Impact of a vancomycin restriction policy on use and cost of vancomycin and incidence of vancomycin-resistant Enterococcus

OBJECTIVE

To review the appropriateness of vancomycin therapy, changes in vancomycin use, and the incidence of vancomycin-resistant Enterococcus (VRE) after implementation of a limited restriction policy requiring approval from the Infectious Diseases Approval service to continue vancomycin therapy beyond 72 hours.

DESIGN

A prospective chart review was conducted in April 1995. Pharmacy billing data and infection control data were compared before and after policy implementation.

SETTING

A 725-bed university teaching institution.

PATIENTS

All patients receiving vancomycin during April 1995.

MAIN OUTCOME MEASURES

Appropriateness of use was based on the Centers for Disease Control and Prevention (CDC) recommendations for prudent vancomycin use.

RESULTS

A total of 333 courses of vancomycin therapy were reviewed. Vancomycin use was appropriate in 219 (66%) courses. Of the 114 courses that did not meet the CDC guidelines, 76 (67%) were for empiric use, 35 (31%) were for prophylactic use, and 3 (3%) were for therapeutic use. Overall, the total number of grams used decreased 9%, grams per 1000 patient-days decreased by 10, and the total number of patients exposed to vancomycin decreased 0.5%. Several services had large decreases in vancomycin use. Vancomycin expenditures decreased by $15788 for the 7-month time period. The incidence of VRE remained unchanged, at 30% of all enterococcal isolates 2 years after policy implementation.

CONCLUSIONS

The limited restriction policy was effective in decreasing the total grams of vancomycin used. However, one-third of vancomycin therapy was inappropriate and the incidence of VRE was unchanged. A more stringent restriction policy could potentially increase appropriate use, further decrease the amount of vancomycin used, and decrease the incidence of VRE.

Design, synthesis, and evaluation of latent alkylating agents activated by glutathione S-transferase

In search of compounds with improved specificity for targeting the important cancer-associated P1-1 glutathione S-transferase (GST) isozyme, new analogs 4 and 5 of the previously reported glutathione S-transferase (GST)-activated latent alkylating agent gamma-glutamyl-alpha-amino-beta-[[[2-[[bis[bis(2-chloroethyl)amino]ph osp horyl]oxy]ethyl]sulfonyl]propionyl]-(R)-(-)-phenylglycine (3) have been designed, synthesized, and evaluated. One of the diastereomers of 4 exhibited good selectivity for GST P1-1. The tetrabromo analog 5 of the tetrachloro compound 3 maintained its specificity and was found to be more readily activated by GSTs than 3. The GST activation concept was further broadened through design, synthesis, and evaluation of a novel latent urethane mustard 8 and its diethyl ester 9. Interestingly, 8 showed very good specificity for P1-1 GST. Cell culture studies were carried out on 4, 5, 8, and 9 using cell lines engineered to have varying levels of GST P1-1 isozyme. New analogs 4 and 5 exhibited increased toxicity to cell lines with overexpressed GST P1-1 isozyme. The urethane mustard 8 and its diethyl ester 9 were found to be not as toxic. However, they too exhibited more toxicity to a cell line engineered to have elevated P1-1 levels, which was in agreement with the observed in vitro specificity of 8 for P1-1 GST isozyme. Mechanistic studies on alkaline as well as enzyme-catalyzed decomposition of latent mustard 3 provided experimental proof for the hypothesis that 3 breaks down into an active phosphoramidate mustard and a reactive vinyl sulfone. The alkylating nature of the decomposition products was further demonstrated by trapping those transient species as relatively stable diethyldithiocarbamic acid adducts. These results substantially extend previous efforts to develop drugs targeting GST and provide a paradigm for development of other latent drugs.

