Staphylococcus aureus bloodstream infections: definitions and treatment.

Clin Infect Dis. 2009 May 15;48 Suppl 4:S254-9

Authors: Corey GR

Bacteremia caused by Staphylococcus aureus is a serious infection associated with high morbidity and mortality and often results in metastatic infections such as infective endocarditis, which have a negative impact on patient outcomes. We review the importance of the use of precise definitions of uncomplicated bacteremia and complicated bacteremia and present a case study to highlight the need for prolonged treatment and close monitoring of patients with risk factors for complications associated with S. aureus bacteremia. Traditionally, the treatment of choice for S. aureus bacteremia has depended to a large extent on the methicillin susceptibility of the pathogen. New antibiotics with proven efficacy against both susceptible and resistant strains are particularly attractive for empirical therapy. The antimicrobial agents that are currently available for use in the treatment of both methicillin-susceptible and methicillin-resistant S. aureus bacteremia and the scientific evidence that forms a basis for the use of these agents for this indication are reviewed.

PMID: 19374581 [PubMed - indexed for MEDLINE]

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Pharmacological management of postoperative ileus.

Can J Surg. 2009 Apr;52(2):153-7

Authors: Zeinali F, Stulberg JJ, Delaney CP

The duration of postoperative ileus following abdominal surgery is quite variable, and prolonged postoperative ileus is an iatrogenic phenomenon with important influence on patient morbidity, hospital costs and length of stay in hospital. Adequate treatment for prolonged postoperative ileus is important to improve patient morbidity and clinical efficiency. Both clinical and pharmacological management strategies have improved rapidly over the last decade, and appropriate and timely management using multimodal techniques should be used for optimal care. In this review, we define postoperative ileus, describe the pathogenesis and briefly discuss clinical management before detailing potential pharmacologic management options.

PMID: 19399212 [PubMed - indexed for MEDLINE]

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Telaprevir: a promising protease inhibitor for the treatment of hepatitis C virus infection.

Curr Med Chem. 2009;16(9):1115-21

Authors: Gentile I, Viola C, Borgia F, Castaldo G, Borgia G

Chronic hepatitis C affects 130,000,000 people worldwide. Hepatitis C virus (HCV) is a single-strand RNA virus responsible for most cases of chronic hepatitis, liver cirrhosis and hepatocellular carcinoma (HCC) in the Western world. The gold standard for the treatment of chronic hepatitis C (combination of pegylated-interferon alpha and ribavirin) results in a sustained virological response (namely, clearance of serum HCV RNA 6 months after therapy withdrawal) in only about half treated patients. Therefore, there is a race to develop new drugs for the treatment of HCV infection. One of the most promising approaches is to use protease inhibitors, i.e. drugs inhibiting NS3/NS4A HCV protease, which plays a crucial role in the viral life cycle. Telaprevir (VX-950) is the protease inhibitor in the most advanced phase of clinical testing. Telaprevir is orally available and when used in monotherapy it induced a median decline of 4 logs of HCV RNA after two weeks of therapy. However, mutants with a lower sensitivity to telaprevir have been demonstrated in a high proportion of patients within 14 days of monotherapy. The drug has been used in clinical trials in combination with pegylated-interferon and ribavirin. This triple combination resulted in a higher rate of SVR but also in a higher rate of side effects (rash, gastrointestinal disorders, and anemia) than standard treatment. This review focuses on the mechanism of action, pharmacokinetics, clinical efficacy, and tolerability of telaprevir, and on possible use of this drug in combination with other drugs for the treatment of HCV infection.

PMID: 19275615 [PubMed - indexed for MEDLINE]

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Poor outcomes after acute myocardial infarction in systemic lupus erythematosus.

J Rheumatol. 2009 Mar;36(3):570-5

Authors: Shah MA, Shah AM, Krishnan E

OBJECTIVE: Systemic lupus erythematosus (SLE) is associated with higher risk for acute myocardial infarction (MI); but the post-infarction outcomes among these patients are unknown. Our objective was to compare post-acute MI outcomes in patients with SLE to those with diabetes mellitus (DM) and those with neither condition. METHODS: We analyzed the risk for prolonged hospitalization and in-hospital mortality following acute MI in the 1993-2002 US Nationwide Inpatient Sample. We used logistic regression to calculate odds ratios (OR) for prolonged hospitalization and Cox proportional hazards regression to calculate hazard ratios (HR) for in-hospital mortality with and without adjustments for age, sex, race/ethnicity, socioeconomic status, and presence of congestive heart failure. RESULTS: For the SLE (n = 2192), DM (n = 236,016), SLE/DM (n = 474), and control (n = 667,956) groups, the in-hospital mortality rates were 8.3%, 6.2%, 5.7%, and 4.7%, respectively. In multivariable regression models, all 3 disease groups had higher adverse outcome risk compared to control. The OR for prolonged hospitalization was higher for those with SLE (OR 1.48, 95% CI 1.32-1.79) compared to those with DM (OR 1.30, 95% CI 1.28-1.32). A similar pattern was observed for hazard ratios for in-hospital mortality as well (SLE, HR 1.65, 95% CI 1.33-2.04; DM, HR 1.11, 95% CI 1.07-1.14). CONCLUSION: SLE, like DM, increases risk of poor outcomes after acute MI. These patients need to be triaged appropriately for aggressive care.

