In routine clinical practice, few physicians use early viral kinetics to guide HCV dual therapy treatment decisions

BACKGROUND & AIMS

PROPHESYS is a large, multinational, non-interventional prospective cohort study of chronic hepatitis C patients treated with peginterferon alfa/ribavirin. This subanalysis assesses rates of premature treatment discontinuation stratified by on-treatment virological response (VR).

METHODS

This PROPHESYS subanalysis is restricted to treatment-naive, hepatitis C virus (HCV) genotype (G)1/2/3 mono-infected patients who received peginterferon alfa-2a (40KD)/ribavirin with intended treatment duration of 48 (G1) or 24 weeks (G2/3). Early virological responses were classified into four mutually exclusive categories [rapid VR (RVR), complete early VR (cEVR), partial EVR (pEVR), no RVR/EVR], using standard criteria.

RESULTS

The likelihood for shortening treatment owing to good efficacy was highest among patients with an RVR and HCV RNA≤400 000 IU/ml (G1 10.0%; G2/3 5.8%) whereas for poor efficacy, it was highest in G1 non-RVR/EVR patients with HCV RNA>400 000 IU/ml (56.6%). Factors significantly associated with early treatment discontinuation as a result of good efficacy in G1 patients included RVR vs. no RVR/EVR and, at baseline, lower HCV RNA, lower FIB-4 score, HCV infection via injection drug use. For G2/3 patients, factors included lower baseline HCV RNA and G2 vs. G3 infection. Most patients started with the recommended peginterferon alfa-2a dose, but a high proportion received a higher-than-recommended ribavirin dose.

CONCLUSIONS

Despite international guidelines, few physicians used early viral kinetics to abbreviate treatment. Therefore, relatively few patients with an RVR and low baseline HCV RNA abbreviated treatment. In addition, there were deviations in ribavirin starting doses, suggesting that physicians tailor treatment according to local guidelines or previous experience.

Knowledge and perceptions about community-acquired staphylococcal infections among health care workers in Hawai'i

Since the early 1990s, national rates of methicillin-resistant Staphylococcus aureus (MRSA) infections have increased dramatically.1,2 Initially identified in health care settings, community-acquired MRSA is now a major public health concern. With Hawai'i's expanding S. aureus and MRSA epidemic closely approximating the national trend in inpatient and outpatient settings,7,8 a high level of knowledge and awareness among health care workers is essential to successfully control this evolving epidemic. Health care and related workers were surveyed to assess their knowledge and perceptions about staphylococcal and MRSA infections. Knowledge was estimated by demonstrated ability to correctly identify risk factors including diabetes and obesity, as well as to demonstrate awareness of a growing staphylococcal and MRSA epidemic.9,10 Perceptions were estimated by level of concern of antibiotic resistance as well as of the severity of the staphylococcal and MRSA epidemic. Variations in knowledge and perception concerning basic principles associated with S. aureus infections as well as characteristics of the evolving S. aureus and MRSA epidemic were observed among various occupations (advance clinical practitioners, nurses, public health professionals, athletic trainers, and non-medical workers) as well as work locations (hospital, community, and non-clinical community). Overall, health care and related workers in community settings demonstrated disparities in knowledge regarding S. aureus and MRSA infections. They were also more likely to misperceive this growing threat. These findings provide support for focused educational interventions targeting community health care and related workers to improve awareness of staphylococcal infections in order to successfully address and combat this evolving epidemic.

Changes in fasting plasma glucose levels with ribavirin and pegylated interferon treatment in normal and impaired glucose tolerant patients with chronic hepatitis C

BACKGROUND

Patients with Hepatitis C Virus (HCV) infection have increased rates of glucose intolerance, and studies have shown the improvement of fasting plasma glucose (FPG) levels after clearance of HCV infection with standard ribavirin plus pegylated interferon treatment. The purpose of this study was to examine glycemic changes with standard HCV treatment in patients with impaired fasting glucose (IFG) and normal fasting glucose (NFG).

METHODS

A retrospective study of FPG changes in HCV patients with IFG and NFG treated with standard HCV therapy was conducted. Baseline characteristics and viral responses were assessed; FPG levels before treatment, at the end of treatment, and more than one-month post treatment were compared.

RESULTS

The mean FPG levels increased by 8.68 mg/dl at the end of treatment in the NFG group but decreased by 9.0 mg/dl in the IFG group, a statistically significant difference (P=0.019). The change in FPG levels remained significantly different after adjusting for weight change (P=0.009) and weight changes and initial weight (P=0.039). FPG change from baseline at more than one month after treatment were similar in both groups (P=0.145). The change in FPG levels was not associated with sustained viral response.

CONCLUSIONS

In HCV-infected patients, standard ribavirin plus pegylated interferon treatment reduced FPG levels in patients with IFG and increased FPG levels in NFG individuals; independent of initial weight, weight change, or viral response. Standard HCV treatment modulates fasting plasma glucose levels which supports the need for a prospective study to determine the clinical significance of this finding.

A probe-based method for confirmation of methicillin-resistant Staphylococcus aureus and detection of Panton-Valentine leukocidin and tst virulence genes

Probe-based detection of mecA, lukS/F-PV (Panton-Valentine leukocidin), and tst virulence genes in 435 isolates of Staphylococcus aureus had comparable sensitivity and specificity to end-point polymerase chain reaction as a reference standard.

Investigating approaches to improving appropriate antibiotic use among higher risk ethnic groups

A field study with follow up investigations sought to: 1. determine whether cold packs (over-the-counter symptomtic treatments), coupled with in-office education, improve antibiotic-related knowledge, attitudes and behaviors more than in-office education alone in patient populations with high percentages of Asian Americans and Hawaiian/Pacific Islanders; 2. identify possible reasons for intervention outcomes as described by physicians who participated in the field study; and 3. explore potential future directions based on a large sample survey of physicians in the field study's highly ethnic county. The intervention resulted in a pre- to post-consultation decrease in perceived need for and an increase in knowledge about antibiotic risks but had no impact on frequency of reported receipt of an antibiotic prescription. Unexpectedly, in-office education alone was more effective in increasing knowledge than in-office education plus the cold pack. In-depth interviews of field study physicians and a large scale physician survey suggest that cold pack interventions targeting patient populations with high percentages of Asian Americans and Hawaiian/Pacific Islanders may be more likely to succeed if accompanied by mass public education regarding risks and physician training regarding effective ways to talk to patients. Use of in-office education with cold packs alone may not achieve desired results.

