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Gamble KC, Rose DT, Thyagarajan RV, Jaso TC, Reveles KR, Mondy KE. Impact of intensified inpatient clindamycin stewardship initiatives in three phases: a pilot quasi-experimental study. J Hosp Infect 2024; 143:227-228. [PMID: 37783342 DOI: 10.1016/j.jhin.2023.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/27/2023] [Accepted: 08/30/2023] [Indexed: 10/04/2023]
Affiliation(s)
- K C Gamble
- McLeod Regional Medical Center, Florence, SC, USA.
| | - D T Rose
- Dell Seton Medical Center at the University of Texas, Austin, TX, USA
| | - R V Thyagarajan
- Dell Seton Medical Center at the University of Texas, Austin, TX, USA; Dell Medical School at the University of Texas, Austin, TX, USA
| | - T C Jaso
- Ascension Seton Medical Center Austin, Austin, TX, USA
| | - K R Reveles
- The University of Texas at Austin College of Pharmacy, Austin, TX, USA; UT Health Science Center at San Antonio School of Medicine, San Antonio, TX, USA
| | - K E Mondy
- Dell Seton Medical Center at the University of Texas, Austin, TX, USA; Dell Medical School at the University of Texas, Austin, TX, USA
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Gamble KC, Rose DT, Chang SY, Hodge EK, Jaso TC, Trust MD, Daley MJ. Cefepime Versus Piperacillin-Tazobactam for the Treatment of Intra-Abdominal Infections Secondary to Potential AmpC Beta-Lactamase-Producing Organisms. Hosp Pharm 2023; 58:575-583. [PMID: 38560541 PMCID: PMC10977065 DOI: 10.1177/00185787231170384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background: Recent studies have established cefepime as an effective treatment option for AmpC beta-lactamase (AmpC) Enterobacterales; however, the efficacy of beta-lactam/beta-lactamase inhibitors is unclear. Objective: The objective of this study was to determine if piperacillintazobactamis an appropriate alternative to cefepime for the treatment of intra-abdominal infections (IAIs) secondary to AmpC-producing organisms. Methods: This multicenter, retrospective cohort study was conducted in hospitalized adults with an IAI caused by an AmpC-producing organism and received either cefepime or piperacillin-tazobactam for definitive treatment after a source control procedure. The primary outcome was a composite of surgical site infections, recurrent IAIs, or in-hospital mortality. Secondary outcomes included the individual components of the composite outcome, hospital length of stay (LOS), microbiologic failure, study antibiotic duration, time to clinical resolution, and incidence of Clostridioides difficile infection (CDI). Results: This study included 119 patients. There was no difference in the primary outcome between the cefepime and piperacillin-tazobactam groups (35% vs 27%, P = 0.14). Microbiological failure was the only secondary outcome with an observed difference between groups (17% vs 0%, P = 0.01): hospital LOS (15 vs 13 days, P = 0.09), days of therapy (7 vs 7 days, P = 0.87), time to clinical resolution (7 vs 4 days, P = 0.30), and CDI (1% vs 2%, P = 0.58) were all similar.
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Affiliation(s)
| | - Dusten T. Rose
- Dell Seton Medical Center at the University of Austin, Austin, TX, USA
| | | | - Emily K. Hodge
- Dell Seton Medical Center at the University of Austin, Austin, TX, USA
| | | | - Marc D. Trust
- University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Mitchell J. Daley
- Dell Seton Medical Center at the University of Austin, Austin, TX, USA
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McAlister MJ, Rose DT, Hudson FP, Padilla-Tolentino E, Jaso TC. Oral β-lactams vs fluoroquinolones and trimethoprim/sulfamethoxazole for step-down therapy for Escherichia coli, Proteus mirabilis, and Klebsiella pneumoniae bacteremia. Am J Health Syst Pharm 2023; 80:S33-S41. [PMID: 35868628 DOI: 10.1093/ajhp/zxac202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To compare rates of treatment failure for patients with bloodstream infections (BSIs) due to Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis who received oral step-down antibiotic therapy with either a fluoroquinolone (FQ) or trimethoprim/sulfamethoxazole (SXT) to rates for those who received an oral β-lactam (BL). METHODS This retrospective, multicenter, cohort study included 397 unique adult hospitalized patients with a BSI due to E. coli, K. pneumoniae, or P. mirabilis at 6 hospitals in central Texas between July 11, 2016, and July 11, 2018. The primary outcome was a composite of treatment failure comprising 30-day readmission due to recurrence, 30-day all-cause mortality, and change in oral antibiotic. Secondary outcomes included 90-day development of Clostridioides difficile infection, 90-day colonization with a multidrug-resistant organism, 90-day all-cause readmission, hospital length of stay, and the individual components of the primary outcome. RESULTS Of the 397 patients included, 200 received oral step-down therapy with a BL while 197 received an FQ or SXT. Most patients had an infection due to E. coli (82.8%) and a urinary source of infection (85%). Median total duration of therapy was 14 days in both groups. No difference in treatment failure was identified between the groups treated with a BL and FQ/SXT (7% vs 5.8%, P = 0.561). Median hospital length of stay was the only secondary endpoint in which there was an observed difference (6 vs 5 days, P = 0.04). CONCLUSION We observed no difference in treatment failure rates for patients receiving an oral BL compared to an oral FQ or SXT for step-down therapy of BSIs due to E. coli, K. pneumoniae, and P. mirabilis.
