Showing papers by "Detroit Receiving Hospital published in 1998"
TL;DR: Eperezolid and linezolid demonstrated good in vitro inhibitory activity, regardless of methicillin susceptibility for staphylococci or vancomycin susceptibility for enterococci, and were bacteriostatic in action in time-kill studies.
Abstract: The activities of the oxazolidinone antibacterial agents eperezolid (PNU-100592) and linezolid (PNU-100766) were compared with that of vancomycin against clinical isolates of methicillin-susceptible and -resistant Staphylococcus aureus (n = 200), coagulase-negative staphylococci (n = 100), and vancomycin-susceptible and -resistant Enterococcus faecalis and Enterococcus faecium (n = 50). Eperezolid and linezolid demonstrated good in vitro inhibitory activity, regardless of methicillin susceptibility for staphylococci (MIC at which 90% of the isolates are inhibited [MIC90] range, 1 to 4 μg/ml) or vancomycin susceptibility for enterococci (MIC90 range, 1 to 4 μg/ml). In time-kill studies, eperezolid and linezolid were bacteriostatic in action. A postantibiotic effect of 0.8 ± 0.5 h was demonstrated for both eperezolid and linezolid against S. aureus, S. epidermidis, E. faecalis, and E. faecium.
147 citations
TL;DR: Continuous monitoring of PiCO2 using capnometric recirculating gas tonometry can serve as an early indicator of systemic hypoperfusion before the onset of systemic supply dependency.
Abstract: Background: As systemic oxygen delivery (DO 2 ) is reduced, oxygen consumption (VO 2 ) is maintained until a critical level is reached (DO 2 crit) below which VO z becomes supply-dependent and anaerobic metabolism ensues. We examined the relationship between gastric intramucosal PcO 2 (Pi CO2 ) and the onset of systemic supply dependency. We also compared Pi CO2 to mixed venous and portal venous blood P CO2 (P mvCO2 and P pvCO2 ) to assess their utility as premonitory indicators of supply dependency. Methods: Six dogs were subjected to stepwise hemorrhage to effect a progressive decrease in Do 2 . Inflection points for changes in V O2 , Pi CO2 , P mvCO2 , and P pvCO2 versus Do 2 were determined. Results: Mean DO 2 crit was 6.0 ± 0.7 mL.kg -1 .min -1 , whereas the Do 2 at which inflection points occurred for Pi CO2 and ; Ppv CO2 were 13.2 ± 1.4 and 11.2 ± 1.5 mL.kg -1 .min -1 , respectively (p < 0.05 for both). Conclusion: Continuous monitoring of Pi CO2 using capnometric recirculating gas tonometry can serve as an early indicator of systemic hypoperfusion before the onset of systemic supply dependency.
70 citations
TL;DR: In this model of left-sided methicillin-resistant Staphylococcus aureusendocarditis, LY333328 was microbiologically effective and may be a therapeutic alternative to vancomycin.
Abstract: The in vivo efficacy of LY333328, a new glycopeptide antibiotic, was compared with that of vancomycin by using the rabbit model of left-sided methicillin-resistant Staphylococcus aureus endocarditis. Animals received LY333328 or vancomycin (25 mg/kg of body weight every 24 or 8 h, respectively) for 4 days. These drugs were equally effective in clearing bacteremia and in reducing bacterial counts in vegetations and tissues. We conclude that in this model, LY333328 was microbiologically effective and may be a therapeutic alternative to vancomycin.
53 citations
TL;DR: The findings replicated the development of resistance reported in humans and emphasized bacterial factors (drug susceptibility, high inoculum, organism growth phase) and infectious conditions (penetration barriers) which could increase chances for clinical resistance.
Abstract: Quinupristin-dalfopristin is a streptogramin antibiotic combination with activity against vancomycin-resistant Enterococcus faecium (VREF), but emergence of resistance has been recently reported. We studied the activity of quinupristin-dalfopristin against two clinical strains of VREF (12311 and 12366) in an in vitro pharmacodynamic model with simulated endocardial vegetations (SEVs) to determine the potential for resistance selection and possible strategies for prevention. Baseline MICs/minimal bactericidal concentrations (microg/ml) for quinupristin-dalfopristin, quinupristin, dalfopristin, and doxycycline were 0.25/2, 64/>512, 4/512, and 0.125/8 for VREF 12311 and 0.25/32, 128/>512, 2/128, and 0.25/16 for VREF 12366, respectively. Quinupristin-dalfopristin regimens had significantly less activity against VREF 12366 than VREF 12311. An 8-microg/ml simulated continuous infusion was the only bactericidal regimen with time to 99.9% killing = 90 hours. The combination of quinupristin-dalfopristin every 8 h with doxycycline resulted in more killing compared to either drug alone. Quinupristin-dalfopristin-resistant mutants (MICs, 4 microg/ml; resistance proportion, approximately 4 x 10(-4)) emerged during the quinupristin-dalfopristin monotherapies for both VREF strains. Resistance was unstable in VREF 12311 and stable in VREF 12366. The 8-microg/ml continuous infusion or addition of doxycycline to quinupristin-dalfopristin prevented the emergence of resistance for both strains over the 96-h test period. These findings replicated the development of resistance reported in humans and emphasized bacterial factors (drug susceptibility, high inoculum, organism growth phase) and infectious conditions (penetration barriers) which could increase chances for clinical resistance. The combination of quinupristin-dalfopristin with doxycycline and the administration of quinupristin-dalfopristin as a high-dose continuous infusion warrant further study to determine their potential clinical utility.