Albinterferon Alfa-2b was not inferior to pegylated interferon-α in a randomized trial of patients with chronic hepatitis C virus genotype 1

BACKGROUND & AIMS

The current standard of care for patients with chronic hepatitis C virus (HCV) genotype 1 is once-weekly pegylated interferon-α (Peg-IFNα) plus daily ribavirin for 48 weeks. We evaluated the efficacy/safety of albinterferon alfa-2b (albIFN), a novel, long-acting, genetic fusion polypeptide of albumin and IFNα-2b.

METHODS

In the phase 3 ACHIEVE-1 trial, 1331 patients were assigned equally to 3 open-label, 48-week treatment groups: Peg-IFNα-2a 180 μg every week, or albIFN 900 or 1200 μg every 2 weeks administered subcutaneously, with weight-based oral ribavirin 1000-1200 mg/day. During the study, the data monitoring committee recommended dose modification for all patients receiving albIFN 1200 μg to 900 μg because of increased pulmonary adverse events (AEs) in the 1200-μg arms of both ACHIEVE studies. Main outcome measure was sustained virologic response (SVR; undetectable serum HCV RNA at week 72).

RESULTS

Intention-to-treat SVR rates were 51.0% (225/441), 48.2% (213/442), and 47.3% (208/440) with Peg-IFNα-2a, and albIFN 900 and 1200 μg, respectively. The primary objective of showing noninferiority of albIFN 900 μg (P < .001) and 1200 μg (P = .003) vs Peg-IFNα-2a for SVR was achieved. Multivariate modeling indicated consistency of treatment effect across subgroups. Serious/severe AE rates were 23.1%, 24.0%, 28.2%; treatment discontinuation rates because of AEs were 4.1%, 10.4%, 10.0%; discontinuation rates because of respiratory AEs were 0%, 0.9%, 1.6%; with Peg-IFNα-2a, and albIFN 900 and 1200 μg, respectively. Hematologic abnormality rates were comparable across the Peg-IFNα-2a and albIFN 900-μg groups.

CONCLUSIONS

albIFN 900 μg every 2 weeks showed comparable efficacy, with similar serious/severe AE rates, although with a higher discontinuation rate, vs Peg-IFNα-2a in patients with chronic HCV genotype 1.

Risk factors for community-associated methicillin-resistant Staphylococcus aureus cellulitis--and the value of recognition

OBJECTIVES

To identify the risk factors for community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) cellulitis.

METHODS

A review of risk factors for CA-MRSA skin and soft tissue infection in previously published literature was first performed. A retrospective cohort study was then conducted in a teaching ambulatory-care clinic of a tertiary medical center in Honolulu, Hawaii.

RESULTS

Of 137 cases with cellulitis diagnosed from January 2005 to December 2007, MRSA was recovered from 85 (62%) of patients who presented with either abscesses or skin ulcers. The recovery of MRSA was significantly associated with obesity (p=0.01), presence of abscesses (p=0.01), and lesions involving the head and neck (p=0.04). Independent risk factors by multivariate logistic regression analysis included the presence of abscesses [adjusted odds ratio (aOR) 2.72; 95% confidence interval (CI) 1.27-5.83; p=0.01] and obesity (aOR 2.33; 95%; CI 1.10-4.97; p%0.03). Patients with CA-MRSA were less likely to receive an appropriate antibiotic (p=0.04) and were more likely to require antibiotic change at evaluation in one week (p=0.04) compared with patients infected with non-MRSA bacteria.

CONCLUSIONS

The presence of abscesses and obesity were significantly associated with CA-MRSA cellulitis. Empiric therapy with antibiotics active against MRSA should be guided by these risk factors.

Prevention of community-associated methicillin-resistant Staphylococcus aureus infection among Asian/Pacific Islanders: a qualitative assessment

BACKGROUND

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has been increasingly reported over the past decade, including in Asian/Pacific Islanders (A/PIs).

METHODS

We conducted ethnographic interviews in O'ahu and Kaua'i, Hawai'i, with 10 Asian/Pacific Islanders identified as having a history of CA-MRSA infections.

RESULTS

Most (7/10) thought skin infections were not a new problem in Hawai'i. Most (8/9) attempted to self-treat the infection prior to seeking medical care with a range of home remedies and store- bought solutions. Most respondents did not initially comprehend the severity of their infection and only sought medical treatment after concern from family, unbearable pain, and/or other symptoms of illness.

CONCLUSION

Clinicians should be aware of the reportedly frequent use of home remedies by this population, as it may potentially contribute to interactions when treatments are combined. If clinicians and public health professionals do not address perceptions and misperceptions of how MRSA is acquired, it will be very difficult to prevent infection, and may also delay individuals from seeking treatment.

Viral hepatitis in Hawai'i--differing perspectives

This publication contains information from a conference titled "Individual Perspectives on the Silent Epidemic of Viral Hepatitis in Hawai'i" held in October of 2007 with updates and additional contributions from annual conferences in 2008 and 2009. These conferences were sponsored by the Hepatitis Support Network of Hawai'i and held in Honolulu, Hawai'i at the Queen's Conference Center. The primary objectives of the conferences have been to heighten awareness of viral hepatitis in Hawai'i and to bring together health care professionals to learn about these infections and to help them respond to the challenges they bring to the people of Hawai'i. The initial conference was oriented to present the unique and individual perspectives of patients, physicians, and other healthcare providers specific to the complex issues of hepatitis in an effort to help them understand their role in the context of others and to develop a team approach in responding to this epidemic.

Weight loss, leukopenia and thrombocytopenia associated with sustained virologic response to Hepatitis C treatment

OBJECTIVE

To identify apparent adverse effects of treatment of chronic hepatitis C and their relationship to sustained virologic response (SVR).

