Brad Spellberg

If we know it’s pneumococcus i do not use a second agent. The beta lactam is adequate. I do not find the theory of “anti inflammatory” benefit compelling or useful. Now, we could consider steroids for severe cap.

People told me it was too radical at my place too. But then we walked everyone through the policy, which was developed with Counsel and Risk input. It is an actual structured policy that creates a due process mechanism for doing the right thing. It turns out to be rational, rather than radical.

The main take away is to implement a Policy to Override Policies at your institutions too.

Yeah but you’re Lawful Good. That’s ok. We need Lawful people too. It’s all about balance, right?

YouTube video by ABIM Foundation Administrator/Clinician Collaboration: Policies to Put Patients First

Thanks to @abimfoundation.bsky.social ation for posting the video of my recent lecture on the LA General Policy to Override Policies. For those of you who know my lectures, this one is among the most entertaining. And it's only 10 min. Check it out & implement the policy!
youtu.be/RuKAKH8A604?...

Another plug for #wikiguidelines @bradspellberg.bsky.social
When guidelines don’t keep up with medicine

I was thinking Samuel Clemens. “…lies, damn lies, and statistics.”

a man in a black shirt is standing in front of a door ALT: a man in a black shirt is standing in front of a door

Me reading DOTS trial #IDsky #DOOR

It’s also an absurd conclusion based on wonky stats. A 48% chance dalba was superior? Seriously? How about, no chance. Based on both pre test prob and the actual clinical endpoint results.

a white monkey with a blue face is sitting on a blue blanket . ALT: a white monkey with a blue face is sitting on a blue blanket .

I love Dalba
I just don’t know why we should do a PhD in statistics to understand a trial now
Or maybe am just getting old and grumpy

#5/5 You have not actually prevented any infections. You simply suppressed colonization growth from non-sterile sites. We are clear in our Discussion that the studies found a statistical reduction in infections that was likely not a true reduction in infections. The trials were poorly designed.

#4/5 When you randomized pts to receive abx or not, and then take cultures from non sterile sites, you will OBVIOUSLY grow more bacteria from the patients randomized to NOT receive abx. You are suppressing colonization with abx. This makes it appear that an infection was prevented. But...

#3/4 The #2 infection type was "pneumonia". Again, numerous studies over the last 20 years have shown that a high percentage of "pneumonias" diagnosed in hospital are not actually pneumonias.
Which brings us the fundamental error in the design of all of these trials...

#2/4 The #1 "infection" type in these RCTs was "UTI" based on positive urine culture, with no description of symptoms being present. Since we know that >50% of "UTIs" in hospitals are not UTIs, but asymptomatic bacteriuria, the majority of infections were not actually infections.

#1/5 The problem is even worse than that. It's not simply a trade off of preventing infections vs. worsening resistance & adverse effects. Indeed, it is not at all clear that infections were actually prevented at all in these RCTs. As we discuss, the definition of infection was highly problematic.

Revisiting diagnostics: erythrocyte sedimentation rate and C-reactive protein: it is time to stop the zombie tests

As @bradspellberg.bsky.social would say CRP is missing a letter as a test "A" (CRAP) - www.sciencedirect.com/science/arti...

Prophylactic Antibiotics for Upper Gastrointestinal Bleeding in Patients With Cirrhosis This systematic review and meta-analysis evaluates the evidence supporting the current guidelines antibiotic prophylaxis use in patients with cirrhosis and upper gastrointestinal bleeding.

International guidelines recommend 5 to 7 days of antibiotic prophylaxis for patients with cirrhosis & upper GI bleeding.
🆕🔥Systematic Review ( 14 RCTs, N=1322) & Bayesian Meta-Analysis challenged this universally held dogma #idsky
jamanetwork.com/journals/jam...

#IDsky The Infectious Disease Brad Boy himself, @bradspellberg.bsky.social , has an updated Oral vs IV table, now including the Plague (Y really) and Lyme!

Link here:

www.bradspellberg.com/oral-antibio...

Oooh i like that! The ID Brad Boy. But it was the OG Gangsta @idiots-pod.bsky.social that came up with this idea. So get on with yo’ bad self!

WikiGuidelines lapel pins are available for purchase on
WikiGuidelines website: www.wikiguidelines.org
Support us to incorporate humility of uncertainty into guidelines!

I tend to agree. Especially if a catheter is in place. But if a pt has signs/symptoms of infection, i do it.

Longer-Duration Antimicrobial Therapy Does Not Prevent Treatment Failure in High-Risk Patients with Complicated Intra-Abdominal Infections - PubMed We were able to identify patients at high risk for treatment failure in the STOP-IT trial. Such patients did not benefit from a longer course of antibiotic administration. Further study is needed to d...

Might this be it? pubmed.ncbi.nlm.nih.gov/28650745/

Q: Is [insert test name] test being over used?

A: Yes!

“We’re asking the wrong question. Let’s use fundamental PK. Let’s get the drug to where the bug is, at a high enough concentration to kill the bug, and not worry about whether we label the drug static or cidal”.
As said by @bradspellberg.bsky.social 🤩😇

Fabulous conversation!
#IDSky #MedSky #AMSSky

Imitation is the sincerest form of flattery, my good friends!

Even more important for sicker patients!!!!

LA Times Today: Strangers in the middle of a city: The John and Jane Does of L.A. General Medical Center Watch L.A.

Really compelling story by @corinnepurtill: "Strangers in the middle of a city: The John and Jane Does of L.A. General Medical Center". This short video tells the powerful story of the unidentified admissions to one of the busiest trauma centers in the US.
www.latimes.com/00000197-c35...

Great article on dogma in ID (with parallels to critical care)

We have HUGE problems re: guidelines making recommendations & *redefining* entire diseases based on minimal data.

Gov't metrics exacerbate this further.

@bradspellberg.bsky.social @absteward.bsky.social @drtoddlee.bsky.social #EMIMCC

Oh snap! I hope this conversation happened near a hospital that has a burn unit @bradspellberg.bsky.social