Can aggressive treatment of diabetic foot infections reduce the need for above-ankle amputation?

We retrospectively evaluated the charts of 112 patients with diabetic foot infection to determine if early aggressive surgical intervention improves outcome. All patients were classified into two groups on the basis of the timing of surgical intervention and appropriate antimicrobial therapy. Group I included patients who underwent no surgical intervention during the first 3 days of hospitalization but received intravenous antimicrobial therapy, and group II included patients who underwent surgical intervention promptly and received intravenous antimicrobial therapy. Group II was further divided; group IIA included patients who underwent debridement, and group IIB included patients who underwent local limited amputation. A higher rate of patients in group I than in group II (27.6% vs. 13%, respectively; P < .01) required above-ankle amputation during the same hospitalization or subsequent admission. Overall, an aggressive surgical approach against foot infection in hospitalized diabetic patients reduced the need for above-ankle amputation and the length of hospital stay by at least 6 days. Treatment of diabetic foot infection requires the combination of early surgical treatment and antimicrobial therapy.

Community-acquired pneumonia. What's needed for accurate diagnosis

Characteristic clinical findings of fever, cough, and rhonchi, together with a new infiltrate on chest films and documentation of a pathogen, establish a diagnosis of infectious pneumonia. Several factors have had an impact on the approach to diagnosis of community-acquired pneumonia by the primary care physician. These include the expanding number of possible pathogens as well as their increasing resistance to antimicrobial therapy. Although the clinical presentation may suggest a specific cause, findings often overlap too much for reliable identification of the specific agent on clinical grounds alone. Isolation of the microorganism or determination of the presence of a specific antigen or antibody is necessary. However, even after extensive studies are performed, the pathogen remains unidentified in 30% to 50% of cases. The primary care physician therefore needs to balance reasonable use of diagnostic tests with empirical therapy.

Antipseudomonal penicillins

Antipseudomonal penicillins retain most of the antibacterial activity of penicillin and aminopenicillins. This group of penicillins has added activities against many gram-negative rods, including P. aeruginosa. Similar to the earlier penicillins, this group continues to be susceptible to hydrolysis by many beta-lactamases and are, therefore, not consistently active against Staphylococcus, some gram-negative rods, and certain beta-lactamase-producing gram-negative anaerobes. The ureidopenicillins, especially piperacillin, appear to have better activity against Enterococcus, Klebsiella, and P. aeruginosa than ticarcillin. The advantages over the newer cephalosporins are (1) better activity against Enterococcus, (2) more consistent activity against Clostridium, and (3) more consistent synergy with aminoglycosides. The ureidopenicillins have certain advantages over carboxypenicillins, including lower sodium load, less frequent hypokalemia, reduced platelet dysfunction, minimal dosage adjustment in patients with renal failure, and a wider spectrum of antibacterial activity, especially against Enterococcus, Pseudomonas, and Klebsiella. The utility of the antipseudomonal penicillins by themselves is limited as agents for monotherapy when the infecting organism is not known. In addition, monotherapy is not recommended in certain infections to avoid the development of resistance. When combined with a beta-lactamase inhibitor or with an aminoglycoside, however, some of the weaknesses can be overcome.

An outbreak of Pseudomonas aeruginosa ventilator-associated respiratory infections due to contaminated food coloring dye--further evidence of the significance of gastric colonization preceding nosocomial pneumonia

An outbreak of ventilator-associated Pseudomonas aeruginosa respiratory infections in an intensive care unit of a teaching hospital was found to be associated with contaminated food coloring dye. Serotyping and bacteriocin typing indicated that the same strain of Pseudomonas was isolated from the food dye and from the respiratory cultures of the majority of patients. This observation lends credence to the importance of gastric colonization preceding pneumonia in ventilated patients.

[Therapy of cantharides extract for perennial allergic rhinitis and its effect on total IgE in serum]

The therapy of 10% Cantharides extract in treating 50 cases of perennial allergic rhinitis (PAR) was studied. The extract was plastered and blistered on Dazhui, Neiguan point. It was observed by nasal mucosa provocative test, cells in nasal secretion test and serum total IgE test. The results showed that its effective rate was 88%, the allergic nasal mucosa provocative test of treated group alleviated obviously after the treatment (P < 0.01), the number of eosinophil and basophil in nasal secretion decreased (P < 0.01, P < 0.05); and the serum total IgE also reduced significantly (P < 0.01).