METHODS

A retrospective study was conducted of all Hepatitis C virus (HCV)-infected patients treated with pegylated interferon and ribavirin in an academic ambulatory infectious disease practice. Clinical and laboratory characteristics were compared between patients with SVR and without SVR.

RESULTS

Fifty-four patients completed therapy with the overall SVR rate of 76%. SVR was associated with genotype non-1 (P=0.01), weight loss more than 5 kilograms (P=0.04), end of treatment leukopenia (P=0.02) and thrombocytopenia (P=0.05). In multivariate analysis, SVR was significant associated with HCV genotype non-1 (Adjusted Odd Ratio [AOR] 15.22; CI 1.55 to 149.72; P=0.02), weight loss more than 5 kilograms, (AOR 5.74; CI 1.24 to 26.32; P=0.04), and end of treatment white blood cell count level less than 3 X 10(3) cells/microl (AOR 9.09; CI 1.59 to 52.63; P=0.02). Thrombocytopenia was not significant after adjustment. Other factors including age, gender, ethnicity, injection drug use, viral load, anemia, alanine transaminase level, and liver histology did not reach statistical significance.

CONCLUSION

Besides non-1 genotype, SVR was found to be independently associated with weight loss during therapy, and leukopenia at the end of HCV treatment. These correlations suggest continuation of therapy despite adverse effects, may be of benefit.

Quantitation of Staphylococcus aureus in seawater using CHROMagar SA

A microbiological algorithm has been developed to analyze beach water samples for the determination of viable colony forming units (CFU) of Staphylococcus aureus (S. aureus). Membrane filtration enumeration of S. aureus from recreational beach waters using the chromogenic media CHROMagar SA alone yields a positive predictive value (PPV) of 70%. Presumptive CHROMagar SA colonies were confirmed as S. aureus by 24-hour tube coagulase test. Combined, these two tests yield a PPV of 100%. This algorithm enables accurate quantitation of S. aureus in seawater in 72 hours and could support risk-prediction processes for recreational waters. A more rapid protocol, utilizing a 4-hour tube coagulase confirmatory test, enables a 48-hour turnaround time with a modest false negative rate of less than 10%.

Viral hepatitis in a homeless shelter in Hawai'i

It is estimated that as many as 21,000 people in the state of Hawai'i may be infected with HCV Most of those infected with viral hepatitis are unaware they are infected. Complications from viral hepatitis include liver cirrhosis and hepatocellular carcinoma. Hawai'i has the highest incidence of hepatocellular carcinoma in the United States. In 2003 there were over 6000 homeless and over 155,000 people at-risk of becoming homeless living in the state of Hawai'i. Risk factors for hepatitis, such as drug use, tattoos, sexual contact, and sharing of personal hygiene equipment are more prevalent in the homeless population. To determine the incidence of hepatitis B and C among a population of homeless individuals, a health fair was held at a Honolulu area homeless shelter with approximately 200 residents. The incidence of hepatitis B and C was determined by anti-HCV and HBsAg blood tests. A survey was also conducted regarding risk factors and basic demographics. Fifty-nine homeless adults volunteered for testing and took the survey. Thirty-one (52%) volunteers were born in Micronesia, twenty-four (41%) were born in the United States, two (3%) were born in Samoa, one (2%) was born in the Philippines, and one (2%) was born in the Marshall Islands. Forty adults were tested for Hepatitis C antibody, three of which tested positive. The primary risk factor among this group was jail time (100%), followed by illegal drug injection (67%), tattoos (67%), ear/body piercing (67%), snorting drugs (33%), blood transfusions (33%), and a sex partner with hepatitis (33%). Forty adults were also tested for HBsAg, One of which tested positive. This was a recent immigrant from Micronesia. Homeless people in Hawai'i are more likely to have hepatitis B or C because risk factors are common among this population. Additionally a large proportion of Hawai'i's homeless people come from the Pacific Islands, where the prevalence of hepatitis B is one of the highest in the world. In addition there are significant risks of hepatitis spread among the homeless and into the general population as many homeless do not realize they are infected. The health fair approach was an effective means for screening homeless people for hepatitis B and C. Our preliminary information suggests homeless shelters may be a good place for education, screening, and possibly interventions as well.

Efficacy and safety of peginterferon alfa-2a/ribavirin in methadone maintenance patients: randomized comparison of direct observed therapy and self-administration

BACKGROUND

Adherence to chronic hepatitis C (CHC) treatment may be particularly challenging in methadone maintenance patients. We assessed the safety, tolerability, and efficacy of peginterferon alfa-2a/ribavirin treatment in methadone maintenance patients previously untreated for CHC.

METHODS

Patients were randomized 1:1 to direct observed therapy (DOT) or self-administration (SA) of peginterferon alfa-2a. DOT patients were seen weekly at methadone clinics; SA patients were seen less frequently, only at investigative sites. Genotype 1-infected patients were treated for 48 wk with peginterferon alfa-2a (180 microg/wk)/ribavirin (1,000/1,200 mg/day); genotypes 2- and 3-infected patients were treated for 24 wk with peginterferon alfa-2a (180 microg/wk)/ribavirin (800 mg/day).

RESULTS

Based on defined efficacy stopping rules, 77% (37/48) completed their targeted length of treatment, and 44% (21/48) achieved sustained virologic response (SVR). Two DOT and 3 SA patients were withdrawn for safety reasons and 6 and 9, respectively, for nonsafety reasons. Over 60% and 50% of each group were >80% compliant with the planned cumulative doses of peginterferon alfa-2a and ribavirin, respectively, and over 60% with overall treatment duration. SVR rates were 54% (13/24) for DOT and 33% (8/24) for SA; 23% (3/13) and 38% (6/16), respectively, for genotype 1 and 91% (10/11) and 25% (2/8), respectively, for genotypes 2 and 3. Stepwise logistic regression analysis, showed that DOT (vs SA; OR 3.27, 95% CI 0.90-11.91, P = 0.073) and Caucasian race (vs Other; OR 13.31, 95% CI 1.42-124.71, P = 0.023) were predictors of SVR.