PMID: 19208594 [PubMed - indexed for MEDLINE]

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Risk factors for delirium in intensive care patients: a prospective cohort study.

Crit Care. 2009 May 20;13(3):R77

Authors: Van Rompaey B, Elseviers MM, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, Bossaert L

ABSTRACT: INTRODUCTION: Delirium is a common complication in the intensive care unit. The attention of researchers has shifted from the treatment to the prevention of the syndrome necessitating the study of associated risk factors. METHODS: In a multicenter study at one university hospital, two community hospitals and one private hospital, all consecutive newly admitted adult patients were screened and included when reaching a Glasgow Coma Scale greater than 10. Nurse researchers assessed the patients for delirium using the NEECHAM Confusion Scale. Risk factors covered four domains: patient characteristics, chronic pathology, acute illness and environmental factors. Odds ratios were calculated using univariate binary logistic regression. RESULTS: A total population of 523 patients was screened for delirium. The studied factors showed some variability according to the participating hospitals. The overall delirium incidence was 30 %. Age was not a significant risk factor. Intensive smoking (OR 2.04), daily use of more than three units of alcohol (OR3.23) and living single at home (OR 1.94), however, contributed to the development of delirium. In the domain of chronic pathology a pre-existing cognitive impairment was an important a risk factor (OR 2.41). In the domain of factors related to acute illness the use of drains, tubes and catheters, acute illness scores, the use of psychoactive medication, a preceding period of sedation, coma or mechanical ventilation showed significant risk with odds ratios ranging from 1.04 to 13.66. Environmental risk factors were isolation (OR 2.89), the absence of visit (OR 3.73), the absence of visible daylight (OR 2.39), a transfer from another ward (OR 1.98) and the use of physical restraints (OR 33.84). CONCLUSIONS: This multicenter study indicated risk factors for delirium in the intensive care unit related to patient characteristics, chronic pathology, acute illness and the environment. Particularly among those related to the acute illness and the environment, several factors are suitable for preventive action.

PMID: 19457226 [PubMed - as supplied by publisher]

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Early drotrecogin alpha (activated) administration in severe sepsis is associated with lower mortality: a retrospective analysis of the Canadian ENHANCE cohort.

Crit Care. 2009 May 20;13(3):R78

Authors: Hodder RV, Hall R, Russell JA, Fisher HN, Lee B

ABSTRACT: INTRODUCTION: Early multimodal treatment of severe sepsis, including the use of drotrecogin alfa (activated) (DrotAA) when indicated, is considered essential for optimum outcome. However, predicting which infected patients will progress to severe sepsis and the need for aggressive intervention continues to be problematic. We therefore wished to explore whether there were any potential early markers that might predict improved survival in response to early use of DrotAA in patients with severe sepsis. In particular, in the dynamic setting of severe sepsis, we postulated that changes in markers reflecting evolving, rather than baseline, clinical status might guide therapy. METHODS: Data on a cohort of 305 Canadian patients from the open label ENHANCE trial of DrotAA in severe sepsis was retrospectively analyzed to search for potential clinical predictors of outcome in severe sepsis. Patients received a 96-hour infusion of DrotAA and were followed for 28 days. The association between time to treatment and mortality within subgroups defined by dynamic changes in various potential markers was explored. RESULTS: Mortality at 28 days was 22.6% and the variables of age, time to treatment, and early changes in serum creatinine and platelet count were identified by logistic regression as independent predictors of mortality. Across all age ranges, 28-day mortality was lower when DrotAA was administered within 24 hours of first sepsis-induced organ dysfunction compared to administration after 24 hours for both subgroups of patients defined by changes in platelet count and creatinine within the first day. CONCLUSIONS: These findings suggest that when indicated, treatment with DrotAA should be initiated as soon as possible, regardless of age. Previous trial registration number: NCT00568893.

