Infection with multi-organ system involvement. It has, for the sake of precision most ignore, the following syndromes:
- Bacteremia: bugs in the blood.
- Sepsis: bacteremia with end-organ manifestations: DIC, ARF, ARDS, hypotension that responds to fluids/low dose pressors.
- Septic shock: bacteremia with end-organ manifestations: DIC, ARF, ARDS, hypotension that does not respond to fluids or pressors. It is not the same as toxic shock syndrome.
Two sets of blood cultures are better than one for finding the infecting organism (PubMed). It is all about getting enough blood volume to capture the pathogen.
It depends on the infecting organism.
The name of the bug has significance. Different bugs have different reasons for being in the blood, so if a patient has, say, S. aureus in the blood, and you can't give me a list of the reasons why perhaps you should look it up or call an ID doc.
Obesity is beneficial for sepsis; they are less likely to die (PubMed). Since I think we will all die of a disease in our specialty I keep telling my wife I do not need to lose weight. She isn't buying it.
Any organism can cause sepsis, but it is aerobic gram-negative organisms that are most likely to kill patients: E. coli, etc.
"> 50% of patients identified and treated for severe sepsis in the emergency department had negative culture results. Of patients identified with a sepsis syndrome at presentation, 18% had a noninfectious diagnosis that mimicked sepsis, and the clinical characteristics of these patients were similar to those of patients with culture-positive sepsis (PubMed)."
Many viruses will reactivate with sepsis: "CMV (24.2%), EBV (53.2%), HSV (14.1%), HHV-6 (10.4%), and TTV (77.5%). 42.7% of septic patients had presence of two or more viruses. (PubMed)." CMV, and other Herpes virus reactivation, is associated with worse outcome (PubMed). Zero data as of 2014 as to whether it is causal or whether treatment would help. The one CMV prophylaxis study shows INCREASED mortality in the treatment arm (PubMed).
Culture negative sepsis has more organ failure and death. (PubMed).
How long to treat? It depends in part the underlying infection, but with the exception of S. aureus, the data suggest that shorter (5-7 days) are no worse than longer courses of antibiotics for bacteremia from a variety of sources. Mostly we treat some multiple of 7 since we have 7 days in the week.
"Twenty-four eligible trials were identified, including one trial focusing exclusively on bacteremia, zero in catheter related bloodstream infection, three in intra-abdominal infection, six in pyelonephritis, 13 in pneumonia and one in skin and soft tissue infection. Thirteen studies reported on 227 patients with bacteremia allocated to ‘shorter’ or ‘longer’ durations of treatment. Outcome data were available for 155 bacteremic patients: neonatal bacteremia (n=66), intra- abdominal infection (40), pyelonephritis (9), and pneumonia (40). Among bacteremic patients receiving shorter (5-7 days) versus longer (7-21 days) antibiotic therapy, no significant difference was detected with respect to rates of clinical cure (45/52 versus 47/49, risk ratio 0.88, 95% confidence interval [CI] 0.77-1.01), microbiologic cure (28/28 versus 30/32, risk ratio 1.05, 95% CI 0.91-1.21), and survival (15/17 versus 26/29, risk ratio 0.97, 95% CI 0.76-1.23) (PubMed)."
There is the above, then there is a retrospective study that suggests for uncomplicated gram-negative bacteremia 14 days of antibiotics is better (PubMed). Others suggest 8 days enough (PubMed) for Enterobacteriaceae bacteremia.
Best study yet (2019): "gram-negative bacteremia, hemodynamically stable by day 7, we found 7 days of antibiotic therapy to be noninferior to 14 days in terms of mortality, clinical failure, readmissions, and prolonged hospitalization (PubMed)." Mostly Enterobacteriaceae and it wasn't all iv.
For streptococcal bacteremia, a quinolone and beta lactam oral therapy are equal BUT give at least three days of iv and do not give low dose beta-lactams (PubMed).
And it does not have to be IV: finishing up with a 7-10 day course of a quinolone or beta-lactam works just fine (PubMed)(PubMed). One meta-analysis suggests an oral quinolone is best, but the beta-lactams were likely underdosed (PubMed).
At ID Weak 2018 they presented an abstract that 7 days is no worse than 14, mostly for uncomplicated Enterobacteriaceae bacteremia (PubMed).
My take? Except for some organisms (S. aureus and Candida) or the presence of endovascular hardware (artificial valves and pacemakers) bacteremia is not important and the blood is likely sterile after a single dose of antibiotics. What is more important is the source of the infection and how well it is controlled and, to a lesser extent, the ability of the host to cure the infection. The more immunosuppressive co-morbidities the more aggressive I tend to be with the antibiotics.
