This week in the BMJ
Volume 333, Number 7563, Issue of 12 Aug 2006Delay prescribing of antibiotics for acute conjunctivitis
Delay prescribing of antibiotics for acute conjunctivitis
Delayed prescribing of topical antibiotics is probably the best strategy for managing acute conjunctivitis in primary care, say Everitt and colleagues (p 321). They randomised more than 300 adults and children with acute infective conjunctivitis from 30 general practices to one of three prescribing strategies—immediate antibiotics (chloramphenicol eye drops), no antibiotics (controls), or delayed antibiotics (prescription to be collected at patients' discretion after three days). Prescribing strategies did not affect the severity of symptoms, but duration of moderate symptoms was less with antibiotics (immediate or delayed). However, delayed prescribing reduced antibiotic use and reattendance compared with immediate prescribing.
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Metoclopramide helps reduce postoperative nausea and vomiting
Intraoperative administration of 50 mg metoclopramide, in addition to dexamethasone, is effective, safe, and cheap in preventing postoperative nausea and vomiting, say Wallenborn and colleagues on page 324. They randomised more than 3100 patients who had received anaesthesia for surgery to different doses of metoclopramide (0, 10, 25, or 50 mg) in addition to the recommended 8 mg dexamethasone. The cumulative incidence of nausea and vomiting decreased in a dose-related fashion with increasing metoclopramide, from 23.1% for dexamethasone alone to 14.5% for dexamethasone plus 50 mg metoclopramide.
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Spironolactone is associated with upper GI events
The risk of gastroduodenal ulcers or upper gastrointestinal bleeding is significantly increased in patients taking spironolactone. A population based case-control study by Verhamme and colleagues (p 330) matched 523 cases of gastroduodenal ulcer or upper gastrointestinal bleeding to 5230 controls from the same Dutch primary care database and found that current use of spironolactone was associated with a 2.7-fold increased risk of a gastrointestinal event. The association increased proportionally with dose and was most pronounced when spironolactone was combined with ulcerogenic drugs.
Managing infective endocarditis: take blood cultures first, treat later
Endocarditis remains an important clinical problem with the rise of intravenous drug misuse, degenerative valve disease, and nosocomial infection, and it should be managed by a multidisciplinary team, say Beynon and colleagues (p 334). This clinical review revisits the pathophysiology and symptoms of infective endocarditis; describes its investigation with blood cultures, echocardiography, and serological and histological testing; discusses diagnostic criteria; and explores antimicrobial and surgical treatment. Boxes list the Duke diagnostic criteria, criteria for tertiary care and surgery, and what general practitioners need to consider.
Algorithm estimates risk of hospital readmission
A sensitive and specific method for identifying patients at high risk of readmission to hospital in the next 12 months is freely available to primary care trusts in the NHS in England. Billings and colleagues (p 327) analysed data from hospital episode statistics showing all admissions within NHS trusts in England over five years. Using two 10% samples of the hospital episode statistics, they developed and validated a "patient at risk for re-hospitalisation" (PARR) algorithm which assigns a risk score from 0-100 to individual patients. Key factors predicting readmission included age, sex, ethnicity, prior hospitalisation, and clinical condition.
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