PMID: 19457240 [PubMed - as supplied by publisher]

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Low-Molecular-Weight Heparins in Renal Impairment and Obesity: Available Evidence and Clinical Practice Recommendations Across Medical and Surgical Settings (June) (CE).

Ann Pharmacother. 2009 May 19;

Authors: Nutescu EA, Spinler SA, Wittkowsky A, Dager WE

OBJECTIVE: To develop practical recommendations for the use of low-molecular-weight heparins (LMWHs) as prophylaxis and treatment of venous thromboembolism and acute coronary syndromes in patients with impaired renal function or obesity. DATA SOURCES: Multiple MEDLINE searches were performed (November 2008) to identify studies for inclusion, using a comprehensive list of search terms including, but not limited to, LMWH, enoxaparin, dalteparin, tinzaparin, obesity, weight, renal, kidney, elderly, monitoring, and anti-Xa. STUDY SELECTION AND DATA EXTRACTION: Only articles published in English that were relevant for this review were included. DATA SYNTHESIS: In the majority of patients, standardized prophylaxis or treatment doses of LMWHs can be used without the need for monitoring and adjusting regimens. For patients with severe renal impairment (estimated creatinine clearance [CrC1] <30 mL/min), doses of some LMWHs should be adjusted or unfractionated heparin should be used instead. CrCl should be estimated using the Cockcroft-Gault method. Differences are noted in the degree of accumulation of various LMWHs in patients with moderate-to-severe renal impairment, and thus, the degree of dose adjustment may differ among the various LMWHs. Increasing the prophylactic doses of LMWH may be appropriate in morbidly obese patients (body mass index >/=40 kg/m(2)). The use of total body weight is appropriate for therapeutic doses of LMWH in obese patients. Laboratory monitoring of the anticoagulation effect of LMWHs is generally not necessary, but should be considered in patients with morbid obesity (weight >190 kg), those with severe renal impairment, and those with moderate renal impairment with prolonged (>10 days) LMWH use. When anti-Xa activity is monitored, it should be determined using a chromogenic method and a calibration curve based on the LMWH used. CONCLUSIONS: Additional data are needed for specific dose guiding in obese and renally impaired patients, who are often excluded from larger clinical trials. Practice recommendations are made based on available evidence and authors' clinical opinions.

PMID: 19458109 [PubMed - as supplied by publisher]

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Clinical practice of obtaining blood cultures from patients with a central venous catheter in place: an international survey.

Clin Microbiol Infect. 2009 May 16;

Authors: Falagas ME, Ierodiakonou V, Alexiou VG

Clin Microbiol InfectAbstract Several aspects of the procedure for obtaining blood cultures are rather controversial. An international survey among 386 experts was performed to investigate the clinical practice of obtaining blood cultures from patients with a central venous catheter (CVC). Among respondents, 64.5% obtain one set of blood cultures from the CVC and one set from the peripheral vein (PV). Other participants answered ‘two sets from PV’, ‘two sets from CVC’, ‘one from PV’, ‘one from CVC’ and ‘other’ (9.1%, 4.1%, 8.3%, 7%, and 7%, respectively). Clinicians who, according to the survey, demonstrated that they know the diagnostic performance characteristics of cultures more often obtain one culture from the CVC and one from the PV (73.9% vs. 61.7%, p 0.037).

PMID: 19456826 [PubMed - as supplied by publisher]

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Early versus delayed invasive intervention in acute coronary syndromes.

N Engl J Med. 2009 May 21;360(21):2165-75

Authors: Mehta SR, Granger CB, Boden WE, Steg PG, Bassand JP, Faxon DP, Afzal R, Chrolavicius S, Jolly SS, Widimsky P, Avezum A, Rupprecht HJ, Zhu J, Col J, Natarajan MK, Horsman C, Fox KA, Yusuf S,