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Affiliation(s)
- Michael J McAlister
- Department of Pharmacy, Dr. P. Phillips Hospital/Orlando Health, Orlando, FL, USA
| | - Dusten T Rose
- Department of Pharmacy, Dell Seton Medical Center at the University of Texas, Austin, TX, USA
| | - F Parker Hudson
- Department of Internal Medicine, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
| | | | - Theresa C Jaso
- Department of Pharmacy, Ascension Seton Medical Center Austin, Austin, TX, USA
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Parker JK, Gu R, Estrera GA, Kirkpatrick B, Rose DT, Mavridou DAI, Mondy KE, Davies BW. Carbapenem-Resistant and ESBL-Producing Enterobacterales Emerging in Central Texas. Infect Drug Resist 2023; 16:1249-1261. [PMID: 36891378 PMCID: PMC9987243 DOI: 10.2147/idr.s403448] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023] Open
Abstract
Purpose Carbapenem-resistant Enterobacterales (CRE) are subject to intense global monitoring in an attempt to maintain awareness of prevalent and emerging resistance mechanisms and to inform treatment and infection prevention strategies. CRE and extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales are not usually examined collectively in regards to their shared pool of resistance determinants. Here, we genetically and phenotypically assess clinical isolates of CRE and extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales in the growing region of Central Texas, where CRE are emergent and occurrence of non-carbapenemase-producing-CRE (non-CP-CRE) infections is increasing. Methods CRE (n=16) and ESBL-producing Enterobacterales (n=116) isolates were acquired from a regional hospital in Central Texas between December 2018 and January 2020. Isolates were assessed genetically and phenotypically using antibiotic susceptibility testing, targeted PCR, and whole genome sequencing. Results CRE infections are increasing in incidence in Central Texas, and Klebsiella pneumoniae is causing the majority of these infections. Moreover, K. pneumoniae sequence type (ST) 307 is commonly found among both non-CP-CRE and EBSL-producing strains. Isolates carry similar plasmids harboring the gene for the ESBL CTX-M-15 and belong to the global lineage, rather than the Texas lineage, of ST307. Antibiotic resistance profiles, sequence data, and clinical records suggest that porin mutations may promote the transition of ST307 isolates from ESBL-producing to non-CP-CRE. In addition to antibiotic resistance mechanisms, several CRE isolates harbor active colicinogenic plasmids, which might influence the competitiveness of these bacteria during patient colonization. Conclusion K. pneumoniae of the global ST307 lineage is circulating in Central Texas and is responsible for both non-CP CRE and ESBL-producing Enterobacterales infections. Enhanced surveillance is needed to understand the possible routes for the emergence of non-CP-CRE from EBSL-producing strains.
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Affiliation(s)
- Jennifer K Parker
- Department of Molecular Biosciences, The University of Texas at Austin, Austin, TX, USA
| | - Richard Gu
- Department of Molecular Biosciences, The University of Texas at Austin, Austin, TX, USA
| | - Gregory A Estrera
- Department of Molecular Biosciences, The University of Texas at Austin, Austin, TX, USA
| | | | - Dusten T Rose
- Department of Pharmacy, Ascension Seton, Dell Seton Medical Center at The University of Texas, Austin, TX, USA
| | - Despoina A I Mavridou
- Department of Molecular Biosciences, The University of Texas at Austin, Austin, TX, USA.,John Ring LaMontagne Center for Infectious Diseases, The University of Texas at Austin, Austin, TX, USA
| | - Kristin E Mondy
- Department of Internal Medicine, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Bryan W Davies
- Department of Molecular Biosciences, The University of Texas at Austin, Austin, TX, USA.,John Ring LaMontagne Center for Infectious Diseases, The University of Texas at Austin, Austin, TX, USA
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Rose DT, Gandhi SM, Bedard RA, Mondy KE, Chu AL, Gamble KC, Gee AT, Kundra MA, Williams AL, Lee BK. Supratherapeutic tacrolimus concentrations with nirmatrelvir/ritonavir in solid organ transplant recipients requiring hospitalization: A case series using rifampin for reversal. Open Forum Infect Dis 2022; 9:ofac238. [PMID: 35854994 PMCID: PMC9277654 DOI: 10.1093/ofid/ofac238] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/11/2022] [Indexed: 11/30/2022] Open
Abstract
Nirmatrelvir/ritonavir was recently granted emergency use authorization for mild to moderate coronavirus disease 2019. Drug–drug interactions between ritonavir and tacrolimus are underappreciated by nontransplant providers. We describe 2 solid organ transplant recipients prescribed nirmatrelvir/ritonavir for outpatient use who developed tacrolimus toxicity requiring hospitalization and were managed with rifampin for toxicity reversal.