51 citations
TL;DR: A retrospective study of blunt chest injuries due to motor vehicle accidents between the years 1990 and 1995 found 9 cases of sternal fracture that had both lateral plain film and thoracic axial CT scans performed, finding plain film identified 8 of the 9 fractured sternums.
Abstract: A retrospective study of blunt chest injuries due to motor vehicle accidents between the years 1990 and 1995 found 9 cases of sternal fracture that had both lateral plain film and thoracic axial CT scans performed. Plain film identified 8 of the 9 fractured sternums. CT scanning was only able to identify 6 sternal fractures. Secondary signs of sternal fracture were only seen in 5 of 9 patients, 3 had retrosternal haematomas and 2 had haematoma of the mediastinum. Conclusions: (1) plain film is still superior to Axial CT scanning for identification of sternal fracture; (2) retrosternal haematoma, although a specific sign for sternal fracture has low sensitivity (3/9); (3) mediastinal haematoma, a poorly specific sign for sternal fracture also demonstrated low sensitivity.
31 citations
TL;DR: The relationship between Q-D, quinupristin (Q), and/or dalfoprist in (D) susceptibility parameters and antibacterial activities against 22 clinical isolates of vancomycin-resistant Enterococcus faecium (VREF) is evaluated by using the concentration-time-kill-curve method and by measuring postantibiotic effects.
Abstract: Quinupristin-dalfopristin (Q-D) is a new water-soluble, semisynthetic antibiotic that is derived from natural streptogramins and that is combined in a 30:70 ratio. A number of studies have described the pharmacodynamic properties of this drug, but most have investigated only staphylococci or streptococci. We evaluated the relationship between Q-D, quinupristin (Q), and/or dalfopristin (D) susceptibility parameters and antibacterial activities against 22 clinical isolates of vancomycin-resistant Enterococcus faecium (VREF) by using the concentration-time-kill-curve method and by measuring postantibiotic effects. Q-D, Q, and D MICs and minimum bactericidal concentrations (MBCs) ranged from 0.125 to 1 and 0.25 to 64, 8 to 512 and >512, and 2 to 8 and 8 to 512 microgram/ml, respectively. There were no significant relationships between susceptibilities to the individual components and the susceptibilities to the Q-D combination product. In the time-kill-curves studies, Q-D at a concentration of 6 microgram/ml was at least bacteriostatic against all VREF tested. There was increased activity against more susceptible isolates when the isolates were grouped either by Q-D MBCs or by Q MICs. By multivariate regression analyses, the percent change in the inoculum from that at the baseline was significantly correlated with the Q MIC (R = 0.74; P = 0.008) and the Q-D concentration-to-MBC ratio (R = 0.58; P = 0.02) and was inversely correlated with the Q-D MBC-to-MIC ratio (R = 0.68; P = 0.003). A strong correlation existed between the killing rate and the Q-D concentration-to-MBC ratio (R = 0.99; P < 0.0001). Time to 99.9% killing was best correlated with the Q-D MBC (R = 0.96; P < 0.0001). The postantibiotic effect ranged from 0.2 to 3.2 h and was highly correlated with the Q-D concentration-to-MBC ratio (R = 0.96; P < 0.0001) and was less highly correlated with the Q MIC (R = 0.42; P = 0.04). Further study of these relationships with in vitro or in vivo infection models that simulate Q-D pharmacokinetics should further define the utility of these pharmacodynamic parameters in the prediction of Q-D activity for the treatment of VREF infections in humans.
30 citations
TL;DR: Although enoxaparin increases overall health care costs, it is associated with a cost/additional life‐year saved of only $2300, which is generally lower than the commonly used hurdle rate of $30,000/life‐ year saved.
