2011 December 07

Contrast-induced nephropathy: controlled study by differential GFR measurement in hospitalized patients.

Dec 072011

Contrast-induced nephropathy: controlled study by differential GFR measurement in hospitalized patients.

Acta Radiol. 2011 Dec 2;

Authors: Erselcan T, Egilmez H, Hasbek Z, Tandogan I

Abstract
BackgroundWithout appropriate control measures, contrast-induced nephropathy (CIN) incidence has been claimed to be overestimated.PurposeTo evaluate the relationship and the difference between differential serum creatinine (DsCr), which is currently surrogating as a marker of CIN, and measured differential GFR values as a control measure (DGFR) in hospitalized patients.Material and MethodsGFR was measured two times by Tc-99m DTPA, before and 48 h after contrast media (CM), along with sCr and BUN in 35 inpatients (22 men, 13 women, mean age ± SD = 61 ± 14) with no known chronic kidney disease.ResultsRelationship was moderate between GFR and sCr (R = 0.50, P < 0.01) in the study population. Pre-CM vs. post-CM values of GFR, sCr and BUN were not statistically different as (mean ± SD); 78 ± 36 vs. 73 ± 35 mL/min/1.73m(2), 0.95 ± 0.26 vs. 0.94 ± 0.26 mg/dl and 21 ± 16 vs. 19 ± 13 mg/dl, respectively, in the study group. According to basal GFR values, 14 patients (40%) seemed carrying risk of CIN (GFR < 60 mL/min/1.73m(2)) in whom only two had sCr >1.5 mg/dl. Twenty-five patients (71%) had discordant results in relation to DsCr and DGFR and two of them had CIN according to classical definition of DsCr, although having basal sCr <1.1 mg/dl. Yet, both had low, but stable GFR values. None of patient from the study group underwent hemodialysis.ConclusionSignificant discordance was observed between differential serum creatinine and measured differential GFR in hospitalized patients, suggesting that CIN incidence calculations only based on hospital registry may carry risk of error.

PMID: 22139722 [PubMed - as supplied by publisher]

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A Retrospective Comparison of Ceftriaxone Versus Oxacillin for Osteoarticular Infections Due to Methicillin-Susceptible Staphylococcus aureus.

Clin Infect Dis Start a Discussion »

Dec 072011

A Retrospective Comparison of Ceftriaxone Versus Oxacillin for Osteoarticular Infections Due to Methicillin-Susceptible Staphylococcus aureus.

Clin Infect Dis. 2011 Dec 5;

Authors: Wieland BW, Marcantoni JR, Bommarito KM, Warren DK, Marschall J

Abstract
Background.?Antistaphylococcal penicillins are the treatment of choice for methicillin-susceptible Staphylococcus aureus (MSSA) infection. Ceftriaxone can be dosed once daily and is less expensive for outpatient therapy than oxacillin. We compared patient outcomes of MSSA osteoarticular infections treated with ceftriaxone versus oxacillin.Methods.?We conducted a retrospective cohort study of patients with MSSA osteoarticular infections at a tertiary care hospital from January 2005 to April 2010. We collected demographic, clinical, and outcome data including treatment-related adverse events. Successful treatment (clinical improvement; improved follow-up markers and imaging; no readmission for treatment) was compared at 3-6 months and >6 months after completion of intravenous antibiotics.Results.?In total, 124 patients had an MSSA osteoarticular infection; 64 (52%) had orthopedic hardware involvement. Of those patients, 74 (60%) received ceftriaxone and 50 (40%) received oxacillin. Oxacillin was more often discontinued due to toxicity (9 of 50 [18%] oxacillin vs 3 of 74 [4%] ceftriaxone; P = .01). At 3-6 and >6 months, data for 97 and 88 patients, respectively, were available for analysis. Treatment success was similar at 3-6 months (50 of 60 [83%] ceftriaxone vs 32 of 37 [86%] oxacillin; P = .7) and >6 months (43 of 56 [77%] ceftriaxone vs 26 of 32 [81%] oxacillin; P = .6). After intravenous antibiotics, 56 (45%) patients received long-term suppression with oral antibiotics (31 of 74 [42%] ceftriaxone vs 25 of 50 [50%] oxacillin; P = .4).Conclusions.?In this comparison of ceftriaxone versus oxacillin for MSSA osteoarticular infections, there was no difference in treatment success at 3-6 and >6 months following the completion of intravenous antibiotics. Patients receiving oxacillin were more likely to have it discontinued due to toxicity.

