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1681. Moxifloxacin for community acquired pneumonia

pneumonia caused by bacteria. Drug (Product Monograph) Category: Moxifloxacin is a member of the fluoroquinolone class of antibiotics. Mechanism of Action: Moxifloxacin 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: Moxifloxacin is indicated for the treatment of adults with upper and lower respiratory tract, skin/skin structure, and intra-abdominal (...) infections. Dose & Duration: the recommended dose is 400mg i.v./oral once daily for 10 days in outpatients and 7-14 days in hospitalized patients. Methodology of Systematic Review Research Question: In double blind randomized controlled trials (DB RCTs), does 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 with community acquired pneumonia

2008 Therapeutics Letter

1682. Moxifloxacin for acute exacerbations of chronic bronchitis

bronchitis. International Journal of Antimicrobial Agents, 29: 56-61, 2007. Talib, S.H., Arshad, M., Chauhan, H., Jain, R. et al. Phase III clinical trial of moxifloxacin hydrochloride in the treatment of acute exacerbations of chronic bronchitis in comparison with azithromycin. Journal, Indian Academy of Clinical Medicine, 3(4): 360-366, 2002. Wilson, R., Allegra, L., Huchon, G., Izquierdo, J-L. et al. Short-term and long-term outcomes of moxifloxacin compared to standard antibiotic treatment in acute (...) of antibiotics. Mechanism of Action: Moxifloxacin 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: Moxifloxacin is indicated for the treatment of adults with upper and lower respiratory tract, skin/skin structure, and intra-abdominal infections. Dose & Duration: The recommended dose is 400mg i.v./oral once daily for 5 days. Methodology of Systematic Review

2008 Therapeutics Letter

1683. Prescription drug costs: BC versus Canada

, e.g. haloperidol newer, e.g. risperidone, olanzapine, quetiapine – 6 Oral antibiotics penicillins, sulfa drugs, cephalosporins, tetracyclines, macrolides, fluoroquinolones, etc. -13 Moderately below national average (-16% to -25%) Hormonal oral contraceptives e.g. ethinyl estradiol /norgestimate -18 Antithrombotics clopidogrel, ticlopidine, warfarin, ASA/dipyridamole – 21 Insulins regular, NPH, lispro, aspart, glargine, etc. – 24 > 25% below national average Antihypertensives thiazides, beta

2008 Therapeutics Letter

1684. Is a stentless aortic valve superior to conventional bioprosthetic valves for aortic valve replacement?

excellent outcomes, stentless valves did not demonstrate superior haemodynamic indices in comparison to stented valves up to 12 months after. Neither valve offered a superior internal diameter for any given annular diameter Maselli et al, 1999 Italy Four groups of 10 patients each were randomly assigned to receive: (1) aortic homograft preserved in antibiotic solution at 4 degrees C, (2) Toronto stentless porcine valve, (3) Medtronic Freestyle stentless valve, or (4) Medtronic Intact aortic valve PRCT

2008 BestBETS

1685. Is the frequency of recurrent chest infections, in children with chronic neurological problems, reduced by prophylactic azithromycin?

evidence from data for children with cystic fibrosis. Macrolide antibiotics are known from studies conducted in Japan in adults with diffuse panbronchiolitis to have both direct antibacterial properties and additional anti-inflammatory properties. They are also thought to reduce so-called virulence factors, such as the production of a mucoid biofilm which protects P aeruginosa from host defences, and hence theoretically have an additional beneficial outcome for those with cystic fibrosis who (...) barium studies and swallow assessments show that he chronically aspirates his secretions. He has no symptoms of upper airway obstruction. Over the last year, he has had increasingly frequent lower respiratory tract infections, requiring admission and intra-venous antibiotics. His weight and height have fallen from the 10th to the 3rd percentile. A chest x ray shows chronic changes suggestive of underlying bronchiectasis and he is now colonised with Pseudomonas aeruginosa. Immune function and a sweat