Isozyme-specific glutathione S-transferase inhibitors potentiate drug sensitivity in cultured human tumor cell lines

Novel glutathione (GSH) analogs, previously shown to inhibit glutathione S-transferase (GST) activity at about 1 microM in vitro, were tested for their ability to potentiate the killing of cultured tumor cells by chemotherapeutic drugs. When tested at doses up to 200 microM, the analogs were neither toxic nor capable of potentiating drug toxicity unless the diethyl ester (DEE) form was used for treatment of the cells. HPLC analysis revealed rapid internalization of the DEE and intracellular conversion to a monoethyl ester form that accumulated in the cell, followed by a more gradual loss of the second ester to generate the active parent form. For the four GSH analogs tested, the ability of the DEE forms to potentiate chlorambucil (CMB) toxicity in HT-29 human colon adenocarcinoma cells strongly correlated with the in vitro ability of the parent form to inhibit recombinant human P1-1. This isozyme is the dominant form of GST present in HT-29 cells. Of the four analog DEEs tested, gamma-glutamyl-S-(benzyl)cysteinyl-R(-)-phenyl glycine (TER 117) DEE was the most effective in potentiating CMB toxicity in several cell lines: HT-29, HT4-1 (HT-29 subclone), SKOV-3 ovarian carcinoma, and SK VLB (vinblastine-resistant variant of SKOV-3) cells. gamma-Glutamyl-S-(octyl)cysteinyl-glycine (TER 143) DEE potentiated mitomycin C (MTC) toxicity in HT4-1 and SK VLB cells while TER 117 DEE did not. TER 117 DEE enhanced melphalan effects on xenografts of HT4-1 in mice to a similar extent as that achieved with the previously described nonspecific GST inhibitor, ethacrynic acid. Taken together, our results indicate that cell-permeable analogs of GSH can potentiate cytotoxicity of common chemotherapeutic drugs and this effect has a strong positive correlation with the ability of the analogs to inhibit specific GST isozymes.

Violence prevention program targeting Connecticut adolescents: description and preliminary results

Recent statistics show that adolescents are increasingly becoming both the perpetrators and the victims of violent crime in our nation. At our institution, we have developed a violence prevention program specifically targeting adolescents. This three-hour workshop utilizes a multimedia style of presenting information that we believe is well suited to young audiences. To date, over 1,000 adolescents from all over the state have participated in our program. In addition to describing the program, we also summarize the results of program evaluations and demographic profiles completed by audience members. Most participants report that the program was successful in educating them about the causes and consequences of violent injury and offered them alternatives to violence in resolving difficult situations. It is our hope that the education we provide will translate into fewer violent injuries within the state of Connecticut.

Factors associated with early onset pneumonia in the severely brain-injured patient

An analysis of 125 patients with closed head injury was completed in order to identify the risk factors involved in the development of early pneumonia. Pneumonia was diagnosed in 60% of the patients. Early pneumonia developed in 47.8% of the patients. Brain-injured patients who developed early pneumonia were found to have a lower Glasgow Coma Scale (GCS) score. Early pneumonia was found more often in patients with swallowing disorders and evidence of aspiration. Patients who had been intubated in the field were found to be at greater risk for the development of early pneumonia than those intubated in the hospital. Patients with early pneumonia had prolonged intubation times, intensive care unit stays, and hospital stays. This study suggests that a GCS score less than 5, evidence for swallowing disorders and aspiration, and field intubation are risk factors for early pneumonia in the brain-injured patient.

Significance of scapular fracture in the blunt-trauma patient

STUDY OBJECTIVE

To determine the significance of scapular fractures in blunt-trauma patients compared with blunt-trauma patients without scapular fractures.

DESIGN

Retrospective chart review of 11,500 blunt-trauma patients with a control group matched for age, sex, and mechanism of injury.

SETTING

Two Level I trauma centers.

PARTICIPANTS

Ninety-two blunt-trauma patients with scapular fractures and 81 control patients.

RESULTS

Mortality, neurovascular injury, and injury severity scores were compared for blunt-trauma patients with scapular fractures with those of the control group. Analysis revealed a 1% incidence of scapular fractures in blunt trauma with no neurovascular injury and no mortality. Scapular fractures were associated with thoracic injury in 49% of the patients, compared with 6% in the control group (difference, 43%; 95% confidence interval, 31.6 to 51.4; P < .001, Fisher's exact test).