PMID: 22144536 [PubMed - as supplied by publisher]

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The effect of hospital-acquired infection with Clostridium difficile on length of stay in hospital.

CMAJ Start a Discussion »

Dec 072011

The effect of hospital-acquired infection with Clostridium difficile on length of stay in hospital.

CMAJ. 2011 Dec 5;

Authors: Forster AJ, Taljaard M, Oake N, Wilson K, Roth V, van Walraven C

Abstract
BACKGROUND:The effect of hospital-acquired infection with Clostridium difficile on length of stay in hospital is not yet fully understood. We determined the independent impact of hospital-acquired infection withC. difficile on length of stay in hospital. METHODS:We conducted a retrospective observational cohort study of admissions to hospital between July 1, 2002, and Mar. 31, 2009, at a single academic hospital. We measured the association between infection with hospital-acquired C. difficile and time to discharge from hospital using Kaplan-Meier methods and a Cox multivariable proportional hazards regression model. We controlled for baseline risk of death and accounted for C. difficile as a time-varying effect. RESULTS:Hospital-acquired infection with C. difficile was identified in 1393 of 136 877 admissions to hospital (overall risk 1.02%, 95% confidence interval [CI] 0.97%-1.06%). The crude median length of stay in hospital was greater for patients with hospital-acquired C. difficile (34 d) than for those without C. difficile (8 d). Survival analysis showed that hospital-acquired infection with C. difficile increased the median length of stay in hospital by six days. In adjusted analyses, hospital-acquired C. difficile was significantly associated with time to discharge, modified by baseline risk of death and time to acquisition of C. difficile. The hazard ratio for discharge by day 7 among patients with hospital-acquired C. difficile was 0.55 (95% CI 0.39-0.70) for patients in the lowest decile of baseline risk of death and 0.45 (95% CI 0.32-0.58) for those in the highest decile; for discharge by day 28, the corresponding hazard ratios were 0.74 (95% CI 0.60-0.87) and 0.61 (95% CI 0.53-0.68). INTERPRETATION:Hospital-acquired infection with C. difficile significantly prolonged length of stay in hospital independent of baseline risk of death.

PMID: 22143235 [PubMed - as supplied by publisher]

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Preventing Hospital-Acquired Infections: A National Survey of Practices Reported by U.S. Hospitals in 2005 and 2009.

J Gen Intern Med Start a Discussion »

Dec 072011

Preventing Hospital-Acquired Infections: A National Survey of Practices Reported by U.S. Hospitals in 2005 and 2009.

J Gen Intern Med. 2011 Dec 6;

Authors: Krein SL, Kowalski CP, Hofer TP, Saint S

Abstract
BACKGROUND: Hospital-acquired infection (HAI) is common, costly, and potentially lethal. Whether initiatives to reduce HAI-such as the Centers for Medicare and Medicaid Services (CMS) no payment rule-have increased the use of preventive practices is not known. OBJECTIVE: To examine the use of infection prevention practices by U.S. hospitals and trends in use between 2005 and 2009. DESIGN, SETTING, AND PARTICIPANTS: Surveys of infection preventionists at non-federal general medical/surgical hospitals and Department of Veterans Affairs (VA) hospitals, which are not subject to the CMS no payment rule, in 2005 and 2009. MAIN MEASURES: Percent of hospitals using practices to prevent central line-associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), and catheter-associated urinary tract infection (CAUTI). KEY RESULTS: Survey response was approximately 70%. More than 1/2 of non-federal hospitals reported a moderate or large increase in CLABSI, VAP and CAUTI prevention as a facility priority due to the non-payment rule; over 60% of VA hospitals reported no change in priority. However, both non-federal and VA hospitals reported significant increases in use of most practices to prevent CLABSI, VAP and CAUTI from 2005 to 2009, with 90% or more using certain practices to prevent CLABSI and VAP in 2009. In contrast, only one CAUTI prevention practice was used by at least 50% of hospitals. CONCLUSIONS: Since 2005, use of key practices to prevent CLABSI, VAP and CAUTI has increased in non-federal and VA hospitals, suggesting that despite its perceived importance, the non-payment rule may not be the primary driver. Moreover, while 65% of non-federal hospitals reported a moderate or large increase in preventing CAUTI as a facility priority, prevention practice use remains low.