Zeroth: get those antibiotics into the patient ASAP. Every hour of delay increases mortality (PubMed) (PubMed). Although the data for promptness is weak, and one analysis suggests "In patients with septic shock, rapid administration of antibiotics was generally associated with a decrease in in-hospital mortality, but no “every hour delay” was seen (PubMed). See Sepsis hysteria: excess hype and unrealistic expectations.
First and foremost find the source and drain it / remove it. If you don't drain it /remove it, the patient has an increased chance of dying (Pubmed). Source control rules. "Central venous catheter removal within 2 days of the onset of gram-negative bloodstream infections significantly improved the infectious outcome and overall mortality of adult cancer patients with catheter-related bloodstream infections (PubMed)." Get the hint? Pull the line.
Second: support per your local intensivist. If there is a professional around call them, don't try it alone.
- Prompt and appropriate antibiotics, both the first and subsequent doses (the second dose is often delayed in transfer from ER to ICU and is associated with worser outcomes) is THE MOST IMPORTANT INTERVENTION to decrease mortality (PubMed).
- the exact nature of which depends on the suspected organisms and the source. Generally speaking, you want at a minimum (my order of preference) third-generation cephalosporins OR carbapenem OR piperacillin OR penicillin/beta-lactamase inhibitors. If penicillin allergic aztreonam OR quinolone. and maybe give at least one 5-7 mg/kg dose of aminoglycoside (see rants below) plus/minus vancomycin (if a reasonable suspicion of MRSA).
- I know for the last decade the current initial decerebrate treatment of choice is zosin (my spelling, not a type for once) and vancomycin. Not only is this combination associated with increased renal damage, but in the ER it has a 25% chance of being wrong: "Patients with known COPD, residence at a skilled nursing facility, a history concerning for Clostridium difficile, and immunosuppression would benefit from an alternative regimen. "(PubMed).
- Combination therapy in most studies does not alter mortality (PubMed) BUT if the monotherapy turns out to be ineffective, the patient is toast, no organism is 100% susceptible in this century, so I think combination therapy is reasonable pending sensitivities, especially if there is a lot of resistance in your neck of the woods.
In areas where resistance is rare, even 2 days of an aminoglycoside leads to increased renal toxicity without improving outcomes (PubMed). But "retrospective observational study including patients with community-acquired sepsis or septic shock and positive blood cultures, who meet Sepsis-3 criteria, shows that the addition of one single dose of gentamicin to β-lactam treatment at admittance was associated with a decreased risk of mortality and was not associated with AKI (PubMed)."
Two active agents decrease mortality to a greater extent than one active agent (51.7% versus 36.4%) and an aminoglycoside is better than a quinolone (PubMed) if the addition of a quinolone does much; some studies show no benefit (PubMed).
Combination therapy may be optimal for the management of high-risk, life-threatening infections, particularly those associated with septic shock but may be detrimental to low-risk patients (PubMed).
If the patient has been on antibiotics in the prior 90 days, the bug will probably be resistant to that antibiotic. Give a different class or watch mortality rise (PubMed). It is amazing how often when patients go south in the hospital after the course of antibiotics and the prior antibiotics are restarted. Change the class of antibiotics; the new infection is probably resistant.
The patient should probably receive a macrolide for its immunomodulatory effects whether or not the organism is susceptible to a macrolide; it decreases mortality (PubMed). Clarithromycin, perhaps due to immunomodulatory effects (PubMed), at a dose of 1 gm a day for three days markedly decreases days on the ventilator and may decrease mortality (PubMed).
After a day or three, when cultures are back, the de-escalation of antibiotics is associated with decreased mortality (PubMed).
Fourth: Adjunctive therapy. Lots and lots and lots of fluids and pressors, which ones I leave to the fad of the day. Goal-directed therapy may not be the cat's pajamas anymore (PubMed).
Steroids? It comes and goes. As of 3/16/18, I would say no, but it is the classic Newton's second law of the medical literature. For every study there is an equal and opposite study as in the (March 1 NEJM). The negative study had 3 times the number of patients and the positive study had a p of 0.04 for the primary endpoint, which is likely negative. I remain convinced that before a result is to be believed the p should be a minimum of 0.005 (5 out of 4 Americans Do Not Understand Statistics).