CONCLUSION

Scapular fractures are not a significant marker of greater mortality or of neurovascular morbidity in blunt-trauma patients.

Hypopituitarism secondary to transfacial gunshot wound

Hypopituitarism secondary to penetrating head trauma is extremely rare, and its diagnosis may be delayed for several years. We present a patient who developed hypopituitarism secondary to a transfacial gunshot wound and who experienced damage to the hypophysis secondary to transmission of energy and bullet fragments. The importance of a computerized tomographic scan of the head in facial gunshot wound is discussed.

Glutathione-S-transferase activates novel alkylating agents

Alkylating agents which are activated by glutathion-S-transferases (GSTs) have been designed and synthesized. The model compound gamma-glutamyl-alpha-amino-beta-[(2-ethyl N,N,N',N'-tetraethylphosphorodiamidate) sulfonyl]propionylglycine (1) and the nitrogen mustards gamma-glutamyl-alpha- amino-beta-[[2-ethyl N,N,N',N'-tetrakis (2-chloroethyl)phosphorodiamidate] sulfonyl]propionylglycine (2) and gamma-glutamyl-alpha-amino-beta-[[2-ethyl-N,N,N',N'-tetrakis(2- chloroethyl)phosphorodiamidate]sulfonyl]-propionyl-(R)-(-)-phenylg lycine (3) were prepared via multistep chemical synthesis. The compounds were tested with recombinant human A1-1, M1a-1a and P1-1 GSTs. HPLC studies showed that the compounds were differentially and catalytically cleaved by biologically relevant concentrations of the GSTs. Mass spectral studies of the cleavage mixture of 2 showed that M1a-1a GST liberated the cytotoxic phosphate moiety needed for efficacy as an alkylating agent. Cell culture studies with MCF-7 breast cancer cells showed that 1 was not toxic at 200 microM, while 2 and 3 showed IC50S of 40.6 and 37.5 microM, respectively, for the same cell line. MCF-7 cells transfected to overexpress P1-1 GST showed enhanced sensitivity with 2 and 3, with IC50S of 20.9 and 9.5 microM, respectively. This result correlates well with the rates of cleavage of 2 and 3 by P1-1 GST observed in vitro and demonstrates that higher levels of cellular P1-1 GST will give increased sensitivity to these drugs.

Risk factors for infection in the trauma patient

The most common cause of late death following trauma is sepsis. The traumatized patient has a significant increased risk of infection. Transfusion, hypotension, and prolonged ventilatory support are predictive of septic complications. In addition, the trauma patient has a higher predisposition to pneumonia than nontrauma patients (18% versus 3% incidence of pneumonia, P < .001). Additional risk factors include the degree of nutrition status and the type of medications used during surgery. Immunologic depression may be an additional risk factor. There is mounting evidence that trauma can result in host defense abnormalities. To prevent the significant mortality caused by sepsis, close surveillance must be maintained, nutritional status must be optimal, and liberal use of antibiotics should be discouraged. Their use should be guided by appropriate cultures and sensitivities.

Portable ultrasonography in critical care

A 2-year retrospective analysis of portable ultrasound examinations in the intensive care unit was conducted to evaluate the indications and efficacy of portable sonography. A total of 86 examinations were performed on 79 patients. Of these, 22 per cent of the examinations supported the suspected diagnosis and contributed to treatment. Seventy per cent of the examinations excluded the suspected diagnosis. There was a 9 per cent incidence that yielded unsuspected information that contributed to treatment. Only 8 per cent of the examinations were misleading or proven false. The authors found that with an overall sensitivity of 79 per cent and specificity of 97 per cent, portable ultrasonography is a valuable, relatively inexpensive test in the critical care setting.