2008 BestBETS

1686. Is the use of chest physiotherapy beneficial in children with community acquired pneumonia?

with presumed viral pneumonia. 32 received chest physiotherapy and 23 did not RCT (level 2b) Time until improvement in pneumonic infiltrate seen on serial CXRs No statistical difference in time until CXR improvement seen between treatment group and controls (means 5.91 and 6.13 days) Poor method of randomisation Different numbers of patients in treatment and control groups not explained Diagnosis of viral pneumonia not confirmed by isolation studies or serology Antibiotic therapy before or after admission (...) into the studies. The Levine study included children with presumed viral pneumonia and therefore the use of antibiotics prior to or during admission was not deemed significant. As they did not confirm the diagnosis of viral pneumonia by viral isolation or serological studies, children with bacterial pneumonia may have been included in the study. If such patients were included, antibiotics are likely to have influenced the pneumonic infiltrates and the duration of fever and so any difference between

2008 BestBETS

1687. What is the best treatment for empyema?

thoracoscopy (VATs) or percutaneous chest drain with fibrinolytic therapy] be used [to resolve symptoms]? Clinical Scenario A 7-year-old child with a history of cough and fever for 1 week, has bronchial breathing over her left lower zone on auscultation. A diagnosis of lobar pneumonia is made, confirmed on plain chest x ray, and she is treated with appropriate intravenous antibiotics. However, she continues to have a spiking fever and develops signs of a left sided pleural effusion. Repeat chest x ray (...) if there was not sufficient drainage within 24 h (7) PRCT (level 1b) Hospital stay VATS significantly shorter 5.8 compared with 13.2) No ethical consent obtained. Chest drain removed when Number of days of chest drain VATS 2.80 (significant), thoracostomy 9.63. Narcotic use (days) VATS 2.20 (significant), thoracostomy 7.63 Sonnappa et al, 2006, USA 60 patients under 16 with radiographic evidence of empyema (CXR and US) and persistent fever or >24 h of parenteral antibiotics or respiratory distress caused by collection

2008 BestBETS

1688. Role of topical analgesia in acute otitis media.

media] is [the use of topical analgesia better than placebo] at [reducing pain and discomfort]? Clinical Scenario A 6 year-old boy presents to the emergency department with a two day history of earache and fever. After examination, Acute Otitis Media was diagnosed and a prescription for analgesia and oral antibiotic course were given. You wonder if the administration of topical analgesia (ie eardrops) would be helpful in providing additional and fast relief of this child's pain symptoms. Search (...) Study type (level of evidence) Outcomes Key results Study Weaknesses Foxlee R et al, 2006, Australia Double-blind randomised or quasi-randomised controlled trials comparing an otic preparation with an analgesic effect (excluding antibiotics) versus placebo or an otic preparation with an analgesic effect (excluding antibiotics) versus any other otic preparation with an analgesic effect, in adults or children presenting at primary care settings with AOM without perforation Meta-Analysis / Review

2008 BestBETS

1689. Dexamethasone in Meningitis

medication with dexamethasone] useful at [improving outcome]? Clinical Scenario A 38-year-old previously fit and well insulin-dependent diabetic presents to the emergency department with a fever, vomiting and reduced Glasgow Coma Score. He has obvious signs of meningism and is suspected to have acute bacterial meningitis. He is appropriately managed with antibiotics and is subsequently intubated and transferred to the intensive care unit. His initial CT brain scan is unremarkable, but the LP is turbid (...) bias and thereby, possibly causing an underestimation of the beneficial effect of corticosteroids Treatment Drug: 17/28 studies used dexamthasone as the treatment drug; while 1 used hydrocortisone, prednisolone or a combination Timing of administration: In only 9/18 studies the drug was administered before or with the first dose of antibiotic. Heterogenecity: Only on RCT (as assessed by the Jadad scale )was included. First study published in 1963, last two in 2002. Adverse Events: Definitions

2008 BestBETS

1690. Should the tricuspid valve be replaced with a mechanical or biological valve?

has been under the care of your cardiologists for 8 weeks with Tricuspid valve endocarditis. She has successfully undergone 6 weeks of antibiotic therapy and 3 blood cultures off antibiotics have all been negative. However she has severe tricuspid regurgitation with hepatic congestion and peripheral oedema and requires tricuspid replacement. You wonder whether to use a biological or mechanical valve. Search Strategy Medline 1950–April 2007 using the OVID interface [exp Tricuspid Valve

2007 BestBETS

1691. Should vacuum-assisted closure therapy be routinely used for management of deep sternal wound infection after cardiac surgery?

