2011 November 18

Duration of antibiotic therapy for bacteremia: a systematic review and meta-analysis.

Nov 182011

Duration of antibiotic therapy for bacteremia: a systematic review and meta-analysis.

Crit Care. 2011 Nov 15;15(6):R267

Authors: Havey TC, Fowler R, Daneman N

Abstract
ABSTRACT: INTRODUCTION: The optimal duration of antibiotic therapy for bloodstream infections is unknown. Shorter durations of therapy have been demonstrated to be as effective as longer durations for many common infections; similar findings in bacteremia could enable hospitals to reduce antibiotic utilization, adverse events, resistance and costs. METHODS: A search of the MEDLINE, EMBASE and COCHRANE databases was conducted for the years 1947-2010. Controlled trials were identified that randomized patients to shorter versus longer durations of treatment for bacteremia, or the infectious foci most commonly causing bacteremia in critically ill patients (catheter-related bloodstream infections (CRBSI), intra-abdominal infections, pneumonia, pyelonephritis and skin and soft-tissue infections (SSTI)). RESULTS: 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). CONCLUSIONS: No significant differences in clinical cure, microbiologic cure and survival were detected among bacteremic patients receiving shorter versus longer duration antibiotic therapy. An adequately powered randomized trial of bacteremic patients is needed to confirm these findings.

PMID: 22085732 [PubMed - as supplied by publisher]

Link to Article at PubMed

Reduction in hospital-wide mortality following implementation of a rapid response team: a long-term cohort study.

Crit Care Start a Discussion »

Nov 182011

Reduction in hospital-wide mortality following implementation of a rapid response team: a long-term cohort study.

Crit Care. 2011 Nov 15;15(6):R269

Authors: Beitler JR, Link N, Bails DB, Hurdle K, Chong DH

Abstract
ABSTRACT: INTRODUCTION: Rapid response teams (RRTs) have been shown to reduce cardiopulmonary arrests outside the intensive care unit (ICU). Yet the utility of RRTs remains in question, as most large studies have failed to demonstrate a significant reduction in hospital-wide mortality following RRT implementation. METHODS: A cohort design with historical controls was used to determine the effect on hospital-wide mortality of an RRT in which clinical judgment, in addition to vital signs criteria, was widely promoted as a key trigger for activation. All non-prisoner patients admitted to a tertiary referral public teaching hospital from 2003 through 2008 were included. A total of 77,021 admissions preintervention (2003 through 2005) and 79,013 admissions postintervention (2006 through 2008) were evaluated. The a priori primary outcome was unadjusted hospital-wide mortality. A Poisson regression model was then used to adjust for hospital-wide mortality trends over time. Secondary outcomes defined a priori were unadjusted out-of-ICU mortality and out-of-ICU cardiopulmonary arrest codes. RESULTS: A total of 855 inpatient RRTs (10.8 per 1,000 hospital-wide discharges) were activated during the three-year postintervention period. Forty-seven percent of RRTs were activated for reasons of clinical judgment. Hospital-wide mortality decreased from 15.50 to 13.74 deaths per 1,000 discharges following RRT implementation (relative risk 0.887, 95% CI 0.817-0.963; p=0.004). After adjusting for inpatient mortality trends over time, the reduction in hospital-wide mortality remained statistically significant (relative risk 0.825, 95% CI 0.694-0.981; p=0.029). Out-of-ICU mortality decreased from 7.08 to 4.61 deaths per 1,000 discharges (relative risk 0.651, 95% CI 0.570-0.743; p<0.001). Out-of-ICU cardiopulmonary arrest codes decreased from 3.28 to 1.62 codes per 1,000 discharges (relative risk 0.493, 95% CI 0.399-0.610; p<0.001). CONCLUSIONS: Implementation of an RRT in which clinical judgment, in addition to vital signs criteria, was widely cited as a rationale for activation was associated with a significant reduction in hospital-wide mortality, out-of-ICU mortality, and out-of-ICU cardiopulmonary arrest codes. The frequent use of clinical judgment as a criterion for RRT activation was associated with high RRT utilization.