Treatment of skin and soft-tissue infections

Bacterial infections of the skin range from mild pyodermas to life-threatening necrotizing infections. Pyodermas are most often due to Staphylococcus aureus or beta-hemolytic Streptococcus sp, whereas infections associated with skin ulcers of the extremities, infections following trauma or surgery, and histotoxic necrotizing infections may involve a large number of additional pathogens, including Enterobacteriaceae, Pseudomonas sp, enterococci, and anaerobes. Management of bacterial skin and soft-tissue infections includes appropriate surgical drainage or excision of infected tissue and antimicrobial therapy. The combination of piperacillin and the beta-lactamase inhibitor tazobactam is a newly released antimicrobial, which has excellent in vitro activity against the vast majority of pathogens involved in skin infections. Two multicenter studies recently evaluated the efficacy and safety of piperacillin/tazobactam in the therapy of skin and soft-tissue infections in hospitalized patients. Piperacillin/tazobactam was well tolerated and demonstrated high clinical efficacy for the treatment of these infections.

Hospital medical directors, quality of care, and financial returns

You are a physician executive working very hard within a hospital on all sorts of medical staff issues and quality of care. You answer to the board. The latter, through its administrators, may still have difficulty documenting the precise value of a full-time physician executive. Your hospital is losing money or not making enough profit for capital expenditures and salary raises. It is considering or will have to consider staff cuts. What can you do that will influence the bottom line, produce a quality image, and quantify your value?

Surface modification of nanoparticles by PEO/PPO block copolymers to minimize interactions with blood components and prolong blood circulation in rats

The biological fate of injected foreign particles is believed to be closely related to their interactions with blood plasma proteins and cells. In order to verify this correlation, we have quantitatively measured protein adsorption and blood retention profiles in rats by using model polystyrene latex nanoparticles. The in vitro interactions of these non-biodegradable particles with plasma proteins and whole blood can be altered by modifying their surfaces with a family of amphiphilic polymeric surfactants, PEO/PPO Pluronic or Tetronic block copolymers. Protein adsorption was measured by several techniques, including photon correlation spectroscopy, centrifugation, high performance liquid chromatography and field-flow fractionation. Pluronic F108 and Tetronic 908 and 1508 copolymers (with PEO terminal block MWPEO > 5000, PPO middle block MWPPO > 3000, and HLB values > 24) were shown to be the most effective surface modifiers in reducing adsorption of plasma proteins on the particles. Minimum interaction of coated particles with whole blood was also observed by optical microscopy. The blood circulation half-life of the particles injected in rats was increased from 20 min to 13 h when the latex particles (75 nm) were precoated with these block copolymers. These results suggest that nanoparticles designed for use as injectable drugs or drug carriers should display similar surface characteristics provided by such amphiphilic surface modifiers.

Treatment of hospitalized patients with complicated skin and skin structure infections: double-blind, randomized, multicenter study of piperacillin-tazobactam versus ticarcillin-clavulanate. The Piperacillin/Tazobactam Skin and Skin Structure Study Group

We compared the efficacy and safety of two beta-lactam-beta-lactamase inhibitor combinations, namely, piperacillin-tazobactam and ticarcillin-clavulanate, in the treatment of complicated bacterial infections of skin that required hospitalization. The study was a randomized, double-blind, comparative trial involving 20 centers. The infections were classified as (i) cellulitis with drainage, (ii) cutaneous abscess, (iii) diabetic or ischemic foot infection, and (iv) infected wounds and ulcers with drainage. The clinical response rates were comparable for the two treatment regimens (61% of the patients were cured with piperacillin-tazobactam and ticarcillin-clavulanate and improvement was seen in 15 and 16% of patients treated with piperacillin-tazobactam and ticarcillin-clavulanate, respectively). Both regimens were found to be safe and well tolerated. These data support the use of piperacillin-tazobactam for initial empiric therapy of hospitalized patients with complicated skin and skin structure infections.

Emergence of antimicrobial resistance in gram-negative bacilli causing bacteremia during therapy

Treatment of serious infections caused by gram-negative bacilli with beta-lactam antimicrobial agents can induce Class I beta-lactamase production. This phenomenon can result in resistant microorganisms, and has been postulated to be a cause of therapeutic failure. The charts of patients bacteremic with Pseudomonas aeruginosa, Serratia marcescens, Enterobacter cloacae, Citrobacter freundii, Proteus vulgaris, and Providencia species (n = 120) during a 3-year period were reviewed to determine how common the emergence of resistance was, and to determine if in vitro susceptibility testing was a reliable therapeutic guide. Emergence of resistance was believed to occur when a subsequent bacteremic isolate showed at least a fourfold increase in minimum inhibitory concentration accompanied by a change of interpretive susceptibility category. In the group of patients who survived at least 48 hours that received beta-lactam therapy (n = 76), one case of emergence of resistance was identified (1.3%). Emergence of resistance to beta-lactam antimicrobial agents did not commonly cause therapeutic failure at our institution, and susceptibility testing of gram-negative bacilli by usual methods was a reliable guide to antimicrobial therapy.