BACKGROUND: Earlier trials have shown that a routine invasive strategy improves outcomes in patients with acute coronary syndromes without ST-segment elevation. However, the optimal timing of such intervention remains uncertain. METHODS: We randomly assigned 3031 patients with acute coronary syndromes to undergo either routine early intervention (coronary angiography < or = 24 hours after randomization) or delayed intervention (coronary angiography > or = 36 hours after randomization). The primary outcome was a composite of death, myocardial infarction, or stroke at 6 months. A prespecified secondary outcome was death, myocardial infarction, or refractory ischemia at 6 months. RESULTS: Coronary angiography was performed in 97.6% of patients in the early-intervention group (median time, 14 hours) and in 95.7% of patients in the delayed-intervention group (median time, 50 hours). At 6 months, the primary outcome occurred in 9.6% of patients in the early-intervention group, as compared with 11.3% in the delayed-intervention group (hazard ratio in the early-intervention group, 0.85; 95% confidence interval [CI], 0.68 to 1.06; P=0.15). There was a relative reduction of 28% in the secondary outcome of death, myocardial infarction, or refractory ischemia in the early-intervention group (9.5%), as compared with the delayed-intervention group (12.9%) (hazard ratio, 0.72; 95% CI, 0.58 to 0.89; P=0.003). Prespecified analyses showed that early intervention improved the primary outcome in the third of patients who were at highest risk (hazard ratio, 0.65; 95% CI, 0.48 to 0.89) but not in the two thirds at low-to-intermediate risk (hazard ratio, 1.12; 95% CI, 0.81 to 1.56; P=0.01 for heterogeneity). CONCLUSIONS: Early intervention did not differ greatly from delayed intervention in preventing the primary outcome, but it did reduce the rate of the composite secondary outcome of death, myocardial infarction, or refractory ischemia and was superior to delayed intervention in high-risk patients. (ClinicalTrials.gov number, NCT00552513.)

PMID: 19458363 [PubMed - in process]

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Cost Implications of Reduced Work Hours and Workloads for Resident Physicians.

N Engl J Med. 2009 May 21;360(21):2202-2215

Authors: Nuckols TK, Bhattacharya J, Wolman DM, Ulmer C, Escarce JJ

BACKGROUND: Although the Accreditation Council for Graduate Medical Education (ACGME) limits the work hours of residents, concerns about fatigue persist. A new Institute of Medicine (IOM) report recommends, among other changes, improved adherence to the 2003 ACGME limits, naps during extended shifts, a 16-hour limit for shifts without naps, and reduced workloads. METHODS: We used published data to estimate labor costs associated with transferring excess work from residents to substitute providers, and we examined the effects of our assumptions in sensitivity analyses. Next, using a probability model to represent labor costs as well as mortality and costs associated with preventable adverse events, we determined the net costs to major teaching hospitals and cost-effectiveness across a range of hypothetical changes in the rate of preventable adverse events. RESULTS: Annual labor costs from implementing the IOM recommendations were estimated to be $1.6 billion (in 2006 U.S. dollars) across all ACGME-accredited programs ($1.1 billion to $2.5 billion in sensitivity analyses). From a 10% decrease to a 10% increase in preventable adverse events, net costs per admission ranged from $99 to $183 for major teaching hospitals and from $17 to $266 for society. With 2.5% to 11.3% decreases in preventable adverse events, costs to society per averted death ranged from $3.4 million to $0. CONCLUSIONS: Implementing the four IOM recommendations would be costly, and their effectiveness is unknown. If highly effective, they could prevent patient harm at reduced or no cost from the societal perspective. However, net costs to teaching hospitals would remain high. Copyright 2009 Massachusetts Medical Society.

PMID: 19458365 [PubMed - as supplied by publisher]

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To nap or not to nap? Residents’ work hours revisited.

N Engl J Med. 2009 May 21;360(21):2242-4

Authors: Blanchard MS, Meltzer D, Polonsky KS

PMID: 19458371 [PubMed - in process]

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Validation of self-reported chronic obstructive pulmonary disease among patients in the ED.

Am J Emerg Med. 2009 Feb;27(2):191-6

Authors: Radeos MS, Cydulka RK, Rowe BH, Barr RG, Clark S, Camargo CA

BACKGROUND: To determine whether the self-reported diagnosis of adults who present to the emergency department (ED) with an acute exacerbation of either asthma or chronic obstructive pulmonary disease (COPD) is validated by medical record review. METHODS: This is cross-sectional study of 78 consecutive adults, 55 years and older, presenting to 3 EDs with symptoms suggestive of an exacerbation of asthma or COPD. We used current spirometric guidelines for a "spirometrically validated" diagnosis of COPD (eg, postbronchodilator forced expiratory volume in 1 second/forced ventilatory capacity <70%). Patients without office spirometry result were classified with COPD using clinical validation based on at least one of the following: primary care physician diagnosis of COPD, chronic bronchitis, or emphysema in the medical record or chest radiography, chest computed tomography, or arterial blood gas (ABG) diagnostic of COPD. RESULTS: Among 60 patients who self-reported diagnosis of COPD, 98% (95% confidence interval, 89-100) had clinically validated or spirometrically validated COPD. In addition, 83% (95% confidence interval, 59-96) of patients who reported either asthma only or no respiratory disease had clinically validated or spirometrically validated COPD. In no case was the chest radiograph or the ABG useful as a stand-alone test in establishing the diagnosis of COPD. CONCLUSIONS: Patients 55 years and older presenting to the ED with acute asthma or COPD, even those with clinical symptoms but no diagnosis of COPD, are likely to have COPD. Clinicians should maintain a high index of suspicion for COPD when older asthma patients deny COPD.

