Cefepime and Mortality—A Dosing Problem, Not a Drug Problem
A meta-analysis of 110 trials found cefepime linked to higher 30-day mortality than other β-lactams, most clearly in adults, febrile neutropenia or severe infections, and at higher doses. That conflicts with the FDA’s earlier finding of no added risk. The authors and an accompanying commentary still don’t recommend dropping the drug. They call all-cause mortality a blunt outcome in critically ill patients, and suggest the deaths may reflect under- or overexposure rather than the drug itself. Cefepime’s safety margin is narrower than that of other β-lactams, so dosing matters. Urgent Care clinical implications: This shouldn’t change practice for typical Urgent Care use, but dose cefepime carefully for renal function and watch for neurotoxicity (confusion, myoclonus) in older adults. Full Access: JAMA
Infant Respiratory Syncytial Virus and Childhood Asthma: A Nationwide Registry-Based, Sibling-Controlled, And Genome-Wide Association Study
Researchers combined Finnish registry data on nearly 1 million children with Nordic genetic cohorts to ask whether severe infant RSV causes childhood asthma or just flags kids already prone to it. Children hospitalized with RSV in their first year had about 3.7 times the risk of later recurrent wheeze or asthma, and the link held in sibling comparisons. Unaffected siblings also had about double the usual rate, so family susceptibility plays a part too. RSV-related wheeze started earlier, needed more inhaled steroids at ages 1–2, faded after age 5, and came with lower eosinophils, which suggests a more transient, less allergic pattern. Urgent Care Clinical implications: Expect early, non-allergic wheeze in children with a history of RSV hospitalization, and reassess the need for controller therapy over time rather than assuming lifelong asthma. Ask about infant RSV history, and reassure families that many of these children improve by school age. Full Access: The Lancet
Most Americans Know How to Control Mosquitoes; Many Unsure How to Use Insect Repellent
A new Annenberg survey found that most people know the basics: 82% say preventing bites and controlling mosquitoes at home is the best defense against West Nile and dengue, and 64% routinely take precautions. Knowledge of how to use repellent is much weaker. Only 31% know to apply sunscreen first and repellent second, 15% know repellent shouldn’t go under clothing, and 18% know to look for an EPA-registered product. Only 16% worry about catching one of these diseases, and 56% can’t identify West Nile symptoms. The CDC has reported 504 human West Nile cases in 41 states so far this year, 363 of them neuroinvasive. Urgent Care Clinical implications: Clinicians should counsel on repellent: EPA-registered products, sunscreen first, nothing under clothing, none for infants under 2 months. Keep West Nile on the differential for febrile or neurologic presentations during mosquito season, since patients often won’t connect their symptoms to a bite. Full Access: APCC
Nationwide Increase in Reported Human Rabies Exposures: Rabies Post-exposure Prophylaxis Administration
CDC issued a Health Advisory on September 10 about a nationwide rise in rabies exposures and errors in post-exposure prophylaxis (PEP). Rabies inquiries to CDC were up 17% in July and August compared with last year, and use of rabies vaccine and HRIG rose about 33% and 76%. Supplies are fine, but mistakes lead to unnecessary treatment, adverse effects, and cost. The most common errors are gluteal vaccine injections, poor HRIG infiltration of wounds, mixing HRIG and vaccine in one syringe or site, and giving HRIG to previously vaccinated patients. Urgent Care Clinical implications: Do a careful risk assessment before starting PEP, check prior vaccination and immune status, and call your health department. Full Access: CDC