Abstract: We attempted to determine health and economic outcomes from the perspective of an integrated health system of administering enoxaparin 30 mg twice/day versus heparin 5000 U twice/day for prophylaxis against venous thrombosis after major trauma. A decision-analytic model was developed from best literature evidence, institutional data, and expert opinion. We assumed that 40% of proximal deep vein thromboses (DVTs) and 5% of distal DVTs are diagnosed and confirmed with initial or repeat duplex scanning; 50% of undiagnosed proximal DVTs result in pulmonary embolism; 2% and 1% of undiagnosed proximal DVTs will lead to readmission for DVT and pulmonary embolism, respectively, and pulmonary embolism-related mortality rates range from 8-30%. Length of hospital stay data and 1996 institutional drug use and acquisition cost data were used to estimate the cost of enoxaparin and heparin therapy. Diagnosis and treatment costs for DVT and pulmonary embolism were derived from institutional charge data using cost:charge ratios. A second analysis of patients with lower extremity fractures was completed. One-way and multiway sensitivity analyses were performed. For 1000 mixed trauma patients receiving enoxaparin versus heparin, our model showed that 62.2 (95% CI -113 to -12) DVTs or pulmonary emboli would be avoided, resulting in 67.6 (8 to 130) life-years saved at a net cost increase of $104,764 (-$329,300 to $159,600). Enoxaparin versus heparin resulted in a cost of $1684 (-$3600 to $9800) for each DVT or pulmonary embolus avoided and a discounted cost/life-year saved of $2303 (-$8100 to $19,000). For 1000 patients with lower extremity fractures, enoxaparin versus heparin resulted in a cost of $751 (-$4200 to $3300) for each DVT or pulmonary embolus avoided and a discounted cost/life-year saved of $1017 (-$10,200 to $6300). Although enoxaparin increases overall health care costs, it is associated with a cost/additional life-year saved of only $2300, which is generally lower than the commonly used hurdle rate of $30,000/life-year saved. The cost-effectiveness ratio is more favorable in patients with lower extremity fractures than in the general mixed trauma population.
29 citations
TL;DR: Ciprofloxacin and gentamicin, each in combination with metronidazole, were equivalent in their ability to prevent infections after penetrating abdominal trauma; other factors, especially the receipt of blood transfusions, had much more effect on the incidence of infection.
Abstract: Objectives: To determine whether a combination of ciprofloxacin hydrochloride and metronidazole hydrochloride would be as effective or more effective than a combination of gentamicin sulfate and metronidazole hydrochloride for preventing infection in patients with penetrating abdominal trauma, to evaluate the factors associated with increased risk of infection, and to determine the serum peak and trough levels of gentamicin with the dosage regimen of 2.5 mg/kg every 12 hours. Design: Randomized double-blind study. Setting: Level trauma center. Patients: Eighty-four patients with penetrating intra-abdominal injuries (gunshot wound, 69; stab wound, 15) thought to require laparotomy. Interventions: The patients were randomized during treatment in the emergency department to be given a combination of ciprofloxacin hydrochloride, 400 mg every 12 hours, and metronidazole hydrochloride, 500 mg every 6 hours, or a combination of gentamicin sulfate, 2.5 mg/kg every 12 hours, and metronidazole hydrochloride, 500 mg every 6 hours. Results: Of 68 patients with intra-abdominal injuries who could be observed for at least 48 hours after laparotomy, posttraumatic infections developed in 12 (18%), and nosocomial infections developed in 6 (9%). The incidence of posttraumatic infections in patients who were given gentamicin and metronidazole (5/33 [15%]) was not significantly lower than the incidence in patients who were given ciprofloxacin and metronidazole (7 of 35 [20%]; P = .75). The presence of any infection increased the mean ± SD length of hospital stay from 8.7 ± 3.5 days to 23.3 ± 10.9 days and increased the mean ± SD hospital charges from $24 507 ± $9860 to $104 920 ± $49 083 (P<.001). Univariate analysis showed the factors most significantly associated with infection were as follows: (1) the use of blood transfusions (P<.001), (2) the penetrating abdominal trauma index of 35 or more (P<.002), (3) injury to the colon requiring a colostomy (P=.004), and (4) a trauma score of less than 12 (P<.02). Multivariate analysis showed the only significant factor was the receipt of blood transfusions (F = 10.165; P<.005). Conclusions: Ciprofloxacin and gentamicin, each in combination with metronidazole, were equivalent in their ability to prevent infections after penetrating abdominal trauma; other factors, especially the receipt of blood transfusions, had much more effect on the incidence of infection. Infection greatly increases the length of hospital stay and hospital charges. The use of an increased dosing regimen of 2.5 mg/kg every 12 hours of gentamicin sulfate was effective at obtaining a therapeutic peak serum concentration.