PMID: 19371527 [PubMed - indexed for MEDLINE]

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Comparative study of omeprazole, lansoprazole, pantoprazole and esomeprazole for symptom relief in patients with reflux esophagitis.

World J Gastroenterol. 2009 Feb 28;15(8):990-5

Authors: Zheng RN

AIM: To clarify whether there is any difference in the symptom relief in patients with reflux esophagitis following the administration of four Proton pump inhibitors (PPIs). METHODS: Two hundred and seventy-four patients with erosive reflux esophagitis were randomized to receive 8 wk of 20 mg omeprazole (n = 68), 30 mg of lansoprazole (n = 69), 40 mg of pantoprazole (n = 69), 40 mg of esomeprazole (n = 68) once a day in the morning. Daily changes in heartburn and acid reflux symptoms in the first 7 d of administration were assessed using a six-point scale (0: none; 1: mild; 2: mild-moderate; 3: moderate; 4: moderate-severe; 5: severe). RESULTS: The mean heartburn score in patients treated with esomeprazole more rapidly decreased than those receiving other PPI. Complete resolution of heartburn was also more rapid in patients treated with esomeprazole for 5 d compared with omeprazole (P = 0.0018, P = 0.0098, P = 0.0027, P = 0.0137, P = 0.0069, respectively), lansoprazole (P = 0.0020, P = 0.0046, P = 0.0037, P = 0.0016, P = 0.0076, respectively), and pantoprazole (P = 0.0006, P = 0.0005, P = 0.0009, P = 0.0031, P = 0.0119, respectively). There were no significant differences between the four groups in the rate of endoscopic healing of reflux esophagitis at week 8. CONCLUSION: Esomeprazole may be more effective than omeprazole, lansoprazole, and pantoprazole for the rapid relief of heartburn symptoms and acid reflux symptoms in patients with reflux esophagitis.

PMID: 19248200 [PubMed - indexed for MEDLINE]

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Further evidence for infection of pigs with human-like H1N1 influenza viruses in China.

Virus Res. 2009 Mar;140(1-2):85-90

Authors: Yu H, Zhou YJ, Li GX, Zhang GH, Liu HL, Yan LP, Liao M, Tong GZ

Classical swine and avian-like H1N1 influenza viruses were reported widely in swine population worldwide, but human-like H1N1 swine viruses were reported occasionally. In 2006, a human-like H1N1 swine virus (A/swine/Guangdong/96/06) was isolated from pigs in Guangdong province, which was reported in China for the first time. To get further evidence for infection of pigs with human-like H1N1 influenza viruses, we analyzed eight gene segments of three human-like swine H1N1 viruses (A/swine/Guangdong/96/06, A/swine/Tianjin/01/04 and A/swine/Henan/01/06) isolated in China. All the eight genes of the three viruses are highly homologous to recent (about 2000) and early (1980s) human H1N1 influenza viruses, respectively. Phylogenetic analyses revealed that A/Swine/Guangdong/96/06 was directly derived from about 2000 human H1N1 influenza viruses, while A/swine/Tianjin/01/04 and A/swine/Henan/01/06 seemed to be descendants of human H1N1 viruses circulating in 1980s. Seroprevalence of our isolate (A/swine/Guangdong/96/06) confirmed the presence of human-like H1N1 virus in pigs in China. Existence of these influenza viruses, especially older viruses (A/swine/Tianjin/01/04 and A/swine/Henan/01/06), indicates that human-like H1N1 influenza viruses may remain invariant for long periods in pigs and provides the evidence that pigs serve as reservoirs of older influenza viruses for human pandemics.

PMID: 19063926 [PubMed - indexed for MEDLINE]

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Are hospitals too clean to trigger good hand hygiene?

J Hosp Infect. 2009 May 13;

Authors: van der Vegt DS, Voss A

Compliance with hand hygiene in the healthcare setting is generally low. The aim of the present study was to investigate the degree of compliance with hand hygiene after toilet visits inside and outside the hospital. We observed hospital/laboratory staff, participants of the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) 2007, and users of public lavatories. Compliance with hand hygiene after toilet visits was 46% for hospital staff, 84% for conference participants and 75% for members of the public. Healthcare workers show different behaviour regarding hand hygiene inside and outside the healthcare setting. Perhaps the feeling of a ‘miasmic’ environment such as public toilets triggers better hand hygiene, whereas the relatively clean hospital environment may block the trigger for hand disinfection.

PMID: 19446365 [PubMed - as supplied by publisher]

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