CONCLUSION

Peginterferon alfa-2a/ribavirin can be used safely and successfully in CHC patients receiving methadone maintenance.

Survey of methicillin-resistant Staphylococcus aureus (MRSA) carriage in healthy college students, Hawai'i

Currently, the carriage rate for Community-Acquired Methicillin Resistant Staphylococcus aureus (CA-MRSA) is unknown in Hawai'i. This survey focuses on a healthy population of 95 college students and 5 faculty who completed a survey related to possible risk factors for colonization of Staphylococcus aureus and were sampled for S. aureus from their anterior nares. Thirty-three (33%) subjects were carrying Staphylococcus aureus and of those, 3 (3%) carried MRSA. There was no significant association between Staphylococcus aureus carriage and ethnicity, gender exposure to seawater, prior Staphylococcus aureus infections, recent antibiotic use, or pets. Additional testing of a larger group of healthy individuals would be beneficial in assessing factors associated with CA-MRSA and Methicillin-susceptible Staphylococcus aureus (MSSA) carriage in Hawai'i.

Clinical predictors of treatment failure for diabetic foot infections: data from a prospective trial

To aid clinicians in selecting the appropriate approach for treating patients with diabetic foot infections, we investigated whether any baseline clinical findings predicted an unfavourable clinical outcome. Using data from a large, prospective treatment trial of diabetic foot infections (SIDESTEP), we assessed the association between clinical treatment failure and baseline history, physical and laboratory findings, by univariate and multivariate logistic regression analyses. Among 402 patients clinically evaluable 10 days after completing antibiotic therapy, baseline factors significantly (P < 0.05) associated by univariate analysis with treatment failure were 'severe' (versus 'moderate') University of Texas (UT) wound grade; elevated white blood cell count, C-reactive protein or erythrocyte sedimentation rate; high wound severity score; inpatient treatment; low serum albumin; male sex; and skin temperature of affected foot >10 degrees C above that of unaffected foot. By multivariate logistic regression only severe UT wound grade (odds ratio 2.1) and elevated white blood cell count [odds ratio 1.7 for a 1 standard deviation (2971 cells/mm(3)) increase] remained statistically significant. Clinical failure rates were 46% for patients with both risk factors compared with 10% for patients with no risk factors and 16-17% for patients with one risk factor. Increased white blood cell count and severe UT wound grade at baseline, but not other features, were significant independent and additive risk factors for clinical failure in patients treated for a diabetic foot infection.

Culturally sensitive strategies designed to target the silent epidemic of hepatitis B in a Filipino community

Hepatitis B is frequent in the Philippines. A high rate of immigration to the United States has brought many Filipinos with infections who are asymptomatic yet will go on to develop liver cancer and cirrhosis unless diagnose and evaluated. Interventions are necessary to educate this ethnic community, identify those infected, and offer therapy. In an effort to reach this high risk population in Hawai'i an intervention program was designed to address the silent epidemic of hepatitis. Ethnic barriers were crossed through involvement of trusted, key stakeholders and individuals within the Filipino health care and church communities, along with groups that had joint missions to address viral hepatitis. After extensive planning and meetings with faith-based organizations and health care providers in the Filipino community, it was decided to hold a community health fair in the Filipino community to provide culturally appropriate health information and services. More than 500 individuals attended the health fair; 167 participated in a survey and were tested for hepatitis B. Significant knowledge gaps were found in relation to risk factors, prevention strategies, and transmission. Five individuals tested positive; all were immigrants and did not know of their disease. The objective to educate people and test them for hepatitis was successful through utilizing ethnic community leaders, religious organizations, health care professionals, and a collaborative health fair.

Comparative costs of ertapenem and piperacillin–tazobactam in the treatment of diabetic foot infections

PURPOSE

To evaluate potential cost savings, trial data were used to determine the clinical outcomes for i.v. ertapenem given once daily and i.v. piperacillin-tazobactam given every six hours daily in treating diabetic foot infections.

METHODS

A cost-minimization analysis (CMA) was conducted on the drug-dosing data of the subset of patients enrolled in a recent double-blind randomized trial who were treated solely as inpatients and were clinically evaluable at fi nal assessment (n = 99). Cost per dose was calculated from (a) average hospital acquisition price per dose for ertapenem ($40.52) or piperacillin-tazobactam ($13.58), (b) average U.S. wages and benefits for labor, based on nine published time-and-motion studies of i.v. antibiotic preparation and administration ($3.10), and (c) consumable supplies, using a 40% discount off the manufacturer list price ($2.90). For each patient, the actual number of antibiotic doses given was multiplied by total cost per dose.

RESULTS

There were no significant differences between antibiotic groups with respect to patient demographics, percentage with a severe wound, and mean days of i.v. therapy. Compared with piperacillin-tazobactam, patients treated with ertapenem received significantly fewer mean doses (25.5 versus 7.5; p < 0.0001) and lower antibiotic-related costs ($502.76 versus $355.55, respectively; p < 0.001). The $147.21 difference between groups accounts for approximately 3% of total hospital Medicare reimbursements for these infections.

CONCLUSION

A CMA of treatment of diabetic foot infections showed that, compared with piperacillin-tazobactam given four times daily i.v., ertapenem given once daily i.v. was associated with lower drug acquisition and supply costs and less time and labor devoted to preparation and administration of i.v. therapy.

Experience of Infectious Diseases Consultants with Outpatient Parenteral Antimicrobial Therapy: Results of an Emerging Infections Network Survey

BACKGROUND

Despite the increasing use of outpatient parenteral antimicrobial therapy (OPAT), little is known about the role of infectious diseases consultants in the process or their perceptions of OPAT.

METHODS

In May 2004, the Infectious Diseases Society of America Emerging Infections Network (EIN) surveyed its members to characterize their involvement and experiences with OPAT.