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Affiliation(s)
- Dusten T. Rose
- Ascension Seton, Dell Seton Medical Center at The University of Texas, Department of Pharmacy, Austin, TX, USA
- College of Pharmacy, University of Texas at Austin, Austin, TX, USA
| | - Saurin M. Gandhi
- Dell Medical School at the University of Texas at Austin, Department of Internal Medicine, Austin, TX, USA
| | - Rachael A. Bedard
- Ascension Seton, Dell Seton Medical Center at The University of Texas, Department of Pharmacy, Austin, TX, USA
- Dell Seton Medical Center at the University of Texas at Austin; Kidney and Pancreas Transplant Program, Austin, TX, USA
| | - Kristin E. Mondy
- Dell Medical School at the University of Texas at Austin; Division of Infectious Diseases, Department of Internal Medicine, Austin, TX, USA
| | - Alexander L. Chu
- Department of Medical Education, Dell Medical School at the University of Texas at Austin, Austin, TX, USA
| | - Kelly C. Gamble
- Ascension Seton, Dell Seton Medical Center at The University of Texas, Department of Pharmacy, Austin, TX, USA
| | - Amanda T. Gee
- Ascension Seton, Dell Seton Medical Center at The University of Texas, Department of Pharmacy, Austin, TX, USA
| | - Monica A. Kundra
- Dell Medical School at the University of Texas at Austin, Department of Internal Medicine, Austin, TX, USA
| | - Amber L. Williams
- Ascension Seton, Dell Seton Medical Center at The University of Texas, Department of Pharmacy, Austin, TX, USA
| | - Brian K. Lee
- Dell Seton Medical Center at the University of Texas at Austin; Division of Nephrology, Department of Internal Medicine, Austin, TX, USA
- Dell Seton Medical Center at the University of Texas at Austin; Kidney and Pancreas Transplant Program, Austin, TX, USA
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Rose DT, Moskhos A, Wibisono A, Reveles KR. Automated Susceptibility Testing With Vitek 2 Compared to MicroScan Reduces Vancomycin Alternative Therapy For Methicillin-Resistant Staphylococcus Aureus Bacteremia. Int J Infect Dis 2022; 117:179-186. [PMID: 35134560 DOI: 10.1016/j.ijid.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Variability in minimum inhibitory concentration (MIC) with automated susceptibility testing instruments may influence methicillin-resistant Staphylococcus aureus (MRSA) treatment. The purpose of this study was to evaluate the difference in vancomycin MIC values and the impact on vancomycin alternative therapy for MRSA bacteremia using the MicroScan and VITEK 2 automated systems. METHODS This was a retrospective multicenter cohort study of adult patients with MRSA bacteremia. Patients were stratified by susceptibility testing with MicroScan (May 2013-December 2016) or VITEK 2 (June 2017-February 2020). The primary outcome was vancomycin alternative therapy use. Secondary endpoints included MRSA MIC, 30-day mortality, 30- and 90-day readmission, and hospital length of stay (LOS). RESULTS A total of 193 patients were included for analysis: 89 in the MicroScan group and 104 in the VITEK 2 group. Vancomycin alternative therapy use was higher in the MicroScan group than the VITEK 2 group (56.2% vs 20.2%; p <0.001). Median MIC value was 2 mg/L and 1 mg/L for MicroScan and VITEK 2, respectively (p <0.001). Median hospital LOS was shorter in the VITEK 2 period (16 vs 12 days; p = 0.02). Thirty-day mortality (10.1% vs 7.7%; p = 0.555) and 90-day readmission (34.8% vs 29.8%; p = 0.457) did not significantly differ between MicroScan and VITEK 2 groups. CONCLUSIONS VITEK 2 use was associated with lower reported vancomycin MICs and less use of vancomycin alternative therapy.
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Affiliation(s)
- Dusten T Rose
- Ascension Seton, Dell Seton Medical Center at The University of Texas, Department of Pharmacy, Austin, TX, USA; College of Pharmacy, The University of Texas at Austin, Austin, TX, USA.