PMID: 22085785 [PubMed - as supplied by publisher]

Link to Article at PubMed

Potentially preventable hospitalizations among older adults with diabetes.

Am J Manag Care Start a Discussion »

Nov 182011

Potentially preventable hospitalizations among older adults with diabetes.

Am J Manag Care. 2011;17(11):e419-e426

Authors: Kim H, Helmer DA, Zhao Z, Boockvar K

Abstract
Objectives: To examine prevalence of and factors associated with different types of potentially preventable hospitalizations (PPHs) among older adults with diabetes. Study Design: Population-based secondary analysis. Methods: We analyzed the California State Inpatient Databases, 2005 to 2006. PPHs for 3 acute and 5 chronic ambulatory care-sensitive conditions relevant for older adults were defined by applying the Prevention Quality Indicator algorithm developed by the Agency for Health Research and Quality. Prevalence and costs of PPHs for acute conditions (acute PPHs) and chronic conditions (chronic PPHs) were examined. Associations of sociodemographic and health-related factors as well as hospitalization history with both types of PPH were estimated. Results: One-fifth of 555,538 hospitalizations of adults 65 years and older with diabetes were PPHs. Of these, 43.7% were acute PPHs and 56.3% were chronic PPHs. The total hospital cost associated with these PPHs was more than $1.1 billion. Having Medi-Cal as the primary payer and hospitalization through the emergency department were positively associated with both types of PPH. Acute PPH rates were lower, but chronic PPH rates were higher, among blacks, patients with multiple chronic conditions, and those with previous admission(s) in the same year. Conclusions: PPHs for common medical conditions are costly and prevalent among older patients with diabetes, suggesting a need for more comprehensive primary care, beyond glycemic control. The groups at risk for acute and chronic PPHs may differ, which suggests that more targeted and tailored approaches are necessary to reduce the rates of each type of PPH.

PMID: 22084920 [PubMed - as supplied by publisher]

Link to Article at PubMed

Comparison of Outcomes of Patients With Painless Versus Painful ST-Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention.

Am J Cardiol Start a Discussion »

Nov 182011

Comparison of Outcomes of Patients With Painless Versus Painful ST-Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention.

Am J Cardiol. 2011 Nov 14;

Authors: Cho JY, Jeong MH, Ahn YK, Kim JH, Chae SC, Kim YJ, Hur SH, Seong IW, Hong TJ, Choi DH, Cho MC, Kim CJ, Seung KB, Chung WS, Jang YS, Cho SY, Rha SW, Bae JH, Cho JG, Park SJ

Abstract
There are few data available on the prognosis of painless ST-segment elevation myocardial infarction (STEMI). The aim of this study was to determine the incidence, clinical characteristics, and outcomes of painless STEMI. We analyzed the Korea Acute Myocardial Infarction Registry (KAMIR) study, which enrolled 7,288 patients with STEMI (61.8 ± 12.8 years old, 74% men; painless STEMI group, n = 763; painful STEMI group, n = 6,525). End points were in-hospital mortality and 1-year major adverse cardiac events (MACEs). Patients with painless STEMI were older and more likely to be women, nonsmokers, diabetic, and normolipidemic and to have a higher Killip class. The painless group had more in-hospital deaths (5.9% vs 3.6%, p = 0.026) and 1-year MACEs (26% vs 19%, p = 0.002). In Cox proportional hazards analysis, hypotension (hazard ratio [HR] 4.40, 95% confidence interval [CI] 1.41 to 13.78, p = 0.011), low left ventricular ejection fraction (HR 3.12, 95% CI 1.21 to 8.07, p = 0.019), and a high Killip class (HR 3.48, 95% CI 1.19 to 10.22, p = 0.023) were independent predictors of 1-year MACEs in patients with painless STEMI. In conclusion, painless STEMI was associated with more adverse outcomes than painful STEMI and late detection may have contributed significantly to total ischemic burden. These results warrant more investigations for methodologic development in the diagnosis of silent ischemia and painless STEMI.