Early intervention in severe head injury: long-term benefits of a formalized program

With traumatic brain injuries numbering more than two million per year, health professionals are faced with the challenges of restoring and maximizing quality of life. This study quantifies the benefits of a formalized head injury program, including the concept of trauma rehabilitation, defined as early, aggressive rehabilitation during acute hospitalization. Thirty-eight severely head injured patients received treatment at the same rehabilitation facility. Twenty-one of these patients received acute care services at ten different hospitals without formalized traumatic brain injury programs, and 17 received services at a hospital with a formalized early intervention program. Comparison of outcome data for the two programs revealed that patients in the formalized program had comas and rehabilitation stays approximately one third the length of patients in nonformalized programs (18.9 vs 53.8 days and 106.5 vs 239.5 days, respectively). Mean cognitive levels at discharge from the acute hospitals (5.6 vs 4.0) and the rehabilitation facility (7.4 vs 6.7) were significantly higher for the formalized program, and they facilitated a significantly higher percentage of discharges to home vs extended care facility (94% vs 57%).

Analysis of 46 intra-abdominal aortic injuries from blunt trauma: case reports and literature review

Blunt trauma causing aortic injury is infrequent and primarily involves the thoracic aorta. Abdominal aortic injury after blunt trauma is much less frequent and has a varied presentation. Within a 3-month period, our trauma unit diagnosed and treated two cases of abdominal aortic injury secondary to blunt trauma. One was a belted passenger in a motor vehicle accident, and one was secondary to a crush injury. The addition of these two cases brings the number found in the literature to 46. Reviewing these cases has emphasized the need for prompt recognition and treatment of this vascular catastrophe.

Characteristics of blunt and personal violent injuries

This study was designed to analyze the characteristics and behavior patterns of individuals involved in nonfatal, traumatic injuries. There were 547 patients included in the study with 363 sustaining blunt trauma injuries, 144 sustaining personal violence injuries, and 40 being burn victims. Motor vehicle accident victims tended to be young, single, white, employed males: substance use was detected in 32%, and 57% were unbelted. Motorcycle accident victims tended to be young, single, unemployed males: substance use was detected in 25% and 90% were not wearing helmets. Pedestrians struck tended to be single, unemployed males. Penetrating injuries involved mostly young, single, black males: substance use was detected in 35% of patients and most incidents occurred from 4:00 P.M. to 8:00 A.M. Assault victims were mostly young, single, black males with substance use detected in 48%. Suicide patients tended to be white males. The incidence of repeat victims was one out of ten for blunt trauma, and one out of five for personal violence injuries and burns.

Traumatic brain injury: improving functional recovery

Most physical injuries in this country are the result of motorized vehicle accidents. Head trauma accounts for one fourth of all trauma deaths, and the cost to treat patients with head trauma is $83 billion. The author discusses injury patterns, methods of resuscitating patients with head injuries, surgical management and monitoring, and the clinical course and prospects for rehabilitation. An interdisciplinary approach to the management of such patients is encouraged, and the medical and surgical interventions undertaken at one institution are reviewed.

Xenografting of fetal pig ventral mesencephalon corrects motor asymmetry in the rat model of Parkinson's disease

A suspension of cells from embryonic day 21 fetal pig ventral mesencephalon was transplanted into the striatum of 20 immunosuppressed rats with 6-hydroxydopamine-induced lesions of the nigrostriatal dopamine pathway. Of these rats, 15 showed reduction of amphetamine-induced ipsilateral rotation by 9 weeks and complete reversal of rotation by 14-17 weeks. Animals maintained stable reversal of rotations (contralateral direction) until cessation of Cyclosporin A (CyA) treatment at 15-20 weeks. Within 4-9 weeks after CyA removal, these rats showed exclusively ipsilateral rotations during behavioral testing which were comparable to pre-transplant levels, suggesting that the grafts were rejected upon cessation of CyA treatment. Rats were sacrificed and tyrosine hydroxylase (TH) immunohistochemistry was performed at several time points, both on and off CyA, to examine a possible correlation between the degree of rotational behavior and the number of TH-positive surviving grafted cells. Staining showed large numbers (230-12,329) of TH-positive surviving cells in animals displaying a high degree of rotational correction (1.6 to -9.6 net ipsilateral rotations/min) after cessation of CyA treatment. Two control groups, those transplanted with non-neuronal cells from the pig ventral mesencephalon (n = 5) and those receiving only daily CyA injections (n = 4) showed no significant reduction of net ipsilateral rotations throughout the experiment. No TH-positive surviving cells were seen in the one non-neuronal transplant analyzed. This data demonstrates long-term retention of xenografted tissue with immunosuppression and its concomitant restoration of normal motor behavior in the rat model of Parkinson's disease.

