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1661. 1 day quadruple therapy was not inferior to 7 day triple therapy for eradication of Helicobacter pylori infection in dyspe Full Text available with Trip Pro

Dyspepsia Severity Score (GDSS) ⩾3 (score range 0–20), and a positive carbon 14 urea breath test result. Exclusion criteria included previous treatment of H pylori infection, pregnancy, personal or family history of gastrointestinal malignancy, antibiotic therapy in the previous 6 weeks, previous gastric surgery, and hepatic insufficiency. Interventions: 1 day regimen of 2 tablets of bismuth subsalicylate, 262 mg each tablet, 4 times; 1 tablet of metronidazole, 500 mg, 4 times; amoxicillin suspension, 2

2005 Evidence-Based Medicine

1662. Should a neonate with possible late onset infection always have a lumbar puncture?

for treatment, such as the increased length of therapy or the choice of antimicrobial agent, where agents with higher CSF penetration may need to be considered. The mortality and morbidity in late onset meningitis is higher than in early onset meningitis. Blood cultures may often be negative in these babies, causing antibiotics to be discontinued too soon. The studies are in agreement that 15–30% of babies with meningitis (CSF culture positive) have negative blood cultures. Some of this may be due (...) of this, nasal continuous positive airway pressure is started, a blood culture taken, and broad spectrum antibiotics commenced. On the ward round the next morning there is a debate as to whether a lumbar puncture (LP) should also have been performed, as part of the investigations for bacterial infection. The registrar opines that this was considered, but that the baby was thought "too unstable" for the procedure. If an LP is performed routinely as part of the investigations for infection, how often

2006 BestBETS

1663. Should steroids be used in children with meningococcal shock?

(complete) Three Part Question In [a child with meningococcal shock] does [steroid replacement therapy] decrease [mortality]? Clinical Scenario A 3 year old boy is admitted to a paediatric intensive care unit with a history of fever, non-blanching petechial rash, decreased conscious level, and grunting; capillary refill is poor. After screening for sepsis, antibiotics are started. He is intubated, receives fluid resuscitation (total of 100 ml/kg), and a central catheter is placed, showing a central

2005 BestBETS

1664. Non-sterile gloves were as safe as sterile gloves for repair of uncomplicated lacerations Full Text available with Trip Pro

, immunodeficiency, liver cirrhosis, tendency to form keloid scars, current use of antibiotics, or need for prophylactic antibiotics. Intervention: wound repair by the physician wearing latex free gloves that were non-sterile (n = 408) or sterile (n = 408) (both types of gloves Allegiance, Cardinal Health Company, IL, USA). Outcomes: wound infection rate determined by the physician providing wound follow up (with culture results if the wound was deemed sufficiently infected to warrant a swab) or by standardised

2005 Evidence-Based Medicine

1665. Review: exercise based cardiac rehabilitation reduces all cause and cardiac mortality in coronary heart disease Full Text available with Trip Pro

guidance and high quality research have been in short supply. The updated systematic review by Koning et al and a recent review by George and Rubin have been published in an attempt to address these deficiencies. These 2 reviews were similarly elegant and rigorous, with high concordance between chosen studies, despite minor differences in inclusion criteria. The conclusions were similar. Mupirocin and fusidic acid appear to be the most effective topical antibiotics. They seem preferable to erythromycin (...) in this important area. Flucoxacillin is listed as the first choice for widespread disease in the British National Formulary, but evidence for its use in preference to topical treatment or alternative oral antibiotics is scanty, and definitions of widespread disease are also lacking. Thus, the usefulness of erythromycin or non-antibiotic disinfecting agents cannot be discounted despite their disadvantages. Both reviews indicate that more research, properly powered and assessing a single disease, is needed

2005 Evidence-Based Medicine

1666. Anticoagulant plus antiplatelet treatment increased the risk of bleeding in atrial fibrillation Full Text available with Trip Pro

-inflammatory drugs (OR 1.41, CI 1.09 to 1.82) or other medications (OR 1.28, CI 1.16 to 1.43) increased the likelihood of being prescribed antiplatelets. Women (OR 0.80, CI 0.72 to 0.88) and patients with previous warfarin use (OR 0.63, CI 0.57 to 0.70), dementia (OR 0.76, CI 0.62 to 0.93), cancer (OR 0.56, CI 0.38 to 0.83), a discharge antibiotic (OR 0.80, CI 0.71 to 0.90), or terminal status (prognosis <6 mo) (OR 0.77, CI 0.64 to 0.92) were less likely to be prescribed antiplatelets. View this table

2006 Evidence-Based Medicine

1667. Neutropenic Precautions Demystified

of antimicrobial prophylaxis and systemic growth factors? Typical strategies to prevent infection among neutropenic patients have included a protective environment, dietary constraints, and protective clothing. With the resource burden associated with maintaining protective measures, there are surprisingly few studies systematically monitoring infection rates in neutropenic patients. In the early eighties, investigators studied the effect of laminar airflow and HEPA filtration in decreasing the rates (...) ]. It is important to note that although the majority of deaths from leukemia and solid tumors are related to infection secondary to neutropenia, the majority of infections are a result of translocation of microbial flora, largely from the patient’s gastrointestinal tract [10,11]. It has been shown that suppression of the patient’s endogenous flora with prophylactic antibiotics has the best outcome, regardless of whether the patient has received standard ward care or has been treated in a protected environment