Treatment of bacteriuria in pregnancy

The presence of bacteriuria during gestation increases the chance of acute pyelonephritis. Treatment of bacteriuria in pregnancy reduces subsequent development of symptomatic disease. Numerous studies have shown that single-dose therapy for asymptomatic bacteriuria is as effective as longer course of treatment. Single-dose therapy also has the advantages of improved compliance, reduced costs, and less adverse effects resulting from long term therapy. Follow-up cultures following antimicrobial treatment should be used for early detection of recurrence or relapse. If the urine culture yields no growth, a urine culture at a monthly interval will suffice. If on the other hand bacteriuria is present, a repeat course of antimicrobial therapy should be chosen based on antimicrobial susceptibility testing. A longer course of therapy, possibly with a different drug, is recommended for women with a positive follow-up urine culture. Acute cystitis may be treated with the same regimen as asymptomatic bacteriuria. When upper urinary tract infection is suspected, hospitalisation and a longer course of therapy is recommended. If the organism is susceptible to cefalexin or nitrofurantoin, postcoital prophylaxis with either agent for the remainder of the pregnancy may be beneficial.

Community-acquired pneumonia. The changing picture

Important changes in the initial management of community-acquired pneumonia have been prompted by the discovery of new respiratory pathogens, the changing susceptibility of traditional pathogens to antimicrobial agents, and the introduction of new antimicrobial agents. Although the clinical presentation may suggest a specific pathogen, findings overlap too much to reliably distinguish the specific cause of the pneumonia on a clinical basis. Useful laboratory studies include Gram's stain and culture of sputum, blood culture, serologic studies, and new tests such as the urinary antigen test for Legionella pneumophila. Empirical antimicrobial treatment must take into consideration that 20% to 30% of cases of community-acquired pneumonia are due to atypical pathogens that are not susceptible to beta-lactam agents.

Results of total hip replacement in renal transplant recipients

A vascular necrosis of the femoral head associated with steroid immunosuppression is a cause of significant morbidity in renal transplant recipients. We review the results of 30 total hip replacements in 20 renal transplant recipients with a mean follow-up of 6.3 years. The mean age at the time of surgery was 35 years. The average Hospital for Special Surgery Hip Score was 17 points before operation and 32 points after operation. Fourteen hips were rated excellent and 12 hips rated good. There were four failures--one hip was revised for symptomatic loosening and three prosthesis were removed for infection. Twenty-seven of the hip replacements were subjectively rated as satisfactory by the patient. There was no significant difference in post-operative hip scores between cemented and uncemented prostheses. Total hip replacement in renal transplant recipients in this study has shown good long term result with a revision rate of about 3%. Late infection was a major problem with an incidence of 13%. Prophylactic antibiotics must be used whenever there is a risk of haematogenous seeding from transient bacteremia in these immunosuppressed patients. Use of uncemented prosthesis may make future revision arthroplasty easier.

Pharmacokinetics of imipenem in serum and skin window fluid in healthy adults after intramuscular or intravenous administration

The pharmacokinetic profiles of imipenem after intramuscular (i.m.) and intravenous injections were examined in adult volunteers. Levels of imipenem in serum after i.m. injection of a microcrystalline suspension of imipenem-cilastatin (500 mg each) reached a peak (8.0 micrograms/ml) at 1.5 h after administration, and concentrations were maintained in excess of 1.5 micrograms/ml for 6 h. Serum elimination half-life (1.3 h), volume of distribution (14.5 liters), and area under the curve (AUC; 27.8 micrograms.h/ml) after i.m. injection did not significantly differ from those of a comparable dose given by intravenous infusion. Bioavailability after i.m. injection was 89%. Imipenem levels in skin window fluid after i.m. administration were maximal (4.3 micrograms/ml) at 4 h after injection, at which time imipenem concentrations exceeded those produced by intravenous infusion. The AUCskin window/AUCserum ratio for skin window fluid after i.m. injection was 68%, indicating good penetration of the drug into skin fluid. This study shows that i.m. injection of 500 mg of imipenem-cilastatin results in concentrations of imipenem in serum and skin fluid that are, for at least 6 h, consistent with antimicrobial activity against susceptible organisms.