20 citations
TL;DR: Administration of urokinase through ventricular catheters is safe and is a promising alternative to current medical or surgical management, and investigation of other fibrinolytic agents such as recombinant alteplase is available, but is even more limited.
Abstract: Large, randomized, double-blind trials on the use of urokinase for IVH are not available, and the studies published in the literature are not without flaws. However, it appears that in the current case-control reports, administration of urokinase through ventricular catheters is safe and is a promising alternative to current medical or surgical management. Investigation of other fibrinolytic agents such as recombinant alteplase is available, but is even more limited. Further trials will help to determine the best dosage and duration of urokinase therapy, as well as the overall efficacy of this new treatment option.
19 citations
TL;DR: It is concluded that in this model trovafloxacin is as efficacious as vancomycin is and may serve as a viable alternative to vancomYcin for use in humans with similar infections.
Abstract: Trovafloxacin is a new fluoronaphthyridone chemically and functionally related to members of the fluoroquinolone class of antimicrobial agents. The in vivo efficacy of the drug was compared with that of vancomycin by using the rabbit model of left-sided endocarditis. Rabbits infected with either a nafcillin-susceptible or -resistant test strain were treated with trovafloxacin (13.3 mg/kg of body weight every 12 h) or vancomycin (25 mg/kg of body weight every 8 h) for 4 days. In comparison with untreated controls, both antimicrobial agents effectively cleared bacteremia and significantly reduced bacterial counts in vegetations and tissues of animals infected with either test strain. No resistance to trovafloxacin emerged in test strains during therapy. We conclude that in this model trovafloxacin is as efficacious as vancomycin is and may serve as a viable alternative to vancomycin for use in humans with similar infections.
16 citations
TL;DR: Using the lower end of the recommended dosing range for TMP/SMX (TMP 15 mg/kg/d) may reduce the incidence of these toxicities while still achieving acceptable TMP concentrations and antimicrobial efficacy.
Abstract: OBJECTIVE:To report a case of trimethoprim/sulfamethoxazole (TMP/SMX)-induced tremor responsive to a reduction in dosage.CASE SUMMARY:A 55-year-old white man with AIDS and Pneumocystis carinii pneumonia (PCP) developed a tremor after receiving 5 days of therapy with TMP/SMX 19.4 mg/kg/d (TMP). The tremor resolved completely 3 days after a dosage reduction to TMP/SMX 15.1 mg/kg/d.DISCUSSION:Central nervous system adverse reactions to TMP/SMX have been reported in both the AIDS and non-AIDS populations. To our knowledge, this is the first reported case of TMP/SMX-induced tremor responsive to a reduction in dosage. Pharmacokinetic and clinical data suggest a concentration-dependent etiology for various adverse effects, including tremor. The mechanism of the tremor is unknown; however, toxic metabolites of SMX and disruptions of biogenic amine neurotransmission by TMP have been hypothesized.CONCLUSIONS:TMP/SMX remains the drug of first choice for treating PCP, but it is clearly not well tolerated by patients ...
TL;DR: This case was atypical because the patient was conscious and apneic, and introducing noninvasive monitoring of end-tidal CO2 and SpO2 and using BIS allowed the weaning to progress with confidence that the patients was as comfortable as possible.
Abstract: This case was atypical because the patient was conscious and apneic. The usual responses that indicate a patient's distress during terminal weaning would not have been evident in this patient. Introducing noninvasive monitoring of end-tidal CO2 and SpO2 and using BIS allowed the weaning to progress with confidence that the patient was as comfortable as possible. We think we kept our commitment to HD to honor his wishes by using the most humane method we could devise, and to address his family's needs at the same time.
TL;DR: The long-term administration of neuromuscular blocking agents in the ICU has increased in frequency the last several years and the neurosurgeon must be aware that NMB agents are paralytics only and should only be used in patients who are sedated and receiving adequate analgesia.
TL;DR: A 41‐year‐old man being treated for severe esophageal reflux disease developed red, exfoliative scaling on his back, trunk, and legs after taking omeprazole 20 mg twice/day for 3 months, and symptoms continued to occur 18 months after treatment.
Abstract: A 41-year-old man being treated for severe esophageal reflux disease developed red, exfoliative scaling on his back, trunk, and legs after taking omeprazole 20 mg twice/day for 3 months. He also had redness and extreme sloughing of the skin on his hands. Even after he discontinued omeprazole and after several courses of topical and systemic steroids, symptoms continued to occur 18 months after treatment, mostly localized to the hands. Exfoliative dermatitis is associated with many drugs, but omeprazole has been implicated only once before in the literature.