2008 Clinical Correlations

1668. Grand Rounds: Regulation of Mammalian Iron Metabolism Reveals a Link to Inflammation

are phagocytosed by macrophages which provides 20-30 mg of iron/day. Iron entry into plasma is regulated through hepcidin. Hepcidin is a small 25 amino acid protein, which is a member of the defensins family of antimicrobial peptides. It is secreted primarily by hepatocytes. Hepcidin synthesis is increased in periods of inflammation, and decreased in hypoxia and anemia. In mice and humans, deletion of the hepcidin gene, HAMP, results in iron overload, and over-expression of HAMP causes anemia, indicating

2008 Clinical Correlations

1669. Grand Rounds: Pseudomonas aeruginosa Pathogenesis-Studies of an Opportunist

quorum sensing signals. Other bacterial virulence factors, such as flagella that enable movement, are also downregulated during chronic persistence, limiting immune detection and host clearance of Pseudomonas . Understanding the pathogenesis of this organism in acute and chronic forms of infection has important clinical implications. Bacteria are increasingly becoming more resistant to our antibiotic armamentarium, especially Pseudomonas , necessitating newer agents designed to target vulnerable

2007 Clinical Correlations

1670. Grand Rounds: Bacterial Meningitis

observations have led to the use corticosteroids in bacterial meningitis, with the thinking that they could attenuate the breach of the blood-brain barrier. In a large clinical trial in the Netherlands, adjunctive dexamethasone reduced mortality and morbidity, but the overall effect appeared limited to those with S. pneumoniae disease and those with Glasgow Coma Scale of <11. Current recommendations for empiric treatment of bacterial meningitis require bactericidal antibiotics. For immunocompetent adults (...) with suspected bacterial meningitis, the recommendations are Ceftriaxone plus Vancomycin (+Ampicillin if age >60 since Listeria is considered in this age group); however, if corticosteroids are given then Rifampin is recommended in place of Vancomycin, because dexamethasone inhibits the penetration of vancomycin, but not rifampin, into the CSF. In immune deficient or neurosurgical patients, double coverage of gram-negative organisms is necessary. In summary: 1. An LP and initiation of antibiotics should

2008 Clinical Correlations

1671. Grand Rounds: 10 Moveable Objects

of medical education. Another problem with graduate medical education addressed by Dr. Wiese includes how to more effectively determine patient caps. He suggests basing caps on a modified APACHE score as opposed to hard numbers. He also referred to “Patient Emeritus Services,” whereby patients hospitalized for long-term are grouped according to need, i.e. antibiotic administration, and are managed by Nurse Practitioners rather than housestaff in order to unburden resident teams and improve

2008 Clinical Correlations

1672. What Is Sezary Syndrome?

therapy. Her rash progressed to a diffuse pruritic erythema covering the vast majority of her body, including palms and soles. (erythroderma). She was noted to have Sezary cells on peripheral smear and diagnosed with Sezary syndrome. She was now admitted to TH with fevers likely secondary to cellulitis on her lower extremities, the site of significant skin breakdown. The patient is improving on treatment with IV antibiotics and interferon alpha. (image courtesy of ) Teaching Points: 1. What is Mycosis

2006 Clinical Correlations

1673. Some say tomato, some say nationwide outbreak of Samonellosis

. Given that the disease is self-limited, antibiotic treatment is usually not indicated unless the patient is severely ill, immunocompromised, or at either end of the age spectrum. Any patients who present to their physician’s office with diarrhea and stomach cramps and who report a history of fresh tomato consumption should have stool cultures sent. All specimens positive for clinical Salmonella isolates should be forwarded to the NYC DOHMH. Share: | | Sites We Follow: Useful Links: Questions

2008 Clinical Correlations

1674. Clinical Pharmacy Corner: Sulfonamide Allergy and Cross-Reactivity

. We must remain informed but know that may more life-years will be saved with these medications than will be lost from adverse effects. I think the nature of the reaction is important. A reaction like anaphylaxis, urticaria and shortness of breath with Sulfur antibiotic is more worrisome. Mild reactions are not an absolute contraindications to topical use of agents such as dorzolamide or brinzolamide which do not carry risk of mortality. Comments are closed. Sites We Follow: Useful Links

2007 Clinical Correlations

1675. Case Presentation: Acute Rheumatic Fever

, and diffuse myalgias. There was no associated cough. Three days later, he visited his primary care physician at an outside facility and was prescribed penicillin 500 mg twice daily for presumed streptococcal pharyngitis. Five days later, he presented to the emergency room of an outside hospital and stopped his antibiotics after a throat culture there was negative for beta-hemolytic strep. The following morning, the patient awoke in the middle of the night with severe left-sided chest pain and presented (...) 5 days after the initial TTE showed improved left ventricular wall motion, and the patient was discharged home with instructions to receive monthly intramuscular injections of penicillin G benzathine 1.2 million units for five to ten years. Prior to his discharge, contact with his outside primary care physician confirmed that his initial culture prior to starting antibiotics was positive for group A beta-hemolytic streptococcus. Discussion: Acute rheumatic fever (ARF) is a delayed, non

