Archive for April 2, 2015

Practice guidelines for the management of infectious diarrhea.

Clinical infectious diseases FEB.1, 2001 V.32 N.3 P.331-51

Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV, Hennessy T, Griffin PM, DuPont H, Sack RB, Tarr P, Neill M, Nachamkin I, Reller LB, Osterholm MT, Bennish ML, Pickering LK, Infectious Diseases Society of America

1Division of Geographic and International Medicine, University of Virginia Health Sciences Center, Charlottesville, VA, USA. rlg9a@virginia.edu

The widening array of recognized enteric pathogens and the increasing demand for cost-containment sharpen the need for careful clinical and public health guidelines based on the best evidence currently available. Adequate fluid and electrolyte replacement and maintenance are key to managing diarrheal illnesses. Thorough clinical and epidemiological evaluation must define the severity and type of illness (e.g., febrile, hemorrhagic, nosocomial, persistent, or inflammatory), exposures (e.g., travel, ingestion of raw or undercooked meat, seafood, or milk products, contacts who are ill, day care or institutional exposure, recent antibiotic use), and whether the patient is immunocompromised, in order to direct the performance of selective diagnostic cultures, toxin testing, parasite studies, and the administration of antimicrobial therapy (the latter as for traveler’s diarrhea, shigellosis, and possibly Campylobacter jejuni enteritis). Increasing numbers of isolates resistant to antimicrobial agents and the risk of worsened illness (such as hemolytic uremic syndrome with Shiga toxin-producing Escherichia coli O157:H7) further complicate antimicrobial and antimotility drug use. Thus, prevention by avoidance of undercooked meat or seafood, avoidance of unpasteurized milk or soft cheese, and selected use of available typhoid vaccines for travelers to areas where typhoid is endemic are key to the control of infectious diarrhea….

PDF

http://cid.oxfordjournals.org/content/32/3/331.full.pdf+html

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April 2, 2015 at 5:02 pm

Antibiotic treatment strategies for community-acquired pneumonia in adults.

N Engl J Med APR.2, 2015 V.372  P.1312-1323

Douwe F. Postma, M.D., Cornelis H. van Werkhoven, M.D., Leontine J.R. van Elden, M.D., Ph.D., Steven F.T. Thijsen, M.D., Ph.D., Andy I.M. Hoepelman, M.D., Ph.D., Jan A.J.W. Kluytmans, M.D., Ph.D., Wim G. Boersma, M.D., Ph.D., Clara J. Compaijen, M.D., Eva van der Wall, M.D., Jan M. Prins, M.D., Ph.D., Jan J. Oosterheert, M.D., Ph.D., and Marc J.M. Bonten, M.D., Ph.D. for the CAP-START Study Group

BACKGROUND

The choice of empirical antibiotic treatment for patients with clinically suspected community-acquired pneumonia (CAP) who are admitted to non–intensive care unit (ICU) hospital wards is complicated by the limited availability of evidence. We compared strategies of empirical treatment (allowing deviations for medical reasons) with beta-lactam monotherapy, beta-lactam–macrolide combination therapy, or fluoroquinolone monotherapy.

METHODS

In a cluster-randomized, crossover trial with strategies rotated in 4-month periods, we tested the noninferiority of the beta-lactam strategy to the beta-lactam–macrolide and fluoroquinolone strategies with respect to 90-day mortality, in an intention-to-treat analysis, using a noninferiority margin of 3 percentage points and a two-sided 90% confidence interval.

RESULTS

A total of 656 patients were included during the beta-lactam strategy periods, 739 during the beta-lactam–macrolide strategy periods, and 888 during the fluoroquinolone strategy periods, with rates of adherence to the strategy of 93.0%, 88.0%, and 92.7%, respectively. The median age of the patients was 70 years. The crude 90-day mortality was 9.0% (59 patients), 11.1% (82 patients), and 8.8% (78 patients), respectively, during these strategy periods. In the intention-to-treat analysis, the risk of death was higher by 1.9 percentage points (90% confidence interval [CI], −0.6 to 4.4) with the beta-lactam–macrolide strategy than with the beta-lactam strategy and lower by 0.6 percentage points (90% CI, −2.8 to 1.9) with the fluoroquinolone strategy than with the beta-lactam strategy. These results indicated noninferiority of the beta-lactam strategy. The median length of hospital stay was 6 days for all strategies, and the median time to starting oral treatment was 3 days (interquartile range, 0 to 4) with the fluoroquinolone strategy and 4 days (interquartile range, 3 to 5) with the other strategies.

CONCLUSIONS

Among patients with clinically suspected CAP admitted to non-ICU wards, a strategy of preferred empirical treatment with beta-lactam monotherapy was noninferior to strategies with a beta-lactam–macrolide combination or fluoroquinolone monotherapy with regard to 90-day mortality. (Funded by the Netherlands Organization for Health Research and Development; CAP-START ClinicalTrials.gov number, NCT01660204.)

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1406330

April 2, 2015 at 10:19 am

Adipocytes Armed against Staphylococcus aureus

N Engl J Med April 2, 2015 V.372 P.1368-1370

Lloyd S. Miller, M.D., Ph.D.

From the Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore.

Staphylococcus aureus is a harmless commensal microorganism in the skin and mucosa. However, S. aureus is also a deadly pathogen responsible for the vast majority of skin infections.

Moreover, it causes pneumonia, sepsis, organ abscesses, endocarditis, and osteomyelitis.

In Alexander Fleming’s laboratory, in 1928, the golden-colored colonies of this gram-positive bacterium grew throughout a petri dish, except on an edge contaminated by the mold Penicillium notatum.

This led to Fleming’s discovery of penicillin, the golden age of antibiotic agents, and then the dreaded consequence of antibiotic resistance…..

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMcibr1500271

April 2, 2015 at 10:17 am


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