RESULTS

Of the 454 respondents (54%) who completed the questionnaire, 426 (94%) indicated that patients in their primary inpatient facility were "frequently" discharged while receiving OPAT, estimating that, on average, 19 patients are discharged from their hospitals while receiving OPAT each month. Although 86% of EIN members stated that they personally order OPAT for some patients, 18% indicated that they have no involvement, and 37% stated they only rarely or occasionally oversee OPAT. EIN members involved in OPAT estimated that approximately 90% of their patients who take OPAT received therapy at home, and the members described variable monitoring and oversight methods. Of the respondents, 68% of providers collectively estimated that they encountered 1951 infectious and serious noninfectious complications of OPAT in the past year. The most frequently used antibiotics included vancomycin, ceftriaxone, and cefazolin, most commonly used for bone and joint infections.

CONCLUSIONS

These results testify to the pervasive use of OPAT in today's health care system, the variable role of infectious diseases consultants, and the heterogeneity in oversight and management practices. The widespread use of OPAT and its frequent complications indicate the need for additional studies to establish optimal methods of delivery and management to insure the quality and safety of the process.

Ertapenem versus piperacillin/tazobactam for diabetic foot infections (SIDESTEP): prospective, randomised, controlled, double-blinded, multicentre trial

BACKGROUND

Diabetic foot infections are a common and serious problem, yet few randomised trials of adequate quality have compared the efficacy of the various antibiotic regimens available for their treatment. Our aim was to assess the efficacy and safety of ertapenem versus piperacillin/tazobactam for foot infections.

METHODS

We did a randomised, double-blinded, multicentre trial in adults (n=586) with diabetes and a foot infection classified as moderate-to-severe and requiring intravenous antibiotics. We assigned patients intravenous ertapenem (1 g daily; n=295) or piperacillin/tazobactam (3.375 g every 6 h; n=291) given for a minimum of 5 days, after which oral amoxicillin/clavulanic acid (875/125 mg every 12 h) could be given for up to 23 days. Investigators retained the option to administer vancomycin to patients in either group to ensure adequate coverage for potentially antibiotic resistant Enterococcus spp and meticillin-resistant Staphylococcus aureus (MRSA). Our primary outcome was the proportion of patients with a favourable clinical response (cure or improvement) on the day that intravenous antibiotic was discontinued. Analyses were by an evaluable-patient only approach. This study is registered with , number NCT00229112.

FINDINGS

Of the 576 patients treated, 445 were available for assessment at the end of intravenous therapy. Both baseline characteristics and favourable clinical response rates were similar for the 226 who received ertapenem and the 219 who received piperacillin/tazobactam (94%vs 92%, respectively; between treatment difference 1.9%, 95% CI -2.9 to 6.9). Rates of favourable microbiological responses (eradication rates and clinical outcomes, by pathogen) and adverse events did not differ between groups.

INTERPRETATION

Clinical and microbiological outcomes for patients treated with ertapenem were equivalent to those for patients treated with piperacillin/tazobactam, suggesting that this once-daily antibiotic should be considered for parenteral therapy of diabetic foot infections, when deemed appropriate.

Evaluation of the Efficacy and Safety of Outpatient Parenteral Antimicrobial Therapy for Infections With Methicillin-sensitive Staphylococcus aureus

OBJECTIVES

As increasing numbers of patients are being treated with outpatient parenteral antimicrobial therapy (OPAT), it becomes ever more important to ascertain the risks and benefits of such treatment for patients.

METHODS

We conducted a retrospective analysis of 1,515 patients with methicillin-sensitive Staphylococcus aureus infections who were treated with outpatient parenteral antimicrobial monotherapy. All patients were included in the adverse drug reaction analysis; 1,252 were evaluable for purposes of evaluating treatment efficacy.

RESULTS

The six antibiotics most frequently used in this study (ceftriaxone, cefazolin, vancomycin, oxacillin, nafcillin, and clindamycin) appeared to be equivalent in achieving the desired efficacy outcome.

CONCLUSIONS

Vancomycin was associated with a significantly greater number of side effects than was ceftriaxone, cefazolin, or oxacillin, and nafcillin was associated with a significantly greater number of adverse events than ceftriaxone.

Ertapenem: a new opportunity for outpatient parenteral antimicrobial therapy

Ertapenem is a parenteral carbapenem antimicrobial with pharmacological properties that allow it to be given once daily. This makes it a consideration for outpatient parenteral antimicrobial therapy (OPAT). In comparison with information from the OPAT Outcomes Registry, ertapenem seems well suited for the types of infections and bacteria that are commonly treated with OPAT, plus it has additional activity against anaerobic bacteria. This added spectrum makes it possible to treat complicated skin/skin-structure, complicated intra-abdominal and pelvic infections with a single antibiotic instead of the multiple agents that have usually been required. Ertapenem is also comparable to other OPAT antimicrobials in terms of adverse effects and clinical outcomes. This antimicrobial can be given with any delivery model, although its stability when mixed is such that daily preparation or self-mixing systems need to be considered. Ertapenem should be added to the growing list of once-daily parenteral antibiotics that can be given to outpatients.

Intestinal parasites of the Pacific

Information about intestinal parasites in Hawaii and the Pacific is not current. We reviewed reports on fecal samples obtained from two laboratories and found recovery rates of 9.3% in Hawaii, 14.2% in Saipan, 18% in Rota and 9.5% in Guam. The most frequently identified parasites were Blastocystis hominis (7.6%), Giardia lamblia (1.2%), and Entamoeba coli (0.7%). Although the incidence and types of organisms have changed with time, physicians in Hawaii should continue looking for intestinal parasites.

Outcomes of osteomyelitis among patients treated with outpatient parenteral antimicrobial therapy

PURPOSE

To examine the effects of diabetes, vascular disease, age, and antimicrobial therapy on clinical outcomes, including amputation rates, in patients with osteomyelitis treated in the outpatient setting.

METHODS

We performed a retrospective chart review of patients treated with intravenous antimicrobial therapy for osteomyelitis at an outpatient infectious diseases practice. All patients were followed for at least 6 months.