The use of oral fluoroquinolones in nursing home patients

The approach to management of patients with presumed infection in the nursing home is influenced by the limited availability of diagnostic tests and support staff. Although antibiotics are most often prescribed in the absence of laboratory data, many studies indicate that empirical therapy for nursing home infections is relatively successful. With the scrutiny on containment of healthcare costs, therapy of nursing home patients has been changing and will continue to shift toward treatment within nursing homes without transfer to a hospital. Better oral antimicrobial agents with a wide spectrum of activity, such as the fluoroquinolones, will play a major role in the treatment of many infections acquired in the nursing home. Because of the favourable characteristics of the fluoroquinolone agents, they should be useful for elderly patients who develop infections in nursing homes. They have excellent in vitro activity against Gram-negative bacteria which are often multidrug-resistant and are common in nursing home patients. Studies indicate that absorption of orally administered fluoroquinolones is very efficient in the elderly and these drugs are well tolerated. Numerous clinical trials have documented good efficacy of the fluoroquinolones in the treatment of elderly patients for the most common infections in the nursing home, including urinary tract infections, respiratory tract infections and skin infections.

Ambulatory management of lower respiratory tract infections

Clinical manifestations and radiographic findings are unreliable guides to the selection of antimicrobial therapy for lower respiratory infections. Laboratory evaluation is necessary to identify the etiologic agent. Multiple oral antibiotics are available for outpatient treatment of bronchitis or pneumonia suspected to be of bacterial origin.

Ticarcillin-clavulanate therapy for bacterial skin and soft tissue infections

Ticarcillin-clavulanate is active in vitro against the vast majority of pathogens involved in skin and soft tissue infections. A compilation of six controlled clinical trials of ticarcillin-clavulanate for treatment of skin infections showed a satisfactory clinical response in 175 (93%) of 189 cases. The bacteriologic response included eradication of Staphylococcus aureus, Enterococcus species, Enterobacteriaceae, and Pseudomonas aeruginosa in 88%, 75%, 88%, and 77% of cases, respectively. In addition, the records of 17 patients with diabetic foot infections who were treated with ticarcillin-clavulanate as monotherapy in controlled trials are reviewed. Eight of these infections were cured and eight were improved at the end of therapy. The available clinical data suggest that ticarcillin-clavulanate is effective antimicrobial therapy for skin infections.

Quality assurance in an IPA setting

The experience at CIGNA Healthplans shows that a quality assurance program can be instituted in an IPA-model HMO at low cost and with the addition of little new staff. Existing resources can be effectively restructured to implement a functional program of a traditional type that is easily understood by employer groups, members, and providers. It can serve as a transitional process until the HMO is large enough to put a total quality management program in place.

A multicenter trial comparing the efficacy and safety of cefuroxime axetil and cefaclor in pneumonia of adults

The 185 hospitalized patients (aged 19 to 95 years) with pneumonia were randomly assigned to receive 500 mg of cefuroxime axetil orally (250 mg q12h), 1,000 mg of cefuroxime axetil orally (500 mg q12h), or 1,500 mg of cefaclor orally (500 mg q8h), daily, for a mean of nine days. Among the 151 evaluable patients, clinical cure was noted in 58% of the 500-mg cefuroxime axetil group, 94% of the 1,000-mg cefuroxime axetil group, and 88% of the cefaclor group, and clinical improvement in 32%, 4%, and 9%. Bacteriologic outcome was similar in the three groups. Adverse events were minor and comparable among the treatment groups. Cefuroxime axetil is a safe and effective oral antimicrobial for the treatment of pneumonia in adults.

Infections due to Corynebacterium group D2. Report of a case

Corynebacterium group D2 is a gram-positive bacillus easily identified in clinical microbiology laboratories. However, this organism is often disregarded as a skin and mucous contaminant. The Spanish literature has recently described Corynebacterium group D2 as a urinary pathogen in a specific patient population. We report a case of Corynebacterium group D2 infection to illustrate the potential pathogenicity and clinical presentation of infection due to this organism in the United States.