The 2008 NEJM study suggests more harm than good from steroids. The data issue is not yet resolved definitively (PubMed). The CID meta-analysis suggests it is safe but not effective at decreasing mortality (PubMed), as does a 2017 NEJM study (PubMed). Back and forth back and forth, for thirty years we still can't say what the use of steroids in sepsis should be, although I lean 90:10 against.
The wonder drug that works wonders? In sepsis "10.9% mortality for acetylsalicylic acid users and 17.2% mortality in the propensity-matched nonusers " (PubMed).
The physiology can be tricky. Increased levels of cell-free hemoglobin are associated with death and, if elevated, acetaminophen may be protective (PubMed). But how often do you check cell-free Hgb? Not often I bet. Perhaps we should.
Drotrecogin alfa [Xigris®] or activated protein C pulled from the market in 2011 as repeat studies demonstrated it is not better than a placebo. 20 grand a course for nothing. A lesson on the importance of remembering that most of the medical literature is wrong.
"Polymyxin B hemoperfusion added to conventional therapy significantly improved hemodynamic's and organ dysfunction and reduced 28-day mortality in a targeted population with severe sepsis and/or septic shock from intra-abdominal gram-negative infections (PubMed)".
That is just the ID part of treatment. There is the whole surviving sepsis protocol, with many interventions that will improve outcome (PubMed) from the abstract:
"Key recommendations and suggestions, listed by category, include (and this is why we have intensivists):
- early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C)
- blood cultures before antibiotic therapy (1C)
- imaging studies performed promptly to confirm a potential source of infection (UG)
- administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy
- reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B)
- infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C)
- initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C)
- initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C)
- fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG)
- norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥ 65 mm Hg (1B)
- epinephrine when an additional agent is needed to maintain adequate blood pressure (2B)
- vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG)
- dopamine is not recommended except in highly selected circumstances (2C)
- dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C)
- avoiding the use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C)
- hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B)
- low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS)
- application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B)
- higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C) - recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C)
- prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of ≤ 100 mm Hg in facilities that have experience with such practices (2C) - head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B)
- a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C)
- protocols for weaning and sedation (1A)
- minimizing the use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B) - avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C)
- a short course of neuromuscular blocker (no longer than 48 hrs) for patients with early ARDS and a Pao2/Fio2 < 150 mm Hg (2C)
- a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose ≤ 180 mg/dL (1A)
- equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B)
- prophylaxis for deep vein thrombosis (1B) - use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B)
- oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C)
- and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hrs of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C)
- for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5 to 10 mins (2C)
- a more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C)
- and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C)."
There are multiple studies to show extended infusion of beta-lactams improves outcomes.
Continuous/extended infusion of piperacillin-tazobactam (TZP) and carbapenems improves the 30-day mortality of patients with liver cirrhosis and bloodstream infection (Pubmed).
The combination of a beta-lactam PLUS an aminoglycoside is arguably the best initial choice for survival.
Not a beta-lactam and a quinolone. I kept this in strike-through as there is now a study to show all-cause 28-day mortality is decreased with the combination of a beta-lactam and a quinolone. Ouch. I hate having to change my mind. One dose of gentamicin cannot hurt anyone kidneys (Pubmed) and if they are in ARF, the kidneys are protected. And what is better? A dead patient with live kidneys or a live patient with dead kidneys? I suppose if you are waiting for a renal transplant, the former (PubMed).
Getting the patient off the usually unneeded anti-Pseudomonal antibiotic in less than 48 hours decreases the risk of C. difficile (PubMed). And every day they are on unneeded anti-Pseudomonal antibiotics the risk of resistant organisms increases (PubMed)(PubMed).
Sepsis is bad for the brain: "Sepsis was specifically associated with moderate to severe vascular brain injury as assessed by microvascular infarcts. This association was stronger for microinfarcts within the cerebral cortex, with those who experienced severe sepsis hospitalization being more than twice as likely to have evidence of moderate to severe cerebral cortical injury in adjusted analyses."(PubMed).
Although it seems that once an antibiotic is started it is continued no matter the sensitivities it is clear that for Enterobacteriaceae bacteremia, de-escalation is safe safe safe (Pubmed).
How long to treat? 5-7 days? It is enough for bacteremic cellulitis, pneumonia, and cystitis (PubMed).
Bacteremia, like most infections, is long term bad for you. People admitted with bacteremia have an increased risk of death in the next year often from cardiovascular disease (PubMed). But then all infections lead to an increase in vascular events.
Present with sepsis and no fever: patients get less aggressive therapy, more delays in antibiotics and have a higher mortality rate (PubMed).
