ITL: Physician Reviews of HM-Relevant Research

In This Edition

Literature At A Glance

A guide to this month’s studies

1. Guidelines on steroids and antivirals to treat Bell’s palsy
2. Probiotics to reduce Clostridium difficile-associated diarrhea
3. Rates of hemorrhage from warfarin therapy higher in clinical practice
4. Less experienced doctors incur higher treatment costs
5. Pay-for-performance incentive reduces mortality in England
6. No benefit in ultrafiltration to treat acute heart failure
7. Hospitalized patients often receive too much acetaminophen
8. Longer anticoagulation therapy beneficial after bioprosthetic aortic valve replacement
9. Antimicrobial-coated catheters and risk of urinary tract infection
10. Patient outcomes improve after in-hospital cardiac arrest

Updated Guidelines on Steroids and Antivirals in Bell’s Palsy

Clinical question: Does the use of steroids and/or antivirals improve recovery in patients with newly diagnosed Bell’s palsy?

Background: The American Academy of Neurology’s last recommendation in 2001 stated that steroids were probably effective and antivirals possibly effective. The current review and recommendations looked at additional studies published since 2000.

Study design: Systematic review of MEDLINE and Cochrane Database of Systematic Reviews data published since June 2000.

Setting: Prospective controlled studies from Germany, Sweden, Scotland, Italy, South Korea, Japan, and Bangladesh.

Synopsis: The authors identified nine studies that fulfilled inclusion criteria. Two of these studies examined treatment with steroids alone and were judged to have the lowest risk for bias. Both studies enrolled patients within three days of symptom onset, continued treatment for 10 days, and demonstrated a significant increase in the probability of complete recovery in patients randomized to steroids (NNT 6-8). Two high-quality studies were identified that looked at the addition of antivirals to steroids. Neither study showed a statistically significant benefit.

Of note, the studies did not quantify the risk of harm from steroid use in patients with comorbidities, such as diabetes. Thus, the authors concluded that in some patients, it would be reasonable to consider limiting steroid use.

Bottom line: For patients with new-onset Bell’s palsy, steroids increase the probability of recovery of facial nerve function. Patients offered antivirals should be counseled that a benefit from antivirals has not been established, and, if there is a benefit, it is modest at best.

Citation: Gronseth GS, Paduga R. Evidence-based guideline update: steroids and antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2012;79(22):2209-2213.

Probiotic Prophylaxis Reduces Clostridium Difficile-Associated Diarrhea

Clinical question: Are probiotics a safe and efficacious therapy for the prevention of Clostridium difficile-associated diarrhea (CDAD)?

Background: CDAD is the most common cause of hospital-acquired infectious diarrhea in high-income countries. There has been a dramatic rise in the incidence and severity of CDAD since 2002. Previous studies suggested that probiotics might reduce the incidence of CDAD with few adverse events.

Study design: Systematic review and meta-analysis of the literature.

Setting: Randomized controlled trials from the U.S., Canada, Chile, China, United Kingdom, Turkey, Poland, and Sweden.

Synopsis: Investigators identified 20 trials including 3,818 participants using a systematic search of randomized controlled trials of a specified probiotic of any strain in adults or pediatric subjects treated with antibiotics. Probiotics reduced the incidence of CDAD by 66% (risk ratio 0.34, 95% CI 0.24 to 0.49). Subgroup analyses showed similar results in both adults and children, with lower and high doses, and with different probiotic species.

Of probiotic-treated patients, 9.3% experienced an adverse event compared with 12.6% of control patients (relative risk 0.82, 95% CI 0.65 to 1.05). There was no report of any serious adverse events attributable to probiotics.

One limitation is the considerable variability in the reported risk of CDAD in the control group (0% to 40%). The absolute benefit from probiotics will depend on the risk in patients who do not receive prophylaxis.