RESULTS

Four hundred and fifty-four patients qualified for inclusion, with follow-up information available for up to 10 years. One hundred and thirty-nine patients (31%) had recurrences and 27 (6%) had amputations. Of the recurrences, 108 (78%) occurred within 6 months and 132 (95%) within 1 year. In univariate analyses, peripheral vascular disease, diabetes, and the combination were all associated with the risk of recurrence; age (>70 years) was not. For osteomyelitis due to Staphylococcus aureus, the relative risk of recurrence, using a Cox regression model, was 0.8 for ceftriaxone (95% confidence interval [CI]: 0.4 to 1.5; P = 0.53), 1.1 for cefazolin (95% CI: 0.5 to 2.2; P = 0.80), and 2.5 for vancomycin (95% CI: 1.1 to 5.6; P = 0.04), as compared with the use of a penicillinase-resistant penicillin.

CONCLUSION

Diabetes and peripheral vascular disease are important factors in determining the prognosis of patients with osteomyelitis, but age is not. Almost all recurrences of osteomyelitis occur within 1 year. Recurrence rates with osteomyelitis associated with S. aureus appear to be higher with the use of vancomycin, whereas ceftriaxone and cefazolin appear to be similar to penicillinase-resistant penicillins.

Risk factors and treatment outcomes in osteomyelitis

Outcome indicators of recurrence and amputation were used to evaluate risk factors and treatment choices in 454 patients with osteomyelitis who completed outpatient parenteral antimicrobial therapy (OPAT). Three hundred and fifteen (69.4%) were apparently cured at the time outcomes were measured and 139 (30.6%) had a recurrence. Of the recurrences, 56% occurred within 3 months, 78% within 6 months and 95% within 1 year. Both the initial pathogen and the choice of antibiotic had an effect on the risk of treatment failure. Osteomyelitis caused by Pseudomonas aeruginosa was associated with more than a two-fold increase in recurrence (P = 0.005) compared with infection caused by Staphylococcus aureus. There was a positive correlation between P. aeruginosa and amputation. With S. aureus infections, the risk of recurrence was more than twice as great with vancomycin therapy as opposed to treatment with beta-lactams (P = 0.03). Treatment with ceftriaxone was as effective as the penicillinase-resistant penicillins and cefazolin.

Bloodborne pathogen exposure and recommendations for management

Bloodborne pathogens pose a continuing threat to healthcare workers. The frequency of needlesticks and wounds from other sharps has been reduced by the use of safety devices in many healthcare workplaces but it has not been eliminated. The need for appropriate management of a needlestick or other exposure that could carry a bloodborne pathogen has become increasingly clear as more is learned about the factors affecting transmission of these infectious agents. With better diagnostic tools and more therapeutic agents the success rate of postexposure prophylaxis (PEP) will continue to improve. This article will focus on those agents as they pose the greatest known threats and offer the potential for intervention.

Cost perspectives for outpatient intravenous antimicrobial therapy

Intravenous antimicrobial therapy often continues after a patient is discharged from the hospital or it begins in the outpatient setting. Reimbursement for this therapy varies by payer. The United States Outpatient Parenteral Antibiotic Therapy (OPAT) Outcomes Registry is a valuable resource for quantifying cost by payer, as well as for describing practice patterns and adverse events related to intravenous antimicrobial therapy. To describe the reimbursement structure and cost of intravenous vancomycin home care therapy for four different types of payers, a survey of home infusion companies was done. Also surveyed were infusion programs participating in the OPAT Outcomes Registry, representing four different types of payers, to determine the cost of outpatient intravenous therapy. A retrospective cohort study of these infusion programs was conducted to describe practice patterns and to identify adverse events that resulted from intravenous vancomycin. We found that the cost of outpatient therapy was substantial, although nonuniform, across payer types. Alternative outpatient therapies associated with lower risks for adverse events and lower costs should be considered.

International outpatient parenteral antimicrobial therapy

On an international basis, outpatient parenteral antimicrobial therapy (OPAT) varies greatly. There are cultural as well as economic issues which make it different in every country. In general, the duration of hospital stay varies with the outpatient resources available and the economic base for them. In some countries, there may not be money available for any intravenous antibiotics, even in the hospital. In addition, there are great differences in outpatient intravenous therapy, with infusion clinics proliferating in China, yet these are scarce in the UK. There is also considerable variation in the use of intramuscular compared with intravenous therapies. In Italy, intramuscular ceftriaxone is used more often than intravenous therapy. While ceftriaxone use is high in the US, its use is surpassed on a per capita basis by Italy, and it is most interesting that the rate of antimicrobial resistance is lower in Italy than in most other European countries. Whether this relates to outpatient use, parenteral use or other unknown factors is unclear. Obviously, further studies are necessary.

Pharmacoeconomic considerations in the ambulatory use of parenteral cephalosporins

It has been clearly documented that outpatient parenteral antibiotic therapy (OPAT) saves money compared with hospital care for patients who need intravenous antimicrobial therapy. The reduced expenses come primarily from savings in facility and hospital staffing costs. In addition to shortening hospital stay, OPAT programmes can be developed so that hospital care is avoided altogether. However, even with the clear potential for savings, to have a successful programme it is necessary to align the interests of the payers, the physicians, the administrators and the patients. The cost of OPAT programmes can also be reduced through patient evaluation and careful selection of the appropriate delivery model, antibiotic, dosage intervals and infusion technology. The fact that antibiotics such as ceftriaxone, the aminoglycosides and vancomycin can be given once daily in the elderly offers particular advantages in terms of convenience as well as cost. In order to achieve cost savings, managed care will increasingly rely on home and outpatient therapy. This pressure will need to be counterbalanced by quality assurance programmes and outcomes measurements.

Outpatient parenteral antimicrobial therapy for central nervous system infections

Patients with central nervous system (CNS) infections are increasingly treated with intravenous antimicrobials outside the hospital, but the safety and problems associated with this therapy have not been well defined. To examine this issue, we reviewed 68 cases in which outpatient intravenous antimicrobial therapy (OPAT) was received through our physician office-based infusion clinic. All infections were cured, and no deaths occurred during therapy. Seizures occurred in 2 patients but without significant injury and apparently were unrelated to antimicrobial therapy. Eleven patients (16%) were hospitalized after starting OPAT, 5 for procedures and 6 for medical reasons. The antimicrobial used was changed in 13 cases (19%) because of an adverse effect or clinical failure. OPAT can be safe and effective for patients with CNS infections, but patients must be carefully selected and monitored closely.

