1) Proton Pump Inhibitors and Upper GI Bleeding
- There is a lot of evidence supporting acid suppression in the setting of bleeding peptic ulcers.
- However, oral dosing of PPIs has not been directly compared with high-dose intravenous therapy.
- A meta-analysis of five trials evaluating oral PPIs found a significant reduction in the risk of recurrent bleeding and surgery compared with treatment with placebo or an H2-receptor antagonist.
- High-dose PPIs given orally achieve adequate acid suppression more rapidly than standard doses. And, high-dose intravenous PPIs achieve adequate acid suppression more rapidly than high-dose oral PPIs. Whether this leads to any appreciable difference on hard clinical outcomes, such as morbidity and mortality is still up in the air.
2) Acute Exacerbation of Bronchiectasis
- Antibiotics are used to treat acute exacerbations of bronchiectasis and prevent recurrent infections by minimizing or erradicating the existing bugs that colonize bronchiectatic airways.
- These problematic bugs include Pseudomonas aeruginosa, Hemophilus influenzae, Streptococcus pneumoniae, Mycobacterium avium complex (MAC), and Aspergillus species (see the "Diagnosis Aspergillosis" post for more information).
- Diagnosed clinically: increased sputum production, change in sputum colour, dyspnea. Fever and CXR findings are not always found.
- A good first-line option for treatment of an uncomplicated exacerbation in the outpatient setting is a fluoroquinolone (e.g. ciprofloxicin).
- Consideration can be made to include dual anti-Pseudomonal coverage for treatment of exacerbations in the inpatient setting.
- Always consider and tailor antimicrobial therapy to previous cultures and sensitivities if they are available.
3) HIV-associated Diarrhea
- The differential diagnosis of diarrhea in a patient with HIV is long(!)
- But, don't be overwhelmed. Always remember your ABCs first. Resuscitate the patient. Then, you will have time to think through your workup and management plan.
- Always take into account their immunologic status (what is the CD4 count?)
- Broadly speaking, the diagnosis typically fits into one of the following categories:
Infectious (the regular stuff, such as E. coli, Salmonella, Campylobacter, Clostridium, etc., as well as the opportunistic bugs, such as CMV, cryptosporidia, microsporidia...and HIV itself)
Malignancy (e.g. Kaposi sarcoma, lymphoma)
Drugs (e.g. ritonavir)
- Send the stool for culture and sensitivity, ova and parasites, and C. difficile toxin. Consider blood cultures, blood for AFB and CMV antigenemia, and abdominal imaging.
- Consider asking for expert advice from our colleagues in Gastroenterology and/or Infectious Diseases.
That's right. All in a night's work.