Effect of vacuum mixing on the mechanical properties of antibiotic-impregnated polymethylmethacrylate bone cement

Polymethylmethacrylate bone cement, containing either no added antibiotic, 0.5 g of Vancomycin, 1.0 g of Vancomycin, or 1.0 g of Tobramycin, was mixed either in air or a vacuum chamber. Following storage in a water bath at 37 degrees C for 48 h, the specimens were tested in four-point bending. The porosity of the specimens was assessed radiographically, and their antibacterial activity was monitored for 21 days. The bending strength of the vacuum mixed specimens containing no antibiotic was 40% greater than that of similar air-mixed specimens. However, there were no significant differences in the bending strength of either the air- or vacuum-mixed specimens when any of the antibiotic dosages were added. The bending modulus of the vacuum-mixed specimens, containing no antibiotic, was significantly greater than the moduli of all the other specimen groups which did not differ from each other. Vacuum mixing reduced the apparent porosity of the specimens fivefold, and while the addition of antibiotic did not effect porosity of the air-mixed specimens, that of the vacuum-mixed specimens was doubled. Although initial rapid decreases were seen, leaching of antibiotic from the cement and antibacterial activity continued through the 21-day monitoring period.

Urinary tract infections in obstetrics and gynecology

Escherichia coli is still the most common bacterial pathogen associated with urinary tract infections in women. Because of increasing resistance, ampicillin or a sulfonamide alone is no longer recommended for the empiric treatment of those infections. Antimicrobial therapy that contains a beta-lactamase inhibitor or that is resistant to the action of beta-lactamase is preferred. For the treatment of acute, uncomplicated lower urinary tract infection in a young woman, a short course of therapy (single dose) may be adequate. For an upper tract or complicated infection a longer course of therapy is advised. Asymptomatic bacteriuria in pregnancy should be treated; a short course of therapy with a beta-lactam antibiotic may be tried only if posttherapy follow-up cultures are planned. When bacteriuria persists or recurs, a longer course of therapy should follow, with consideration given to a urologic workup after delivery.

Diagnosis and treatment of staphylococcal diseases

Staphylococcus is, by far, the most commonly seen organism in podiatric infections. Although common, staphylococcal infections are difficult to understand and treat. These bacteria have undergone significant changes in their pathogenicity and antibiotic susceptibility over the last few years. Methicillin-resistant strains, once relatively rare, are becoming a major therapeutic dilemma in some centers.

[Pathological study of bronchio-alveolitis induced by xinkang short-fiber chrysotile asbestos in rats]

Eighty-four rats were exposed intratracheally to 25 mg of locally produced Xinkang short-fiber chrysotile asbestos (98% of the fibers are less than 5 microns in length). In 1 to 3 d after instillation, the pathological changes in rat lungs demonstrated that the affection was mainly acute bronchio-alveolitis characterized by acute inflammatory exudation and injuries of the small airways and alveolar structural units. The four main manifestations of alveolitis induced by the chrysotile asbestos were of the neutrophilic, serous, alveolar macrophages and granulomatous varieties. Three types of pulmonary fibrosis developed gradually from 7 to 90 d following the exposure to the asbestos, i.e. the intraluminal, murally incorporated, and interstitial fibrosis. Findings showed the complete process from the acute inflammatory exudation and the damage to lung tissue, with the following repair and proliferation of injuried lung tissue and organization of exudate, to the final fibrosis and destruction of the lung. The results suggested that the persistent and irreversible damage to the epithelial cells of respiratory bronchioles and pneumocytes, and denudation and destruction of the basement membrane played an important role in the development of pulmonary fibrosis by forming a channel for the inflammatory exudates and fibroblasts migrating into the bronchioalveolar spaces. Therefore, the experimental results have proved that Xinkang chrysotile asbestos fibers less than 5 microns in length certainly have a fibrogenic effect.

Urinary tract infections in the elderly

Urinary tract infection (UTI) is common in the elderly, with a prevalence of approximately 20% in women over 65 years of age. The elderly are predisposed to UTI by anatomic changes in the genitourinary system, by underlying disease, by instrumentation, and by residing in long-term care settings. Indwelling urinary catheters are a frequent cause of UTI, and catheter-associated sepsis is the most common cause of gram-negative sepsis in hospitals. Resistant organisms, prevalent in long-term care settings and hospitals, are increasingly responsible for UTI. Empiric antibiotic therapy has changed with the availability of new agents that cover resistant organisms. Oral antibiotics are appropriate for most UTIs; however, more serious infections require parenteral therapy. Length of antibiotic therapy is generally increased for UTI in the elderly.