| | - Alexander Moskhos
- Ascension Seton, Dell Seton Medical Center at The University of Texas, Department of Pharmacy, Austin, TX, USA; College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Arya Wibisono
- Ascension Seton, Dell Seton Medical Center at The University of Texas, Department of Pharmacy, Austin, TX, USA; College of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Kelly R Reveles
- College of Pharmacy, The University of Texas at Austin, Austin, TX, USA; Pharmacotherapy Education & Research Center, University of Texas Health San Antonio, San Antonio, TX, USA
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Gamble KC, Rose DT, Sapozhnikov J. Intravenous to Oral Antibiotics Versus Intravenous Antibiotics: A Step-Up or a Step-Down for Extended Spectrum Beta-Lactamase Producing Urinary Tract Infections Without Concomitant Bacteremia? Int J Antimicrob Agents 2022; 59:106541. [DOI: 10.1016/j.ijantimicag.2022.106541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/15/2022] [Accepted: 01/20/2022] [Indexed: 11/25/2022]
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Shephard EA, Mondy KE, Reveles KR, Jaso T, Rose DT. 185. Does an Infectious Diseases Consultation Improve Clinical Outcomes and Treatment Bundle Adherence for Enterococcal Bacteremia in a Multicenter Healthcare System? Open Forum Infect Dis 2021. [PMCID: PMC8643982 DOI: 10.1093/ofid/ofab466.387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Infectious diseases consultation (IDC) for Staphylococcus aureus bacteremia has a known mortality benefit, but for other gram positive bacteremias the benefit is not known. This study examined differences in outcomes for enterococcal bacteremia when management includes IDC. Methods This retrospective multicenter observational cohort study included adults with at least 1 positive blood culture with Enterococcus species. Patients who died or transferred to palliative care within 2 days of positive blood cultures were excluded. The primary outcome was a composite of clinical failure, including persistent blood cultures or fever for 5 days and in-hospital mortality. Secondary outcomes included adherence to a treatment bundle (appropriate empiric/definitive antibiotics, echocardiography (ECHO), duration of treatment, and repeat blood cultures). Results A total of 250 patients were included. IDC was obtained in 62.0% of patients. More patients in the IDC group had endocarditis (20% vs 0%, p < 0.0001) and bone and joint infections (13.5% vs 1.1%, p = 0.001), compared to more UTI (16.8% vs 39.0%, p < 0.0001) in the non-IDC group. Patients in the IDC group had more murmurs on initial exam (21.3% vs 6.3%, p = 0.002), prosthetic device (49.7% vs 27.4%, p = 0.001), and NOVA scores of ≥ 4 (40.6% vs 18.9%, p < 0.0001). Most infections were due to E. faecalis (78.4%) and most were susceptible to vancomycin and ampicillin at 90.4% and 92.4%, respectively. The composite of clinical failure occurred in 22.6% of patients with IDC and 16.8% in the non-IDC group (p=0.274). There was higher adherence to the treatment bundle in the IDC group (Figure 1). More patients in the IDC group were treated with ampicillin (47.1% vs 22.1%, p < 0.0001), and numerically more patients received treatment with vancomycin in the non-IDC group (17.4% vs 24.2%, p = 0.068). In the multivariate analysis, vasopressors were the only independent predictor of the primary outcome (OR 9.3, 95% CI 3.5-24.8, p < 0.0001). Figure 1. Adherence to treatment bundle. IDC = infectious diseases consultation, Echo = echocardiogram, * = p < 0.05 ![]()
Conclusion There was no difference in rates of composite failure in patients with or without IDC; however, adherence to a treatment bundle was higher in the IDC group. IDC demonstrated stewardship benefits with regards to vancomycin usage. Disclosures All Authors: No reported disclosures
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Gamble KC, Rose DT, Sapozhnikov J. 195. Intravenous to Oral Antibiotics Versus Intravenous Antibiotics: A Step-Up or a Step-Down for Extended Spectrum Beta-Lactamase Producing Urinary Tract Infections? Open Forum Infect Dis 2021. [PMCID: PMC8644008 DOI: 10.1093/ofid/ofab466.195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background The treatment of extended-spectrum beta-lactamase (ESBL)-producing urinary tract infections (UTI) may include either intravenous (IV) or oral (PO) antibiotics, according to the Infectious Diseases Society of America guidelines for resistant gram negative infections. The purpose of this study is to evaluate if PO step-down antibiotics, the switch group, compared to continued IV therapy in these UTIs affects clinical outcomes. Methods This multicenter retrospective cohort study was conducted in hospitalized patients with an ESBL-producing UTI between July 2016 and March 2020. The control group received a complete antibiotic course with a carbapenem. The switch group was transitioned to an oral agent within five days from initiation of a carbapenem. The primary endpoint was a composite all-cause clinical failure, which was defined as readmission or hospital mortality within 30 days of hospital discharge or a change in antibiotic during hospital admission. The secondary endpoints included individual components of the primary outcome, readmission indication, inpatient length of stay, direct antibiotic costs, and adverse events. Results The study included 153 patients: 95 and 58 patients in the control and switch groups, respectively. Demographics between the two groups were similar (Table 1). The mean ± SD duration of therapy was 8.7 ± 3.1 and 7.1 ± 3.3 days, respectively. Four oral agents were used for step-down therapy (Figure 1). The primary outcome occurred in 28% in both groups (27 vs 16 patients, p=0.91). The individual components of the primary outcome and readmission indication were also similar: readmission (93% vs 94%, p=0.95), readmission due to a recurrent UTI (33% vs 25%, p=0.73), hospital mortality (7% vs 6%, p=1.0), and change in antibiotic (0% vs 2%, p=0.38). The median (IQR) length of stay and direct antibiotic cost in the control and switch groups were 8 (6) vs 5 (2) days (p< 0.01) and &278 (&244) vs &180 (&104) (p< 0.01), respectively. Adverse events were similar in both groups except for diarrhea (15% vs 2%, p=0.01). Table 1. Baseline Demographics. SD: standard deviation, ICU: intensive care unit, qSOFA: quick Sequential Organ Failure Assessment, ESBL: extended spectrum beta-lactamase, UTI: urinary tract infection ![]()
Figure 1. Oral Antibiotics. QD: once daily, BID: twice daily, Q2D: every 2 days, Q3D: every 3 days, DS tab: double strength tablet ![]()
Conclusion There was no difference in clinical failure, readmission rate, mortality rate, or change in antibiotic between the control and switch groups; however, the switch group was associated with reduced hospital length of stay and direct antibiotic cost. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | | | - Julia Sapozhnikov
- Ascension Texas- Dell Children’s Medical Center of Central Texas, Austin, Texas
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Thyagarajan RV, Mondy KE, Rose DT. Cryptococcus neoformans blood stream infection in severe COVID-19 pneumonia. IDCases 2021; 26:e01274. [PMID: 34485078 PMCID: PMC8406549 DOI: 10.1016/j.idcr.2021.e01274] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/20/2021] [Accepted: 08/30/2021] [Indexed: 11/24/2022] Open
Abstract
Severe coronavirus disease (COVID-19) associated pneumonia leads to acute respiratory distress syndrome and emerging data suggest fungal coinfections also contribute to mortality in this patient population. Aspergillus ventilator associated pneumonia is increasingly recognized. We describe a case of likely reactivation of community acquired Cryptococcus neoformans in a patient with severe COVID-19.
