skin healing and lower mortality rate compared with intravenous prednisolone [9]. Serious adverse events, including sepsis, respiratory failure, and upper gastrointestinal bleeding were less frequent in the etanercept group. Although this study provides further evidence of efficacy of etanercept for SJS/TEN, additional studies are needed to determine the optimal dose and duration of treatment, particularly in patients with severe and rapidly progressing disease. (See "Stevens-Johnson syndrome and toxic epidermal necrolysis: Management, prognosis, and long-term sequelae", section on 'Tumor necrosis factor inhibitors'.)
Procalcitonin to guide antibiotic use for lower respiratory tract infections (May 2018)
Procalcitonin is a serum biomarker that helps distinguish bacterial infection from other causes of infection or inflammation. In a randomized trial evaluating 1656 patients presenting to the emergency department with an acute lower respiratory tract infection of any kind (ie, asthma exacerbation, acute chronic obstructive pulmonary disease [COPD] exacerbation, acute bronchitis, or community-acquired pneumonia [CAP]), a procalcitonin-guided approach to inform indications for antibiotic therapy did not result in decreased antibiotic use when compared with usual care [10]. This finding is in contrast to multiple prior studies that have shown procalcitonin to be a helpful adjunct to clinical judgement for guiding antibiotic decision-making and reducing antibiotic overuse [11-15]. Overall, this study highlights that knowledge of procalcitonin is evolving, and additional studies are needed to help refine its use. (See "Procalcitonin use in lower respiratory tract infections", section on 'Practical considerations'.)
Prothrombin complex concentrates for warfarin reversal (May 2018)
Prothrombin complex concentrates (PCCs) are used to reverse the effect of warfarin in patients with serious or life-threatening bleeding. Available products include 4-factor PCCs (II, VII, IX, and X) and 3-factor PCCs that contain little or no factor VII, often resulting in the need for a supplemental source of factor VII. The 3-factor and 4-factor products have not been directly compared in a randomized trial. However, a retrospective observational study found an association between improved survival and fewer thrombotic events for patients treated with the 4-factor PCC, compared with those treated with a 3-factor PCC plus recombinant activated factor VII (rFVIIa) [16]. A number of factors unrelated to the PCC product may have contributed to these outcomes. Nevertheless, when warfarin reversal with a PCC is indicated, we continue to suggest that a 4-factor product be used. (See "Management of warfarin-associated bleeding or supratherapeutic INR", section on 'PCC products, efficacy, risks'.)
Propranolol in addition to amiodarone for treatment of electrical storm (May 2018)
Beta blockers reduce the adrenergic surge associated with frequent ventricular tachyarrhythmias (VT) requiring defibrillator shocks. However, there have been limited data to guide the choice of a selective or non-selective beta blocker in the management of VT, in particular electrical storm (three or more episodes of sustained VT within 24 hours). In a randomized, double-blind study of patients with an implantable cardioverter-defibrillator (ICD) and electrical storm in which all patients received intravenous (IV) amiodarone and were randomized to propranolol (40 mg every 6 hours) or metoprolol (50 mg every 6 hours) for the first 48 hours, VT terminated significantly earlier in patients receiving propranolol (3 hours versus 18 hours with metoprolol) [17]. Additionally, patients receiving propranolol had lower rates of ICD shocks during the intensive care unit (ICU) stay and shorter hospitalizations. For patients with electrical storm, we now recommend propranolol, rather than metoprolol, to be used in addition to IV amiodarone. (See "Electrical storm and incessant ventricular tachycardia", section on 'Beta blockers'.)
Reversal agent for direct factor Xa inhibitor anticoagula
Procalcitonin to guide antibiotic use for lower respiratory tract infections (May 2018)
Procalcitonin is a serum biomarker that helps distinguish bacterial infection from other causes of infection or inflammation. In a randomized trial evaluating 1656 patients presenting to the emergency department with an acute lower respiratory tract infection of any kind (ie, asthma exacerbation, acute chronic obstructive pulmonary disease [COPD] exacerbation, acute bronchitis, or community-acquired pneumonia [CAP]), a procalcitonin-guided approach to inform indications for antibiotic therapy did not result in decreased antibiotic use when compared with usual care [10]. This finding is in contrast to multiple prior studies that have shown procalcitonin to be a helpful adjunct to clinical judgement for guiding antibiotic decision-making and reducing antibiotic overuse [11-15]. Overall, this study highlights that knowledge of procalcitonin is evolving, and additional studies are needed to help refine its use. (See "Procalcitonin use in lower respiratory tract infections", section on 'Practical considerations'.)
Prothrombin complex concentrates for warfarin reversal (May 2018)
Prothrombin complex concentrates (PCCs) are used to reverse the effect of warfarin in patients with serious or life-threatening bleeding. Available products include 4-factor PCCs (II, VII, IX, and X) and 3-factor PCCs that contain little or no factor VII, often resulting in the need for a supplemental source of factor VII. The 3-factor and 4-factor products have not been directly compared in a randomized trial. However, a retrospective observational study found an association between improved survival and fewer thrombotic events for patients treated with the 4-factor PCC, compared with those treated with a 3-factor PCC plus recombinant activated factor VII (rFVIIa) [16]. A number of factors unrelated to the PCC product may have contributed to these outcomes. Nevertheless, when warfarin reversal with a PCC is indicated, we continue to suggest that a 4-factor product be used. (See "Management of warfarin-associated bleeding or supratherapeutic INR", section on 'PCC products, efficacy, risks'.)
Propranolol in addition to amiodarone for treatment of electrical storm (May 2018)
Beta blockers reduce the adrenergic surge associated with frequent ventricular tachyarrhythmias (VT) requiring defibrillator shocks. However, there have been limited data to guide the choice of a selective or non-selective beta blocker in the management of VT, in particular electrical storm (three or more episodes of sustained VT within 24 hours). In a randomized, double-blind study of patients with an implantable cardioverter-defibrillator (ICD) and electrical storm in which all patients received intravenous (IV) amiodarone and were randomized to propranolol (40 mg every 6 hours) or metoprolol (50 mg every 6 hours) for the first 48 hours, VT terminated significantly earlier in patients receiving propranolol (3 hours versus 18 hours with metoprolol) [17]. Additionally, patients receiving propranolol had lower rates of ICD shocks during the intensive care unit (ICU) stay and shorter hospitalizations. For patients with electrical storm, we now recommend propranolol, rather than metoprolol, to be used in addition to IV amiodarone. (See "Electrical storm and incessant ventricular tachycardia", section on 'Beta blockers'.)
Reversal agent for direct factor Xa inhibitor anticoagula