study (Level 3b) Mortality and morbidity Fifty-three of the 96 patients required only sternal debridement, followed by wound vacuum therapy and closure by secondary intention, while the remaining 43 had an additional procedure. Of these, 33 patients underwent omental transposition and 10 patients had a pectoralis flap. The length of stay for all patients was 27 +/- 12 days. This was related in part to intravenous antibiotics. Hospital mortality for all patients was 3.7% (4 patients). Large case

2007 BestBETS

1692. Is interval appendectomy necessary after conservative treatment of appendiceal mass in children?

had previously presented with a 1 day history of severe abdominal pain and fever and had been discharged the following day with a diagnosis of gastroenteritis. He was transferred to the tertiary hospital and a diagnosis was made on ultrasound scan of appendiceal mass with abscess. His condition was stable. He was commenced on conservative management and supportive care with intravenous (iv) antibiotics followed by a 2 week course of oral antibiotics. He responded well to conservative management (...) ) with supportive care and antibiotics active against enteric flora (eg, cefuroxime, gentamicin and metronidazole). Non-surgical management usually requires that the patient has well localised tenderness over an appendix mass, is not overtly ill or deteriorating, and is without generalised peritonitis. Should the mass enlarge, clinical condition worsen or fevers continue after a few days of antibiotics, conservative management is considered to have failed and appendectomy is usually performed. Conservative

2008 BestBETS

1693. Diagnostic utility of rapid immunochromatographic urine antigen testing in suspected pneumococcal infections

with a provisional diagnosis of bronchiolitis. Nasopharyngeal aspirate for respiratory syncytial virus turns out to be negative. Over the next few hours, he is noted to have high grade pyrexia with a gradual clinical deterioration. As the on-call specialist registrar in paediatrics, you are now worried about a possible bacterial aetiology. You decide to commence antibiotics after sending a sample for blood culture. A chest radiograph, full blood count and C-reactive protein level do not help to distinguish (...) positivity, blood culture Among 56 children, 14.3% had positive cultures and 55% had positive ICT. ICT:Sensitivity 88%, specificity 75% Positivity not influenced by age, duration of previous antibiotic therapy or nasopharyngeal colonisation Main purpose of this study was to evaluate utility of PCR in comparison with culture, serology and urinary antigen excretion. Specificity of assay and assessment of impact of colonisation not reliable as study is underpowered by the limited sample size. Concludes

2008 BestBETS

1694. Ertapenem (Invanz) - for the prophylaxis of surgical site infection following elective colorectal surgery in adults

of a long-acting prophylactic agent are unclear. The manufacturer proposed advantages for the use of a single agent, as opposed to 2 antibiotics, with regard to preparation time and administration issues; these are not so significant if it is accepted that cefuroxime and metronidazole are frequently co-administered. Clinical experts raised concerns about the routine use of ertapenem for prophylaxis in colorectal surgery as it has a broader antimicrobial spectrum than current regimens there is potential (...) is summarised as follows: ADVICE: following a full submission ertapenem (Invanz ® ) is accepted for restricted use within NHS Scotland for the prophylaxis of surgical site infection following elective colorectal surgery in adults. It is effective in reducing the incidence of surgical site infection, although there are currently no comparisons with regimens used in Scotland. It is restricted to use in line with local antimicrobial policies and Microbiologist advice. Overleaf is the detailed advice

2007 Scottish Medicines Consortium

1695. Is a once daily dose of gentamicin safe and effective in the treatment of uti in infants and children?

in children, after those of the ear and throat (Bonadio). If intravenous antibiotics are required, aminoglycosides or third generation cephalosporins are usually used. Escherichia coli is a causative organism in 80–90% of cases (Poole) of UTI in children, making it a suitable clinical setting for aminoglycoside use in children. When compared to cephalosporins, aminoglycosides are favoured because of their efficacy, low rate of resistance (Lortholary) widespread availability and low cost. Gentamicin

2007 BestBETS

1696. Leukocytosis as a predictor for progression to haemolytic uraemic syndrome in Escherichia coli O157:H7 infection

HUS:Adjusted RR 6 (1.2 to 29.8) p Exclusive paediatric study with sound methodology, strict inclusion criteria and clear definitions. Main aim of the study was to evaluate antibiotic-associated risk Kawamura et al, 1999, Japan 126 junior high school children with proven E Coli O157:H7 infection in the 1996 Sakai outbreak Prospective cohort study (level 4) Risk factor: WBC >10x10 to the power of 9/l Confirmed HUS:34% of patients with WBC above the cut-off level of 10x10 to the power of 9/l developed HUS (...) . Buteau C, Proulx F, Chaibou M, et al. Leukocytosis in children with Escherichia coli O157:H7 enteritis developing the hemolytic-uremic syndrome. Pediatr Infect Dis J 2000; 19 (7): 642–7. Wong CS, Jelacic S, Habeeb RL, et al. The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections. N Engl J Med 2000; 342 (26): 1930–6. Kawamura N, Yamazaki T, Tamai H. Risk factors for the development of Escherichia coli O157:H7 associated with hemolytic uremic