2008 Clinical Correlations

1676. New Drugs VIII ? Telithromycin (Ketek®), Ezetimibe (Ezetrol®), Topical Pimecrolimus (Elidel®), and Tacrolimus (Protopic®)

) Approved indications: Community-acquired pneumonia (mild to moderate) (CAP), acute bacterial exacerbation of chronic bronchitis (AECB), and tonsillitis/pharyngitis (patients intolerant to beta-lactam antibiotics). Mechanism of action: Telithromycin is a synthetic derivative of erythromycin, with a mechanism of action and spectrum of antibiotic sensitivity and resistance similar to other macrolide antibiotics. Pharmacokinetics: Telithromycin is 60% bioavailable by mouth and widely distributed throughout

2004 Therapeutics Letter

1677. Levofloxacin for acute bacterial sinusitis

and signs suggesting bacterial, as opposed to viral sinusitis include purulent nasal discharge in combination with facial pain and maxillary toothache, facial swelling and tenderness. Most diagnoses are based on history and physical examination as opposed to laboratory cultures and sinus xrays, which are considered unreliable. Drug (Product Monograph) Category: Levofloxacin is a fluoroquinolone class, broad-spectrum antibacterial agent. It is the L- isomer of the racemate, ofloxacin. Mechanism of Action (...) for 5 days (short-course therapy). Methodology of Systematic Review Research Question: In double blind randomized controlled trials (DB RCTs), does levofloxacin (normal or short-course of therapy) provide a significant therapeutic advantage in terms of mortality or morbidity when compared to other fluoroquinolones or other classes of antibacterial agents in the treatment of adult patients ≥ 18 years of age with acute bacterial sinusitis? Assessment principles: Double blind randomized controlled

2008 Therapeutics Letter

1678. Moxifloxacin for acute bacterial sinusitis

and signs suggesting bacterial, as opposed to viral sinusitis include purulent nasal discharge in combination with facial pain and maxillary toothache, facial swelling and tenderness. Most diagnoses are based on history and physical examination as opposed to laboratory cultures and sinus xrays, which are considered unreliable. Drug (quoted from Product Monograph) Category: Moxifloxacin is a fluoroquinolone class, broad-spectrum antibacterial agent. Mechanism of Action: moxifloxacin exerts its action (...) moxifloxacin provide a significant therapeutic advantage in terms of mortality or morbidity when compared to other fluoroquinolones or other classes of antibacterial agents in the treatment of adult patients ≥ 18 years of age with acute bacterial sinusitis? Assessment principles: Double blind randomized controlled trials comparing moxifloxacin to other fluoroquinolones or other classes of antibacterial agents in adult patients with acute bacterial sinusitis will be critically appraised. Therapeutic impact

2008 Therapeutics Letter

1679. Levofloxacin for acute exacerbations of chronic bronchitis

, is a member of the fluoroquinolone class of antibiotics. Mechanism of Action: Levofloxacin exerts its action by inhibiting the bacterial topoisomerases II (DNA gyrase) and topoisomerases IV, which interferes with bacterial DNA replication, transcription, repair, and recombination. Indications: Levofloxacin is indicated for the treatment of adults with upper and lower respiratory tract, skin/skin structure, and urinary tract infections. Dose & Duration: The recommended dose is 500mg i.v./oral once daily (...) for 7 days (normal course of therapy) or 750mg i.v./oral once daily for 5 days (short-course therapy). Methodology of Systematic Review Research Question: In double blind randomized controlled trials (DB RCTs), does levofloxacin (normal and short-course therapy) provide a significant therapeutic advantage in terms of mortality or morbidity when compared to other fluoroquinolones or other classes of antibacterial agents in the treatment of adult patients with acute exacerbations of chronic bronchitis

2008 Therapeutics Letter

1680. Levofloxacin for community acquired pneumonia

pneumonia caused by bacteria. Drug (Product Monograph) Category: Levofloxacin, the L-isomer of the racemate ofloxacin, is a member of the fluoroquinolone class of antibiotics. Mechanism of Action: Levofloxacin exerts its action by inhibiting the bacterial topoisomerases II (DNA gyrase) and topoisomerases IV which interferes with bacterial DNA replication, transcription, repair, and recombination. Indications: Levofloxacin is indicated for the treatment of adults with upper and lower respiratory tract (...) or other classes of antibacterial agents in the treatment of adult patients with community acquired pneumonia? Assessment principles: Double blind randomized controlled trials comparing levofloxacin to other fluoroquinolones or other classes of antibacterial agents in adult patients with community-acquired pneumonia were critically appraised. Therapeutic impact was assessed according to the following hierarchy of health outcomes – mortality, non fatal serious adverse events, quality of life

2008 Therapeutics Letter

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