Highlights for Monday, August 15

Below are the 3 articles selected as suggested reading for this week by McMaster editors.
Please be advised that until the end of August Publications of the Week will be temporarily published in a less frequent, biweekly cycle.

Glucocorticosteroids for Bell palsy

Using moderate doses of oral glucocorticosteroids provides benefits to patients with Bell palsy.

This Cochrane meta-analysis examined the effect of moderate doses of glucocorticosteroids (usual doses of 30 to 60 mg of prednisone or equivalent per day) given within a few days of the beginning of symptoms.

The main results indicated a lower probability of incomplete motor function recovery (17% among people on steroids vs 28% in the control group; risk ratio [RR], 0.63; 95% confidence interval [CI], 0.50–0.80). The number of people who needed to be treated with glucocorticosteroids to avoid 1 incomplete recovery was 10 (95% CI, 6–20). There was also a significant reduction in motor synkinesis (unwanted facial movements) and “crocodile tears” (watery eyes when eating or chewing) during follow-up in participants receiving glucocorticosteroids (from about 26% to 17%; RR, 0.64; 95% CI, 0.45–0.91). There was no reduction in the proportion of participants with cosmetically disabling sequelae 6 months after randomization (RR, 0.96; 95% CI, 0.40–2.29; 2 trials, n = 75, low-quality evidence). There was no major difference in adverse effect rates between people receiving glucocorticosteroids and people receiving placebo (RR, 1.04; 95% CI, 0.71 to 1.51; n = 715).

Duration of antibiotic treatment in community-acquired pneumonia

This Spanish study provides reassurance about a relatively short, 5-day course of antibiotics used in hospitalized patients with community-acquired pneumonia (CAP).

The study included “real-life” treatment of 312 patients with CAP. Patients in the intervention (shorter-duration) group were treated with antibiotics for a minimum of 5 days; the antibiotic treatment was stopped at this point if their body temperature was 37.8°C or less for 48 hours and they had no more than 1 CAP-associated sign of clinical instability (systolic blood pressure <90 mm Hg, heart rate >100 beats/minute, respiratory rate >24/minute, arterial oxygen saturation <90%, or PaO₂ <60 mm Hg in room air). The duration of antibiotic treatment in the control group was decided by physicians as in clinical practice. In both groups, the antibiotic type was chosen empirically by physicians according to local guidelines. The primary outcomes were clinical success rate at days 10 and 30 (defined as resolution or improvement in signs and symptoms related to pneumonia without further antibiotics) and CAP-related symptoms at day 10.

The time of receiving antibiotic treatment was significantly longer in the control than the intervention group (median, 10 days [interquartile range, 10–11] vs 5 days [interquartile range, 5–6.5], respectively). Four patients (2.9%) from the control group and 101 patients (70.1%) from the intervention group were receiving antibiotics for only 5 days (P < .001).

The clinical success rate at day 10 was 49% in the control group and 56% in the shorter-duration group. At day 30, the success rate improved to 89% and 92%, respectively (differences not statistically significant). There was also no difference in the symptom assessments. There were 3 deaths in each group (2%), which indicates a relatively low level of severity of the disease.

Recommendations for the management of ANCA-associated vasculitis

This practice guideline provides 15 recommendations concerning the management of rare but frequently devastating diseases termed antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs), which include granulomatosis with polyangiitis (GPA) (also known as Wegener granulomatosis), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA) (also known as Churg-Strauss syndrome). The 5-year survival rates for GPA, MPA, and EGPA are estimated to be 74%–91%, 45%–76%, and 60%–97%, respectively.

Among others, the authors recommend:

• Management of patients with AAV in close collaboration with, or at, centers of expertise (strength of recommendation C [with A based on the strongest evidence]).
• Biopsies to assist in establishing a new diagnosis and for further evaluation in patients suspected of having relapsing vasculitis (C).
• For remission induction of new-onset organ-threatening or life-threatening AAV, treatment with a combination of glucocorticosteroids and either cyclophosphamide or rituximab (A for GPA/MPA, C for EGPA).
• For remission induction of non-organ-threatening AAV, treatment with a combination of glucocorticosteroids and either methotrexate or mycophenolate mofetil (B for methotrexate, C for mycophenolate mofetil).
• Consideration of plasma exchange for patients with AAV and a serum creatine level ≥500 mmol/L (5.7 mg/dL) due to rapidly progressive glomerulonephritis in the setting of new or relapsing disease (B).
• For remission maintenance of AAV, treatment with a combination of low-dose glucocorticosteroids and either azathioprine, rituximab, methotrexate, or mycophenolate mofetil (order of medications reflects voting among authors) (A for GPA/MPA, C for EGPA and azathioprine).
• Continuation of remission maintenance therapy for AAV for at least 24 months following induction of sustained remission (D).
• Investigation of persistent unexplained hematuria in patients with prior exposure to methotrexate.