PMID: 22143455 [PubMed - as supplied by publisher]

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Fidaxomicin: In Clostridium difficile Infection.

Drugs Start a Discussion »

Dec 072011

Fidaxomicin: In Clostridium difficile Infection.

Drugs. 2011 Dec 24;71(18):2445-56

Authors: Duggan ST

Abstract
Fidaxomicin is a first-in-class macrocyclic antibacterial that primarily demonstrates activity against species of clostridia, predominantly Clostridium difficile, while having limited or no activity against normal faecal microflora. Fidaxomicin is minimally absorbed following oral administration and is excreted almost solely in the faeces. Fidaxomicin displayed a high level of antibacterial activity against C. difficile in vitro, with a minimum inhibitory concentration required to inhibit 90% of C. difficile strains of 0.125-0.5??g/mL, and was ?2- to 8-fold more active than vancomycin or metronidazole. Fidaxomicin demonstrated a prolonged postantibiotic effect against C. difficile relative to vancomycin and metronidazole. In two randomized, double-blind, phase III trials, oral fidaxomicin 200?mg every 12 hours for 10 days was no less effective than oral vancomycin 125?mg every 6 hours for 10 days in the treatment of C. difficile infection, based on noninferiority analyses of clinical cure rates (primary endpoint). Fidaxomicin therapy was associated with a significantly lower rate of recurrence, as well as a significantly higher rate of global cure (i.e. sustained clinical response; resolution of diarrhoea without recurrence) compared with vancomycin therapy in the two clinical trials. Fidaxomicin was generally well tolerated in patients with C. difficile infection, with a tolerability profile generally similar to that of vancomycin.

PMID: 22141387 [PubMed - in process]

Link to Article at PubMed

Triazole antifungal agents in invasive fungal infections: a comparative review.

Drugs Start a Discussion »

Dec 072011

Triazole antifungal agents in invasive fungal infections: a comparative review.

Drugs. 2011 Dec 24;71(18):2405-19

Authors: Lass-Flörl C

Abstract
Invasive fungal disease continues to be a problem associated with significant morbidity and high mortality in immunocompromised and, to a lesser extent, immunocompetent individuals. Triazole antifungals have emerged as front-line drugs for the treatment and prophylaxis of many systemic mycoses. Fluconazole plays an excellent role in prophylaxis, empirical therapy, and the treatment of both superficial and invasive yeast fungal infections. Voriconazole is strongly recommended for pulmonary invasive aspergillosis. Posaconazole shows a very wide spectrum of activity and its primary clinical indications are as salvage therapy for patients with invasive aspergillosis and prophylaxis for patients with neutropenia and haematopoietic stem-cell transplant recipients. Itraconazole also has a role in the treatment of fungal skin and nail infections as well as dematiaceous fungi and endemic mycoses. Fluconazole and voriconazole are well absorbed and exhibit high oral bioavailability, whereas the oral bioavailability of itraconazole and posaconazole is lower and more variable. Posaconazole absorption depends on administration with a high-fat meal or nutritional supplements. Itraconazole and voriconazole undergo extensive hepatic metabolism involving the cytochrome P450 system. The therapeutic window for triazoles is narrow, and inattention to their pharmacokinetic properties can lead to drug levels too low for efficacy or too high for good tolerability or safety. This makes these agents prime candidates for therapeutic drug monitoring (TDM). Target drug concentrations for voriconazole and itraconazole should be >1??g/mL and for posaconazole >1.5??g/mL for treatment. Blood should be drawn once the patient reaches steady state, which occurs after 5 and 7 days of triazole therapy. Routine TDM of fluconazole is not required given its highly favourable pharmacokinetic profile and wide therapeutic index. The aim of this review is to provide a brief update on the pharmacology, activity, clinical efficacy, safety and cost of triazole agents (itraconazole, fluconazole, voriconazole and posaconazole) and highlight the clinical implications of similarities and differences.

PMID: 22141384 [PubMed - in process]

Link to Article at PubMed

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