Sternal fractures--the natural history

A five-year retrospective study was undertaken to analyze the natural history of sternal fractures and to scrutinize the current method of management. Sixty-six patients with documented sternal fractures were evaluated. The most common mechanism of injury was motor vehicle accidents (59%). Most of these victims did not wear seat belts. Thirty-five patients (53%) had associated injuries, of which rib fractures were the most common. Thirty-one patients (47%) had sternal fractures with no associated injury. The incidence of myocardial contusion in our study was 18%. Of the patients without associated injuries, the incidence of myocardial contusion was 6%. There were no mortalities in our study population, and there was no significant morbidity necessitating mechanical or pharmacologic support. The majority of these patients were managed by admission, observation, IV therapy, and placement of monitored beds. Our findings of no life-threatening sequelae suggest that we might question the necessity of current management criteria. This proves to be of special interest in view of the economic restraints imposed on health care today.

Blunt bladder trauma: manifestation of severe injury

Twenty-nine patients with bladder injuries requiring operative treatment as a result of blunt trauma are presented. Motor vehicle accidents accounted for 86 per cent of the injuries. Hypotension and gross hematuria were the most prevalent clinical features, 68 per cent and 97 per cent, respectively. All patients had multiple associated injuries requiring operative treatment, average 2.9 per patient. Pelvic fractures occurred in 93 per cent and intra-abdominal injuries in 48 per cent of patients. The majority of ruptures (72%) were intraperitoneal. Mortality, related to associated injuries, was high (34%), attesting to the magnitude of injury sustained by the victim.

A prospective randomized study evaluating periumbilical versus infraumbilical peritoneal lavage: a preliminary report. A combined hospital study

Peritoneal lavage has been proved to be a fairly safe and reliable diagnostic tool in evaluating blunt abdominal trauma. However, the operation is not always a simple procedure. In an attempt to determine the ease and reliability of the procedure, the authors conducted a combined hospital approach, prospectively randomizing the performance of periumbilical and infraumbilical approaches to the peritoneal lavage. To date, 53 lavages have been performed. Reliability of the procedures appears to be equal. The greatest differences in the techniques are with regard to the greater efficacy and performer acceptance of the periumbilical approach. The operative approaches are discussed in detail and literature regarding peritoneal lavage is reviewed.

Flexible choledochoscopy and removal of impacted stones of the common bile duct

A technique of direct, piecemeal removal of impacted stones of the common bile duct is described. This routine eliminates the need for performance of an isolated Kocher maneuver or one done in conjunction with duodenotomy and sphincteroplasty. In addition, all stone fragments are removed under direct vision without damage to ductal structures.

Blunt injury to the diaphragm: an analysis of 44 patients

Forty-four patients sustaining blunt trauma with resultant diaphragmatic rupture during a 5 1/2-year period are presented. In 41 (93%), the diagnosis was established within 6 hours of admission. The correct diagnosis was made preoperatively in 19 patients operated on acutely (42%), in 22 (53%), ruptured diaphragm was an incidental finding at celiotomy or thoracotomy. The admission chest roentgenography, diagnostic peritoneal lavage, UGI contrast studies, and computed tomography were the most useful diagnostic aids. The transabdominal operative approach was utilized in 39 patients (89%). All patients had associated extra-abdominal injuries and 26 patients (59%) had associated intra-abdominal injuries. The mortality rate was 20.4%; early deaths were attributable to hemorrhage and severe head injury, late deaths to sepsis and progressive multiorgan failure.