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Affiliation(s)
- Rama V Thyagarajan
- Dell Seton Medical Center at the University of Texas, USA.,Dell Medical School, University of Texas at Austin, 1500 Red River St, Austin, TX 78701, USA
| | - Kristin E Mondy
- Dell Seton Medical Center at the University of Texas, USA.,Dell Medical School, University of Texas at Austin, 1500 Red River St, Austin, TX 78701, USA
| | - Dusten T Rose
- Dell Seton Medical Center at the University of Texas, USA
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Maguire C, Rose DT, Jaso T. 216. Are Automatic Antimicrobial Stop Orders an Effective Stewardship Tool for Urinary Tract and Intra-Abdominal Infections? Open Forum Infect Dis 2020. [PMCID: PMC7777725 DOI: 10.1093/ofid/ofaa439.260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Automatic antimicrobial stop orders (ASOs) are a stewardship initiative used to decrease days of therapy, prevent resistance, and reduce drug costs. Limited evidence outside of the perioperative setting exists on the effects of ASOs on broad spectrum antimicrobial use, discharge prescription duration, and effects of missed doses. This study aims to evaluate the impact of an ASO policy across a health system of adult academic and community hospitals for treatment of intra-abdominal (IAI) and urinary tract infections (UTI). ASO Outcome Definitions ![]()
ASO Outcomes ![]()
Methods This multicenter retrospective cohort study compared patients with IAI and UTI treated before and after implementation of an ASO. Patients over the age of 18 with a diagnosis of UTI or IAI and 48 hours of intravenous (IV) antimicrobial administration were included. Patients unable to achieve IAI source control within 48 hours or those with a concomitant infection were excluded. The primary outcome was the difference in sum length of antimicrobial therapy (LOT). Secondary endpoints include length and days of antimicrobial therapy (DOT) at multiple timepoints, all cause in hospital mortality and readmission, and adverse events such as rates of Clostridioides difficile infection. Outcomes were also evaluated by type of infection, hospital site, and presence of infectious diseases (ID) pharmacist on site. Results This study included 119 patients in the pre-ASO group and 121 patients in the post-ASO group. ASO shortened sum length of therapy (LOT) (12 days vs 11 days respectively; p=0.0364) and sum DOT (15 days vs 12 days respectively; p=0.022). This finding appears to be driven by a decrease in outpatient LOT (p=0.0017) and outpatient DOT (p=0.0034). Conversely, ASO extended empiric IV LOT (p=0.005). All other secondary outcomes were not significant. Ten patients missed doses of antimicrobials due to ASO. Subgroup analyses suggested that one hospital may have influenced outcomes and reduction in LOT was observed primarily in sites without an ID pharmacist on site (p=0.018). Conclusion While implementation of ASO decreases sum length of inpatient and outpatient therapy, it may not influence inpatient length of therapy alone. Moreover, ASOs prolong use of empiric intravenous therapy. Hospitals without an ID pharmacist may benefit most from ASO protocols. Disclosures All Authors: No reported disclosures
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Moskhos A, Wibisono A, Reveles KR, Rose DT. 310. The Impact of Microscan versus Vitek-2 for Automated Susceptibility Testing on the Utilization of Vancomycin Alternatives for the Treatment of Methicillin-Resistant Staphylococcus aureus Bacteremia. Open Forum Infect Dis 2020. [PMCID: PMC7777214 DOI: 10.1093/ofid/ofaa439.353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Automated susceptibility testing (AST) provides minimum inhibitory concentrations (MIC) to guide effective antibiotic therapy. AST is critical for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, as susceptible MIC values ≥ 1.5 µg/mL are associated with vancomycin (VAN) failure. The Microscan (MS) instrument may report elevated MIC values compared to Vitek-2 (VTK), thus impacting treatment. This study aimed to evaluate the impact of MS versus VTK on VAN alternative use in the treatment of MRSA bacteremia in a Texas health system. Methods This was a retrospective cohort study of patients admitted to the Ascension Seton health system in Austin, TX. Patient eligibility included: age ≥18 years, ≥1 positive MRSA blood culture, ≥72 hours of MRSA therapy, and VAN use within 48 hours of positive culture. Patients were stratified into the MS group (May 2013-Dec 2016) and VTK group (Jun 2017-Mar 2020). The primary outcome was therapy switch from VAN to VAN alternatives. Secondary endpoints include S. aureus MIC, 30-day all-cause mortality, 30 and 90-day readmission, and length of hospital stay (LOS). Outcomes were compared between groups using appropriate bivariable comparisons, as well as multivariable logistic regression and propensity score-adjusted logistic regression. Results A total of 199 patients were included: 91 in the MS group and 108 in the VTK group. Switch to VAN alternative was 56% vs. 19% (p< 0.0001) for MS and VTK, respectively. The median (interquartile range) MIC value reported was 2 μg/mL (2 – 2) and 1 μg/mL (0.5 – 1) for MS and VTK, respectively (p< 0.0001). Thirty-day readmission (19% vs. 20%, p=0.7647) and 30-day mortality (10% vs. 9%, p=0.5262) were comparable between MS and VTK groups, respectively. Hospital LOS significantly decreased in the VTK period (16 days vs. 12 days, p=0.0153). The MS group was the only independent positive predictor of VAN alternative therapy: logistic regression, OR 5.64 (95% CI 1.67–18.99) and propensity score adjusted, OR 4.21 (95% CI 1.32–13.48). Conclusion Since implementation of VTK from MS, Ascension Seton hospitals experienced a decreased median VAN MIC for MRSA bacteremia as well as therapy switches from VAN to VAN alternatives without affecting other patient health outcomes. Disclosures All Authors: No reported disclosures