2007 BestBETS

1697. In children under age three does procalcitonin help exclude serious bacterial infection in fever without focus?

and clean catch urine is normal. There are no respiratory symptoms and no clinical signs of meningitis. You think he has a low risk of a serious bacterial illness. You wonder if procalcitonin can help you exclude serious bacterial illness that may need antibiotics? Search Strategy The primary source was Medline using PubMed: (("procalcitonin"[Substance Name] OR procalcitonin[Text Word]) AND ("infant"[MeSH Terms:noexp] OR "child, preschool"[MeSH Terms])) OR (("procalcitonin"[Substance Name (...) 700. The outcome for this 340 remaining is not mentioned. Lacour, AG 2001 Switzerland 124 children age 7 days to 36 months presenting to a single children's hospital with a temperature > 38 degrees without an obvious focus. Excluded fever > 7 days, antibiotics 48 hours prior, immunodeficiencies. Exploratory prospective cohort with blind allocation (level 2b). Serious Bacterial Illness versus benign infection using PCT = 0.9 (26,2,21,75) Bacteraemia 4/124. Sensitivity 0.93 (0.77-0.98). Specificity

2007 BestBETS

1698. Are young infants treated with erythromycin at risk for developing hypertrophic pyloric stenosis?

procedure were identified. Exposure to erythromycin or other antibiotics between 3 and 90 days of life was identified from prescription files Among 314 029 infants enrolled in Medicaid, 804 (2.6/100 infants) met the criteria for pyloric stenosis Retrospective cohort study (level IIb) Association between erythromycin use and development of pyloric stenosis Very early exposure to erythromycin (between 3 and 13 days of life) was associated with nearly eightfold increased risk of pyloric stenosis (adjusted (...) incidence rate, 7.88; 95% CI 1.97 to 31.57) Exposure to erythromycin before 90 days of life was associated with a twofold increase risk of pyloric stenosis (adjusted rate ratio, 2.05; 95% CI 1.06 to 3.97). No increased risk of pyloric stenosis was seen in infants exposed to antibiotics other than erythromycin. Retrospective study Decent sample size Infants included in Honein et al's study were not included Sorensen et al, 2003, Denmark All women who had live or still births after 28 weeks of gestation

2007 BestBETS

1699. Safety of anti-infective agents for skin preparation in premature infants

problems related to skin burns in infants. (Grade C) Alcohol based preparations have good antibacterial activity in adults and have an excellent safety profile. (Grade C) References Hibbard J S. Mulberry K G, Brady A R. A clinical study comparing the skin antisepsis and safety of chloraprep, 70% isopropyl alcohol, and 2% aqueous chlorhexidine. J Infus Nurs 2002;4:244–9. Hibbard J S. Analyses comparing the antimicrobial activity and safety of current antiseptic agents: a review. J Infus Nurs 2005;28:194 (...) source: Medline (1956–2005), MeSH terms were used. An advance search was carried out and close matches from mapping were chosen and another search was carried out using explode and major subheadings. Secondary sources: Cochrane and EMBASE. Search terms: Premature and anti-infective agents and invasive procedures and safety and complications. Search Outcome Only four hits matched all our search criteria. We further searched for trials that looked at the safety and efficacy of different antimicrobials

2007 BestBETS

1700. Silver sulphadiazine cream in burns

and undisturbed environment to allow healing. One confounding factor in these studies may be that the flamazine dressings tended to be changed 12hrly while the other dressings were left intact for longer. Clinical Bottom Line Despite evidence of the antibacterial properties of this compound no evidence was found showing a definitive improvement in outcome in terms of infection rates or healing time. Local advice should be followed. Level of Evidence Level 3 - Small numbers of small studies or great

2007 BestBETS

Evidence-based Synopses

Synopses are typically easily digested, critical commentaries of articles e.g. critically appraised topics.