The current indication for troponins is the presence of heart; if elevated in sepsis it portends increased mortality (PubMed).
In bacteremic UTIs, step down to a beta-lactam is as effective as a quinolone (PubMed).
Get the blood cultures before antibiotics just for once, would you puh-lease?
And vitamin C? Here is my take from Science-Based Medicine from April 2017
Before you read it, in 2019 a before and after study showed "Hospital mortality, the primary outcome, did not differ significantly between groups. Secondary outcomes including ICU, 28-day, and 60-day mortality were also not different, nor were vasopressor duration or hospital length of stay. However, ICU length of stay was significantly reduced in the treatment group compared to control (7.1 vs 15.6days, respectively, p=0.04). CONCLUSIONS: Although no significant mortality benefit was observed, the vitamin C protocol was not associated with patient harm. In this Veteran population, there was reduced ICU length of stay, suggesting possible benefit. Though further investigation is warranted, utilization of IV vitamin C, thiamine, and hydrocortisone in patients with sepsis or septic shock may be a treatment option worth considering (PubMed)."
And "In this preliminary study of patients with sepsis and ARDS, a 96-hour infusion of vitamin C compared with placebo did not significantly improve organ dysfunction scores or alter markers of inflammation and vascular injury (PubMed)."
And a randomized study from 2020? Did not do squat: "Among patients with sepsis or septic shock, the combination of hydrocortisone, vitamin C, and thiamine did not reduce mortality compared with placebo." (Pubmed).
And yet again, no benefit of hydrocortisone, vitamin C, and thiamine (Pubmed).
What? It. Didn't. Do. Anything. But add cost. And promoting interventions based on analysis of one secondary endpoint? Always BS. Remember Xigris anyone?
So there is the SBM analysis.
Doctor: Not so sick, my lord,
As she is troubled with severe sepsis,
That keep her from her rest.
Macbeth: Cure her of that…
Doctor: Therein the patient
Must minister to himself.
Macbeth: Throw ascorbic acid to the dogs; I’ll none of it.
Writing about pseudo-medicine is relatively easy. Most pseudo-medicines are simple and self-contained. Being fundamentally fictional, outside of real complications, you do not have to fret overmuch about physiology and anatomy and plausibility and all the other aspects of medicine that make being a doctor a lot like Barbie in a math class. It’s tough.
After the flood, I’m left high and dry
I have been inundated (two is an inundation for me) with emails about “Hydrocortisone, Vitamin C and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study.” What, they ask, as an ID doctor and skeptic, do you make of it?
I have 34 years plus of taking care of severe sepsis and septic shock and I have seen interventions come and go in the attempt to decrease the mortality from sepsis. Using steroids has waxed and waned, combination antibiotics have had their day in the sun, anti-endotoxin antibodies looked promising, and over a billion dollars was spent on Xigris before studies showed it didn’t work, so never mind.
A career of disappointed hopes has rendered me skeptical. Headlines like:
- “Virginia doctor’s possible cure could save millions from sepsis.”
- “Sepsis is the number 1 killer of patients in hospitals. A doctor might have just stumbled on the cure.”
- “Sepsis: Deadly condition can now be treated through intravenous vitamin C.”
They fail to impress. Been there, done that. Vitamin C has had such a bad reputation for so long as King of the overhype, having actually efficacy would be like an apology from the current POTUS. Never gonna happen. But let us have a Joan Jett moment and see where the literature leads us.
Before we get to the study, back to basics. Is there any reason to suspect vitamin C would have any effect on sepsis? Maybe.
Highlighting just how poorly the mice reflected the human disease, the correlations of the gene changes in the mouse models with their human disease counterparts came close to those expected by random chance alone.
Vitamin C levels are often very low in septic patients, so repletion and/or super-therapeutic doses may have beneficial effects on a variety of septic pathophysiologic processes, especially the low blood pressure that accompanies sepsis.
Patients with severe sepsis present with hypovitaminosis C, and pre-clinical and clinical studies have indicated that administration of high-dose ascorbate decreases the levels of pro-inflammatory biomarkers, attenuates organ dysfunction and improves haemodynamic parameters. It is conceivable that administration of ascorbate to septic patients with hypovitaminosis C could improve endogenous vasopressor synthesis and thus ameliorate the requirement for exogenously administered vasopressors.
I never find these kinds of extrapolations compelling. Sepsis/septic shock is a jaw-droppingly complex reaction to a variety of processes, most often infection, and most of these hoped for effects would appear to be no more than pissing on a forest fire.