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Affiliation(s)
- Alexander Moskhos
- College of Pharmacy, The University of Texas at Austin, Austin, TX, Austin, Texas
| | - Arya Wibisono
- College of Pharmacy, The University of Texas at Austin, Austin, TX, Austin, Texas
| | | | - Dusten T Rose
- Ascension Texas, Dell Seton Medical Center at The University of Texas, Department of Pharmacy, Austin, TX, Austin, Texas
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Maguire C, Agrawal D, Daley MJ, Douglass E, Rose DT. Rethinking Carbapenems: A Pharmacokinetic Approach for Antimicrobial Selection in Infected Necrotizing Pancreatitis. Ann Pharmacother 2020; 55:902-913. [PMID: 33135457 DOI: 10.1177/1060028020970124] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To provide an overview of pathophysiological changes to the pancreas during infected necrotizing pancreatitis (INP), optimal drug properties needed to penetrate the pancreas, human and animal studies supporting the use of antimicrobials, and carbapenem-sparing strategies in INP. DATA SOURCES A literature analysis of PubMed/MEDLINE was performed (from 1960 to September 2020) using the following key terms: infected necrotizing pancreatitis, necrotizing acute pancreatitis, and infected pancreatitis antimicrobial concentration. Individual antimicrobials were investigated with these search terms. STUDY SELECTION AND DATA EXTRACTION All relevant studies describing the management of INP, and human and animal pharmacokinetic (PK) data supporting antimicrobial use in the pancreas were reviewed for possible inclusion regardless of sample size or study design. DATA SYNTHESIS Piperacillin/tazobactam and cefepime achieve adequate pancreatic tissue concentrations in INP studies. A majority of the literature supporting carbapenem use in INP involves imipenem, and meropenem Monte Carlo simulations suggest that standard dosing regimens of meropenem may not achieve PK targets to eradicate Pseudomonas aeruginosa. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Carbapenems are often utilized for INP treatment based on guideline recommendations. This review discusses PK data, the history of carbapenem use in INP, and the pathophysiology of pancreatitis to suggest carbapenem-sparing strategies and provides stewardship tactics such as when to start antimicrobials, which empirical antimicrobial to use, and when to discontinue antimicrobials in the INP setting. CONCLUSIONS Noncarbapenem antipseudomonals, such as piperacillin/tazobactam and cefepime, are appropriate carbapenem-sparing options in INP, based on PK data, spectrum of activity, and risk of collateral damage.
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Affiliation(s)
| | - Deepak Agrawal
- Dell Medical School at the University of Texas, Austin, TX, USA
| | | | | | - Dusten T Rose
- Ascension Seton at Dell Seton Medical Center, Austin, TX, USA
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Evans M, Merkel KG, Harder J, Rose DT. Impact of the implementation of a rapid meningitis/encephalitis multiplex polymerase chain reaction panel on IV acyclovir duration: multicenter, retrospective cohort of adult and pediatric patients. Diagn Microbiol Infect Dis 2020; 96:114935. [DOI: 10.1016/j.diagmicrobio.2019.114935] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 11/03/2019] [Accepted: 11/03/2019] [Indexed: 11/30/2022]
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McAlister M, Rose DT, Jaso T, Olivares B, Parker Hudson F. 1022. Is it Time to Re-Evaluate Oral Β-Lactam Antibiotics for Step-Down Therapy of Uncomplicated Gram-Negative Bacteremia? Open Forum Infect Dis 2019. [PMCID: PMC6811050 DOI: 10.1093/ofid/ofz360.886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Bloodstream infections (BSI) due to Enterobacteriaceae often require empiric intravenous (IV) antibiotics. Oral antibiotics for the definitive treatment of these infections have been reserved to antibiotics with “high” oral bioavailability, mainly fluoroquinolones (FQ). Safety concerns and increasing resistance associated with FQ has modified clinical practice to identify alternative oral therapies. Select β-lactam (BL) antibiotics are well-tolerated, have moderately high bioavailability, and possess in-vitro activity against Escherichia coli (E. coli), Klebsiella pneumoniae (K. pneumoniae), and Proteus mirabilis (P. mirabilis). Limited evidence exists for oral BL step-down therapy for definitive treatment of BSI due to these organisms.