Demographic, clinical, and treatment parameters influencing the outcome of acute cystitis

A meta-analysis of six double-blinded clinical trials was undertaken to identify risk factors associated with bacteriologic outcome in 3,108 women with acute cystitis. Eleven antibiotic regimens were used, including ciprofloxacin, ofloxacin, norfloxacin, trimethoprim-sulfamethoxazole, and nitrofurantoin. Entry criteria for all studies were identical. Among 2,409 patients who were defined to be valid for efficacy analysis, pathogens included Escherichia coli (78.6%), Staphylococcus saprophyticus (4.4%), Klebsiella pneumoniae (4.3%), Proteus mirabilis (3.7%), and "other" (9%). Causative bacteria were eradicated at the end of treatment in 93% of patients. The following parameters were associated with successful bacteriologic outcome: not using a diaphragm (P = .0041), treatment for > or = 3 days (P = .0043), pathogen not "other" (P = .0043), symptom duration of < 2 days (P = .0096), and African American race (P = .0147). K. pneumoniae (P = .0496) and "other" pathogens (P = .0018) were associated with increased probability of bacteriologic treatment failure. The presence of pyuria (> or = 10 WBCs per high-power field) did not correlate with outcome and was inversely correlated with the finding of > or = 10(5) bacterial colony-forming units per mL of urine (P < .001). This large database identifies new parameters associated with treatment outcomes of acute cystitis and calls into question current clinical trial guidelines.

Comparison of sparfloxacin and ciprofloxacin in the treatment of community-acquired acute uncomplicated urinary tract infection in women. Sparfloxacin Multicenter Uncomplicated Urinary Tract Infection Study Group

Urinary tract infection (UTI) is a common illness, with > or =30% of all women experiencing a UTI during their lifetime. Less than a decade ago, the standard therapy for acute uncomplicated UTIs involved treatment with > or =7 days of an antibacterial agent, but recent studies using a variety of newly introduced antibiotics, including the fluoroquinolones, have demonstrated that a 1- to 5-day treatment regimen can be equally effective. This randomized, double-masked, multicenter study was conducted to compare the efficacy and tolerability of a single dose of sparfloxacin with those of a 3-day regimen of sparfloxacin and a 7-day regimen of ciprofloxacin in the treatment of women with community-acquired acute uncomplicated urinary tract infection. A total of 1175 women were enrolled; 395 received sparfloxacin as a single 400-mg dose on day 1, 394 received sparfloxacin as a 400-mg loading dose on day 1 followed by 200 mg once daily for 2 additional days, and 386 received ciprofloxacin 250 mg twice daily for 7 days. Patients were comparable with respect to demographic characteristics and underlying conditions. A total of 954 patients were clinically assessable; 490 of these were also bacteriologically assessable. All patients treated were included in the tolerability analysis. Escherichia coli (75.4%), Klebsiella pneumoniae (4.9%), Enterococcus faecalis (4.6%), and Staphylococcus saprophyticus (4.1%) were the most commonly isolated organisms. In the all-treated population, clinical success was achieved 5 to 9 days after therapy in 91.8%, 92.2%, and 91.6% of patients in the single-dose sparfloxacin, 3-day sparfloxacin, and 7-day ciprofloxacin groups, respectively; bacteriologic success was observed in 91.7%, 92.6%, and 96.6% of those in the 3 groups. Sustained clinical success rates 4 to 6 weeks after therapy were 76.6%, 80.2%, and 79.5% in the single-dose sparfloxacin, 3-day sparfloxacin, and 7-day ciprofloxacin groups, respectively; sustained bacteriologic success rates were 80.7%, 90.1%, and 92.6%. The most common adverse events were nausea, headache, vaginal thrush, dizziness, and diarrhea; >92% of adverse events were mild or moderate in severity. The 2 drugs had comparable frequencies of adverse events, except for photosensitivity, which occurred in 3.3% of the 3-day sparfloxacin group, 1.3% of the single-dose sparfloxacin group, and 0.3% of the ciprofloxacin group (P = 0.005). The 3-day sparfloxacin regimen was effective and well tolerated. The initial response to single-dose sparfloxacin treatment was comparable to the response to the other 2 regimens, but the single-dose regimen proved less effective over time, with higher rates of clinical recurrence and bacteriologic relapse. Sparfloxacin provides an alternative to ciprofloxacin for patients with acute uncomplicated urinary tract infection who are not at risk for photosensitivity reactions or adverse events associated with a prolonged corrected QT interval.

Short-course therapy of acute cystitis: a brief review of therapeutic strategies

Acute cystitis is one of the commonest medical problems encountered by primary care physicians. It affects more women than men (8:1), but the incidence among men is increasing. Uncomplicated cystitis by definition occurs in healthy patients with a normal urinary tract, whereas complicated cystitis implies a predisposing or underlying condition. A narrow range of aetiological agents is responsible for most uncomplicated cystitis in women (Escherichia coli in 80% of cases). Recently, however, pathogens usually associated with sexually transmitted disease have been implicated. In women with typical symptoms of acute uncomplicated cystitis, an abbreviated laboratory work-up followed by empirical therapy is recommended. Single-dose and 3 day regimens of co-trimoxazole and the quinolones are as effective as longer regimens and have a higher eradication rate than other commonly used antimicrobials. Relapse rates are slightly higher with single-dose therapy. With this success rate plus the reduced cost and improved patient compliance, these regimens have replaced traditional 5 to 14 day courses of treatment. With increasing resistance of the common urinary pathogens to amoxycillin and, now, co-trimoxazole, the quinolones are a logical choice for empirical therapy of uncomplicated urinary tract infections.