But there are a pair of prior studies. One is a prior small, placebo-controlled trial that showed benefit from intravenous vitamin C, with septic patients requiring less vasopressors and a decrease in mortality. Another preliminary safety trial also showed benefit. And vitamin C has been used with some benefit in other severely ill patients, including burn unit and surgical patients. The studies had different designs and endpoints, but pointed the same direction: less organ failure, less mortality, and faster resolution. And with no side effects. A wonder drug working wonders?
A good start, but…
So an encouraging, albeit a small and preliminary, literature. Which brings us to the current paper. It is everything you don’t want a clinical trial to be. It is not blinded, placebo-controlled, or randomized, and has small numbers of patients. It is the kind of paper that, when seen through the lens of “Why Most Published Research Findings Are False” leads to a sigh and an eye roll.
After a Hail Mary of giving vitamin C to three septic patients who unexpectedly survived, they started routinely giving vitamin C (plus thiamin and low dose steroids) to all their septic patients.
The paper is a comparison of 47 patients before the intervention with vitamin C and 47 patients after the intervention. In other words 94 anecdotes, an extended riff on the theme of what I call the three most dangerous words in medicine: in my experience.
The patients were similar in both groups, but only a small number had positive blood cultures. But, in line with prior studies, the treatment decreased the need for vasopressors and mortality:
The hospital mortality was 8.5% (4 of 47 patients) in the treatment group compared to 40.4% (19 of 47 patients) in the control group (p < 0.001).
The treatment group also improved their SOFA score (a measure of disease severity) more rapidly:
The 72-hour delta SOFA score was 4.8 ± 2.4 in the treatment group compared to 0.9 ± 2.7 in the control group
Impressive results from an unimpressive methodology. Such an impressive effect by vitamin C on such complex pathophysiology seems just too good to be true. Which means it probably is.
What does the future hold?
What is going to happen now? If history repeats itself, first IV vitamin C will be in short supply followed by a marked increase in acquisition cost. Never saw a pharmaceutical company yet that that didn’t take the opportunity to price gouge. There will be a clinical trial with a good methodology that will show no overall benefit but there will be a benefit in post hoc subgroup analysis. And another trial of the subgroup will be done and, a decade from now, after I am retired or dead, vitamin C will be found to be ineffective for sepsis. I sure hope I am wrong.
The pseudo-medical world is already getting their paranoid conspiracy boxers in a twist over suppression of a ‘natural’ way to treat sepsis while demonstrating a lack of understanding of the scientific process.
This story also provides a good case study into how medicine should work: doctors use their knowledge and experience—as well as the work of their colleagues—to test new treatments for intractable diseases, and then determine what works. The government has time and time again proven itself incapable of determining whether the drugs it approves are effective, and the FDA is, of course, susceptible to the self-interested manipulation of scientific research carried out by Big Pharma. The question of efficacy should be left to doctors and patients.
As if massive doses of intravenous vitamin C is natural. I would not be surprised if a naturopath gave patients IV orange juice, you know, to potentiate the effects with a natural source of vitamin C.
I like big buts and I cannot lie
But but but but but. One big but.
What to do now as a clinician? When a patient hits the ICU septic, how to apply this scant, preliminary, unsatisfactory information? Death. That is one hard, impressive, endpoint. Death is not the usual subjective, biased, soft result that is the effect of pseudo-medical interventions. An 8.5% mortality rate for sepsis is damn good. It may be the ICU equivalent of flipping a coin and getting heads 10 times in a row. Or it may be the real deal. It appears they keep coming up heads.
We have now treated over 150 patients with severe sepsis and septic shock. We have had only one patient die from sepsis, this being a complex surgical case who died in the immediate post-operative period. While a few of the treated patients have died, none died from progressive organ failure related to sepsis. All these patients were weaned off pressors/mechanical ventilation and died from their underlying disease
Vitamin C for decreasing mortality from sepsis, no matter how preliminary the data, is so far consistent, and is so tempting, despite my pessimism that it will be yet another overhyped flash in the pan. But we have to fight our wars with the equipment at hand. The future? Hamlet or Macbeth?
Let me see. (Takes the vial) Alas, poor ascorbate! I knew it, Horatio, a vitamin of infinite therapeutic effects, of most excellent fancy. It hath treated a thousand pestilences, and now, how abhorred in my imagination it is!
I dreamt last night of the three weird trials:
To you they have show’d some truth.
But given the risks, the benefits, and the data until there is a definitive trial I have to side with Vizzini:
Never go in against vitamin C when death is on the line!
Relevant links to my Medscape blog
Last Update: 12/27/21.