Methods
This retrospective cohort study compares clinical outcomes of patients treated with oral BL antibiotics to those who received oral FQ or trimethoprim/sulfamethoxazole (TS) for the treatment of BSI due to E. coli, K. pneumoniae, and P. mirabilis. The primary outcome is a composite of 30-day all-cause mortality, 30-day readmission due to recurrence, and/or change in oral antibiotic therapy. Secondary endpoints include 90-day development of Clostridium difficile infection, 90-day all-cause readmission, hospital length of stay (LOS), and 90-day recovery of a multi-drug-resistant organism.
Results
Nine hundred eighty-one patients were screened and 397 adult patients were included. Excluded patients: IV only (n = 291), polymicrobial blood culture (n = 112), immunocompromised (n = 61), other (n = 120). Two-hundred patients received oral step-down therapy with a BL, and 197 with either an FQ or TS. E. coli was the causative organism for most patients in both groups, and urinary tract was the most common source of BSI. The median total duration of therapy was 14 days in both groups. There was no significant difference in the primary composite endpoint (7% vs. 5.6%, P = 0.561). There was no mortality or differences in secondary outcomes, except LOS (6 vs. 5 days, P = 0.043).
Conclusion
Utilization of oral BL for the step-down therapy of uncomplicated BSI due to E. coli, K. pneumoniae, and P. mirabilis did not result in worse outcomes compared with those receiving oral FQ or TS.
Disclosures
All authors: No reported disclosures.
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Affiliation(s)
| | | | | | - Brian Olivares
- The University of Texas at Austin College of Pharmacy, Austin, Texas
| | - F Parker Hudson
- Dell Medical School The University of Texas at Austin, Austin, Texas
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Carr AL, Daley MJ, Givens Merkel K, Rose DT. Clinical Utility of Methicillin-Resistant Staphylococcus aureus Nasal Screening for Antimicrobial Stewardship: A Review of Current Literature. Pharmacotherapy 2018; 38:1216-1228. [PMID: 30300441 DOI: 10.1002/phar.2188] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Significant clinical and financial consequences are associated with both inadequate and unnecessary exposure to broad-spectrum antibiotics. As such, antimicrobial stewardship programs seek objective, reliable, and cost-effective tests to identify patients at highest or lowest risk for drug-resistant organisms to guide empirical antimicrobial selection. Use of methicillin-resistant Staphylococcus aureus (MRSA) nasal screening to rule out MRSA in lower respiratory tract infections has led to significant reductions in duration of vancomycin therapy. The clinical utility of MRSA nasal screening in other types of infection remains less clear. This review describes the performance of MRSA nasal screening in predicting MRSA infection, highlights practical considerations for use of MRSA nasal screening, and provides guidance for incorporating MRSA nasal screening into clinical practice. With a high negative predictive value when the prevalence of MRSA is low, MRSA nasal screening is a valuable antimicrobial stewardship tool with potential applications beyond lower respiratory tract infections. In appropriately selected patients, negative MRSA nasal screening can prevent initiation or guide discontinuation of anti-MRSA therapy. Antimicrobial stewardship programs should develop institutional guidelines to promote proper use of MRSA nasal screening. Pharmacists are well positioned to assist with education, interpretation, and application of MRSA nasal screening results.
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Affiliation(s)
- Amy L Carr
- Department of Pharmacy, Florida Hospital Orlando, Orlando, Florida
| | - Mitchell J Daley
- Department of Pharmacy, Seton Healthcare Family, Dell Seton Medical Center at The University of Texas, Austin, Texas
| | - Kathryn Givens Merkel
- Department of Pharmacy, St. David's Healthcare, St. David's South Austin Medical Center, Austin, Texas
| | - Dusten T Rose
- Department of Pharmacy, Seton Healthcare Family, Dell Seton Medical Center at The University of Texas, Austin, Texas
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Rhodes NJ, Grove ME, Kiel PJ, O'Donnell JN, Whited LK, Rose DT, Jones DR, Scheetz MH. Population pharmacokinetics of cefepime in febrile neutropenia: implications for dose-dependent susceptibility and contemporary dosing regimens. Int J Antimicrob Agents 2017; 50:482-486. [DOI: 10.1016/j.ijantimicag.2017.04.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/30/2017] [Accepted: 04/05/2017] [Indexed: 11/16/2022]
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Gibb BE, Alloy LB, Abramson LY, Rose DT, Whitehouse WG, Hogan ME. Childhood maltreatment and college students' current suicidal ideation: a test of the hopelessness theory. Suicide Life Threat Behav 2002; 31:405-15. [PMID: 11775716 DOI: 10.1521/suli.31.4.405.22042] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Few studies have examined the relation between childhood maltreatment and adult suicidality within the context of a coherent theoretical model. The current study evaluates the ability of the hopelessness theory of depression's (Abramson, Metalsky, & Alloy, 1989) etiological chain to account for this relation in a sample of 297 undergraduates. Supporting the model, emotional, but not physical or sexual, maltreatment was uniquely related to average levels of suicidal ideation across a 2.5-year follow-up. Further, students' cognitive styles and average levels of hopelessness partially mediated this relation. Although these results cannot speak to causality, they support the developmental model evaluated.
