as a safer alternative to saline which has a risk of inducing hyperchloremia.
González-Castro. Meta-analysis of the effects of normal saline on mortality in intensive care. Rev Esp Anestesiol Reanim 2018;epublished August 9th 
and
Yazan. Balanced crystalloids versus isotonic saline in critically ill patients: systematic review and meta-analysis. J Intensive Care 2018;6:51 

   The first meta analysis looked at 8 RCTs involving more than 20000 patients. This meta analysis included studies which had mortality as the primary end point. The authors report a significant increase in mortality with the use of Saline although the OR is 1.0972. Other surrogate outcomes related to length of stay and AKI did not seem to be different.
  The second meta analysis also looked at nearly 19000 + patients and evaluated the effect of saline and balanced crystalloids on mortality, LOS and incidence of AKI. There did not seem to be any difference in the outcomes when saline is used in comparison to balanced crystalloids. Incidence of RRT was also not higher in the saline group.
         So, the debate seems to be unresolved. However, the odds ratio for mortality in the first Meta Analysis is not overwhelmingly against saline.
My interpretation of these two studies would be
1. Saline is not as harmful as previously thought
2. Balanced crystalloids don't seem to justify the economic impact
3. Larger studies may be needed but are likely to come out with similar results.

APOLOGISE FOR THE SILENCE
CODE OF CONDUCT FOR ISCCM ELECTIONS IN PLACE
WILL RESUME ON 8 AUGUST