Infectious Disease and Sepsis

May 082011
 

Last month we reported the success of the MTB/RIF test in identifying tuberculosis when smears are negative, which occurs ~40% of the time in TB-HIV coinfection. Shah et al publish their success with the sputum MODS assay in an all-HIV clinic in South Africa. The MODS is a rapid (~7-day) culture that also identifies multi-drug resistant TB. The test was 85% sensitive [… read more]

May 072011
 

De Smet et al reheat the data from their 2009 NEJM study, in which they cluster-randomized and crossed-over 5,939 patients staying >48hrs in 13 Dutch ICUs to receive either 1) standard care; 2) selective oropharyngeal decontamination (topical amphotericin B, colistin, and tobramycin in the oropharynx), or 3) selective digestive tract decontamination (the same drugs in the mouth, stomach, [… read more]

May 022011
 

Databases suggest that 60-70% of patients with severe respiratory failure due to H1N1 received steroids. Brun-Buisson et al looked back at a French registry including 208 patients with H1N1 and ARDS, 83 of whom received steroids. They found a hazard ratio of 2.4 for death associated with steroid administration, rising to 2.8 after applying their propensity scoring [… read more]

Apr 262011
 

Four-drug therapy (RIPE) requires high patient commitment and imposes logistical demands on health systems in developing countries. Lienhardt et al report that a fixed-drug combination (FDC) of rifampin, isoniazid, pyrazinamide, and ethambutol was noninferior in producing negative cultures at 18 months compared to taking the drugs separately (both arms ~94% cure rate) in Africa, Asia and Latin [… read more]

Apr 242011
 

Maki et al randomized 407 patients at 25 dialysis units to have their catheters “locked” for up to 6 months with either heparin, or “C-MB-P solution” (citric acid, methylene blue, and propylparaben). The patients getting the antimicrobial potion had a 0.29 relative risk for bloodstream infection (BSI) without loss of catheter patency. (n=407) Crit Care Med 2011;39:613-620.

Apr 192011
 

A systematic review of 3 trials (n=337) by the Bed Head Elevation Study Group (not to be confused with the Bedhead photo group) found no good evidence that head-of-bed (HOB) elevation to 45′ helps or harms in any way (pneumonia, decubiti, mortality, VTE, or hemodynamic instability). Nevertheless, a consensus panel of 22 experts agrees with previous [… read more]

Apr 182011
 

The MTB/RIF test is a rapid nucleic acid amplification test for TB. In a rollout in developing countries on 6,648 patients, the test was 90% sensitive for active TB, vs. 67% for smear microscopy (sputum culture was the gold standard). In smear-negative, culture-positive TB, the test was 77% sensitive and 99% specific. It also accurately detects rifampin [… read more]

Apr 182011
 

After implementing an “MRSA bundle” in 2007 including nasal surveillance, contact precautions for positive patients, hand hygiene, and culture-indoctrination of employees, MRSA infections among all VA hospital ICUs fell from 1.64 to 0.62 per 1000 patient-days (a 62% reduction, p<0.001). MRSA infections on the wards fell from 0.47 to 0.26 per 1000 patient-days (45% reduction, [… read more]

Apr 182011
 

Huskins et al cluster-randomized 18 ICUs to an intervention of surveillance cultures with contact precautions for positive patients, or a control of no cultures and universal precautions (gloves). The intervention ICUs used contact precautions more frequently (51% vs. 38%), but had the same MRSA/VRE colonization/infection rates, the primary endpoint (40 vs 35%, p=0.35). Clinician compliance [… read more]

Apr 172011
 

Overt vancomycin resistance in MRSA is still unusual, but ID docs are worried about the bug’s rising minimum inhibitory concentrations in some regions, with MICs > 1 mcg/mL associated with worse outcomes. Kullar et al retrospectively looked at Detroit’s Henry Ford Hospital’s 5-year micro data in 320 patients with MRSA bacteremia, reporting a 52% rate [… read more]

Apr 162011
 

Death, long hospital stays, and treatment failures are more likely when vancomycin is used for MRSA bacteremia with minimum inhibitory concentrations (MIC) > 1 mcg/mL. Lubin et al propose a clinical prediction rule to predict relative vancomycin resistance, based on a retrospective analysis of 272 patients with MRSA bacteremia at Tufts. Oversimplifying slightly: Having less [… read more]

Apr 152011
 

Patel et al ran 9,999 computer simulations using various vancomycin doses and MICs. When the MIC was 2.0 or greater, 2 g IV q12 hours failed to achieve target drug levels 57% of the time, with 35% predicted nephrotoxicity. But…it’s also true that multiple vancomycin models have been published, which are each internally valid using their own [… read more]