Short-course therapy of acute cystitis: a brief review of therapeutic strategies

Acute cystitis is one of the commonest medical problems encountered by primary care physicians. It affects more women than men (8:1), but the incidence among men is increasing. Uncomplicated cystitis by definition occurs in healthy patients with a normal urinary tract, whereas complicated cystitis implies a predisposing or underlying condition. A narrow range of aetiological agents is responsible for most uncomplicated cystitis in women (Escherichia coli in 80% of cases). Recently, however, pathogens usually associated with sexually transmitted disease have been implicated. In women with typical symptoms of acute uncomplicated cystitis, an abbreviated laboratory work-up followed by empirical therapy is recommended. Single-dose and 3 day regimens of co-trimoxazole and the quinolones are as effective as longer regimens and have a higher eradication rate than other commonly used antimicrobials. Relapse rates are slightly higher with single-dose therapy. With this success rate plus the reduced cost and improved patient compliance, these regimens have replaced traditional 5 to 14 day courses of treatment. With increasing resistance of the common urinary pathogens to amoxycillin and, now, co-trimoxazole, the quinolones are a logical choice for empirical therapy of uncomplicated urinary tract infections.

Medicare coverage of outpatient ambulatory intravenous antibiotic therapy: a program that pays for itself

A number of studies have documented the safety, efficacy, and cost-effectiveness of outpatient intravenous (i.v.) antibiotic therapy for patients with infectious diseases. Nevertheless, Medicare policy prohibiting coverage of outpatient, self-administered drugs has severely limited access of Medicare patients to ambulatory i.v. therapy, thus forcing them to rely on more costly, impatient hospital care. To test the hypothesis that a new Medicare benefit providing coverage for ambulatory i.v. antibiotic therapy could significantly reduce the program's expenditures for the treatment of infectious diseases (including pneumonia, osteomyelitis, cellulitis, and endocarditis), a cost model was constructed with use of patient care information from the clinical literature as well as clinical experts, Medicare data, and other medical claims databases. The model shows cumulative 5-year savings of nearly $1.5 billion associated with the new Medicare benefit. Policy makers should consider implementing such a benefit.

Outpatient parenteral antibiotic therapy for fever and neutropenia

The treatment of fever and neutropenia following chemotherapy lends itself well to outpatient parenteral antimicrobial therapy (OPAT). Patients prefer to be at home rather than hospitalized again. There is a clear cost advantage of outpatient therapy. With a quality program and careful patient selection, OPAT can be provided effectively and safely. The chances of an infection due to resistant bacteria also appear to be reduced. There are an increasing number of studies that support the use of empiric antibiotic therapy for the first fever in neutropenic patients. The choice of antimicrobial, dose, as well as vascular access and infusion devices must be tailored to the individual patient needs and circumstances.

Outpatient parenteral antimicrobial therapy for osteomyelitis

OPAT for osteomyelitis is effective, safe, and well-established. There are particular considerations with osteomyelitis, however, that relate to patient selection and the plans of therapy. Orthopedic infections may impose physical considerations that need to be considered. Concomitant medical problems, such as diabetes, must be considered and may be good reasons for hospital care aside from the infection. Further investigations of treatment of osteomyelitis are clearly needed, with OPAT patients being good subjects to study.

Ceftriaxone once daily for four weeks compared with ceftriaxone plus gentamicin once daily for two weeks for treatment of endocarditis due to penicillin-susceptible streptococci. Endocarditis Treatment Consortium Group

This randomized, multicenter, open-label study compared the efficacy and safety of monotherapy with 2 g of intravenous ceftriaxone once daily for 4 weeks with those of combination therapy with 2 g of intravenous ceftriaxone and 3 mg of intravenous gentamicin/kg once daily for 2 weeks as therapy for endocarditis due to penicillin-susceptible streptococci. Sixty-one patients were enrolled in the study. Clinical cure was observed for 51 evaluable patients both at termination of therapy and at the 3-month follow-up: 25 (96.2%) of 26 monotherapy recipients and 24 (96%) of 25 combination therapy recipients. Of the 23 patients in each treatment group who were microbiologically evaluable, 22 (95.7%) in each group were considered cured. No patient had evidence of relapse. Fourteen patients (27.5%) required cardiac surgery after initiation of treatment, including five monotherapy recipients and nine combination therapy recipients. Adverse effects were minimal in both treatment groups. We conclude that 2 g of ceftriaxone once daily for 4 weeks and 2 g of ceftriaxone in combination with 3 mg of gentamicin/kg once daily for 2 weeks are both effective and safe for the treatment of streptococcal endocarditis.

Practice guidelines for community-based parenteral anti-infective therapy. ISDA Practice Guidelines Committee

This is the fourth in a series of practice guidelines commissioned by the Infectious Diseases Society of America through its Practice Guidelines Committee. The purpose of this guideline is to provide assistance to clinicians when making decisions on when and how to best administer parenteral antimicrobial therapy. The targeted providers are internists, pediatricians, family practitioners, and other providers of outpatient antiinfective therapy. Criteria for selecting the appropriate patients and settings to deliver therapy in the community are described. Panel members represented experts in adult and pediatric infectious diseases. The guidelines are evidence-based. A standard ranking system is used for the strength of the recommendations and the quality of the evidence cited in the literature reviewed. The document has been subjected to external review by peer reviewers as well as by the Practice Guidelines Committee and was approved by the IDSA Council. An executive summary and tables highlight the major recommendations.

Managed care and the infectious diseases specialist

There is growing demand to contain health care costs and to reassess the value of medical services. The traditional hospital, academic, and research roles of the infectious disease (ID) specialist are threatened, yet there is an increasing need for expertise because of growing antimicrobial resistance and emerging pathogens. Opportunities exist to develop and expand services for the care of patients infected with human immunodeficiency virus and in infection control, epidemiology, outcomes research, outpatient intravenous therapy, and resource management. It is important for ID physicians to appreciate the principles involved in managed care and the areas in which ID services can be valuable. To be effective, physicians need to know about tools such as practice guidelines, physician profiling, outcomes monitoring, computerized information management, risk sharing, networking, and marketing, as well as related legal issues. With a positive attitude toward learning, application, and leadership, ID physicians can redefine their role and expand their services through managed care.