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Affiliation(s)
- B E Gibb
- Department of Psychology, Temple University, Philadelphia, Pennsylvania 19122-6085, USA.
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Alloy LB, Abramson LY, Hogan ME, Whitehouse WG, Rose DT, Robinson MS, Kim RS, Lapkin JB. The Temple-Wisconsin Cognitive Vulnerability to Depression Project: lifetime history of axis I psychopathology in individuals at high and low cognitive risk for depression. J Abnorm Psychol 2000; 109:403-18. [PMID: 11016110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
The authors tested the cognitive vulnerability hypotheses of depression with a retrospective behavioral high-risk design. Individuals without current Axis I diagnoses who exhibited either negative or positive cognitive styles were compared on lifetime prevalence of depressive and other disorders and the clinical parameters of depressive episodes. Consistent with predictions, cognitively high-risk participants had higher lifetime prevalence than low-risk participants of major and hopelessness depression and marginally higher prevalence of minor depression. These group differences were specific to depressive disorders. The high-risk group also had more severe depressions than the low-risk group, but not longer duration or earlier onset depressions. The risk group differences in prevalence of depressive disorders were not mediated by current depressive symptoms.
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Affiliation(s)
- L B Alloy
- Department of Psychology, Temple University, USA.
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Alloy LB, Abramson LY, Whitehouse WG, Hogan ME, Tashman NA, Steinberg DL, Rose DT, Donovan P. Depressogenic cognitive styles: predictive validity, information processing and personality characteristics, and developmental origins. Behav Res Ther 1999; 37:503-31. [PMID: 10372466 DOI: 10.1016/s0005-7967(98)00157-0] [Citation(s) in RCA: 222] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Two of the major cognitive theories of depression, the theory of Beck [Beck, A. T. (1967). Depression: clinical, experimental and theoretical aspects. New York: Harper & Row. and Beck, A. T. (1987) Cognitive models of depression. Journal of Cognitive Psychotherapy: an International Quarterly, 1, 5-37] and the hopelessness theory [Abramson, Metalsky, & Alloy, (1989) Hopelessness depression: a theory-based subtype of depression. Psychological Review, 96, 358-372], include the hypothesis that particular negative cognitive styles increase individuals' likelihood of developing episodes of depression, in particular, a cognitively mediated subtype of depression, when they encounter negative life events. The Temple-Wisconsin Cognitive Vulnerability to Depression (CVD) project is a two-site, prospective longitudinal study designed to test this cognitive vulnerability hypothesis, as well as the other etiological hypotheses of Beck's and the hopelessness theories of depression. In this article, based on CVD project findings to date, we review evidence that the hypothesized depressogenic cognitive styles do indeed confer vulnerability for clinically significant depressive disorders and suicidality. In addition, we present evidence regarding moderators of these depressogenic cognitive styles, the information processing and personality correlates of these styles and the possible developmental antecedents of these styles. We end with a consideration of future research directions and the clinical implications of cognitive vulnerability to depression.
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Affiliation(s)
- L B Alloy
- Department of Psychology, Weiss Hall, Temple University, Philadelphia, PA 19122, USA
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Abstract
In this, the second decade of the AIDS epidemic, most gay men have adequate knowledge of the most efficient transmission routes. Men know the techniques recommended to significantly reduce the likelihood of transmission. Men do not want to be infected. Yet some continue to take chances for sexual transmission of HIV. Why? This paper will explore the reasons given by men in a small city for engaging (or not) in specific sexual practices. Our primary finding is that most men do consider themselves to be taking adequate precautions against infection--even if an outside observer might disagree on "objective" grounds.
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Affiliation(s)
- L J Ames
- State University of New York, Plattsburgh 12901, USA
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Abstract
An inference from the cognitive theories of depression is that only a subset of depressed individuals should exhibit distinctively negative cognitive styles. Although this inference has been supported by previous research, attempts to characterize these depressives have yielded few identifying variables. This study of psychiatric inpatients and normal control subjects identified several characteristics of depressives with very negative cognitive styles by (a) examining traditional depression subtypes, (b) grouping depressives on the basis of clinical observations, and (c) asking whether sex, developmental events, and history and severity of depression predict cognitive styles. We found that borderline personality disorder, negative family dynamics during childhood, a history of sexual abuse, and severity of depression predict cognitive styles. We speculate that aversive developmental events may contribute to cognitive vulnerability to depression.
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Affiliation(s)
- D T Rose
- Department of Psychology, University of Wisconsin. Madison
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