PMID: 22088201 [PubMed - as supplied by publisher]

Link to Article at PubMed

PS2-23: Reducing Rehospitalization in Survivors of Critical Illness: Description of a Novel Interventional Strategy.

Clin Med Res Start a Discussion »

Nov 182011

PS2-23: Reducing Rehospitalization in Survivors of Critical Illness: Description of a Novel Interventional Strategy.

Clin Med Res. 2011 Nov;9(3-4):157

Authors: Jones S

Abstract
Background/Aims Older patients who survive a critical illness are at increased risk for mortality and rehospitalization. Ten percent of ICU survivors discharged to home are rehospitalized within a week, and nearly one-third are readmitted within 180 days. Contributors to these negative outcomes may include complex discharge plans, unrecognized ICU-associated illnesses and separation of inpatient and outpatient medicine through shorter outpatient visits and the hospitalist movement. These factors contribute to the challenges of care transitions and further limit the care coordination of the ICU survivor with complex medical problems. The purpose of the project is to pilot a model of transitional care for older ICU survivors. We propose an innovative model of transitional care for older ICU survivors that has the potential to reduce rehospitalization rates, improve morbidity and decrease risk of mortality. Methods We will target patients 55 years of age or older who have survived a critical illness in the medical ICU and are to be discharged home. We will exclude patients who are unwilling or unable to assume patient responsibilities. Patients (and caregivers) will be empowered through the support of a transitional coach who encourages the patient and caregiver to have a more active role in the health of the patient. Such efforts include medication reconciliation, identification of patient-selected goals, and education about self-management and communication of medical issues. The ICU Survivors Follow-up Care Clinic will be created to address ICU-specific issues that we believe may contribute to the negative outcomes of critical illness. Through these two interventions, we will create a detailed care plan and deliver a coordinated handoff to the primary care physician. Results The project will be evaluated for feasibility and effectiveness using the RE-AIM framework. We will conduct cost analysis to determine the long term sustainability of the program. Conclusions Older ICU survivors are at risk of hospital readmissions for many reasons. A novel program that integrates patient empowerment and early recognition and follow-up of ICU associated illness may impact these negative outcomes.

PMID: 22090566 [PubMed - as supplied by publisher]

Link to Article at PubMed

The use of insulin in elderly patients with type 2 diabetes mellitus.

Expert Opin Pharmacother Start a Discussion »

Nov 182011

The use of insulin in elderly patients with type 2 diabetes mellitus.

Expert Opin Pharmacother. 2011 Nov 16;

Authors: Mannucci E, Cremasco F, Romoli E, Rossi A

Abstract
Introduction: Older patients with diabetes sometimes present comorbidities that increase the risk of other common geriatric syndromes. In such patients, treatment with insulin is usually started when full doses of oral hypoglycemic agents are no longer adequate to achieve acceptable glycemic control. Areas covered: This article reviews the available literature on the use of insulin in elderly patients with type 2 diabetes. The aims are to gain information on: the benefits and risks of initiating insulin treatment, the efficacy and safety of different types of insulin and the most appropriate initial dosing and titration regimens. Thirteen published trials have evaluated the effects of different insulin regimens in the management of elderly subjects with type 2 diabetes but, given that older people are generally excluded in clinical studies with insulin, only three published reports on subgroup analyses are limited to elderly patients. Expert opinion: The available literature shows that the addition of insulin to current oral treatments is generally safe and effective in improving metabolic control, with a low risk for hypoglycemia. Further research is needed to better understand the most appropriate insulin regimens necessary to achieve glycemic goals while appropriately addressing the risk of hypoglycemia.

PMID: 22087577 [PubMed - as supplied by publisher]

Link to Article at PubMed

Older Entries

November 2011
M	T	W	T	F	S	S
« Oct				Dec »
	1	2	3	4	5	6
7	8	9	10	11	12	13
14	15	16	17	18	19	20
21	22	23	24	25	26	27
28	29	30