Emergence of highly antibiotic-resistant Pseudomonas aeruginosa in relation to duration of empirical antipseudomonal antibiotic treatment

OBJECTIVE

This study examines antibiotic resistance in Pseudomonas aeruginosa in hospitalized patients in relation to prior empirical antibiotic therapy.

DESIGN

Two retrospective case analyses comparing patients who manifested P aeruginosa with differing patterns of antibiotic resistance.

SETTING AND PARTICIPANTS

Patients acquiring P aeruginosa in a community hospital.

MEASURES

Patients were compared on duration of hospitalization and days and doses of antibiotics prior to recovery of P aeruginosa. Patients were grouped, based on susceptibility patterns of their P aeruginosa isolates classified as follows: (1) fully susceptible (susceptible to all classes of antipseudomonal antibiotics [SPA]), (2) multidrug-resistant (resistant to two classes of antipseudomonal antibiotics [MDRPA]), or (3) highly drug-resistant (resistant to > or = 6 classes of antipseudomonal antibiotics [HRPA]). To control for duration of hospitalization, antibiotic treatments of HRPA and SPA patients were compared during the first 21 days of care.

RESULTS

Prior to recovery of HRPA, six HRPA patients received greater amounts of antibiotics, both antipseudomonal and non-antipseudomonal, than did six SPA patients prior to recovery of SPA. For 14 patients with hospital-acquired SPA who later manifested MDRPA, duration and dosage of antipseudomonal antibiotics, but not all antibiotics, were significantly higher for the SPA-to-MDRPA interval than for the preceding admission-to-SPA interval. The median duration of antipseudomonal antibiotic treatment prior to the recovery of P aeruginosa was 0 days for SPA, 11 days for MDRPA, and 24 days for HRPA.

CONCLUSION

Duration of empirical antipseudomonal antibiotic treatment influences selection of resistant strains of P aeruginosa; the longer the duration, the broader the pattern of resistance.

Factors associated with multiple hospitalizations of patients with borderline personality disorder

OBJECTIVE

The study sought to identify aspects of borderline personality disorder and comorbid axis I conditions associated with multiple hospitalizations in a sample of patients with borderline personality disorder.

METHODS

Data were collected as part of a larger study of treatment course of inpatients with this disorder. Predictors of multiple hospitalization from three domains were considered: demographic characteristics, criteria of borderline personality disorder, and comorbid axis I pathology. A sequential model-building strategy was used, with each domain considered separately and result combined into an overall regression model of factors related to multiple hospitalization.

RESULTS

Three factors were related to frequency of hospitalization: anorexia, psychotic symptoms, and suicidality. Other variables that are often assumed to be related to hospitalization, such as depression, did not emerge as significant predictors.

CONCLUSIONS

Clinicians should intervene early to address the emergence of certain axis I conditions among patients with borderline personality disorder. Increased expenditure of outpatient resources may prevent hospitalization when these conditions are present.

Antisocial traits as modifiers of treatment response in borderline inpatients

The relationship of antisocial traits to treatment response in 35 female inpatients with borderline personality disorder was studied. Antisocial traits were measured with the Personality Assessment Inventory. Treatment response was measured by weekly ratings on the Symptom Checklist-90-Revised over 25 weeks of hospitalization. Treatment course was found to be significantly associated with the level of antisocial behavior reported at admission.

Studying the treatment contract in intensive psychotherapy with borderline patients

A pilot study on the process of psychodynamic psychotherapy of borderline personality disorder at the Cornell University Medical College is designed to investigate the teaching and application of a specific model of treatment for borderline patients (Clarkin et al. 1992; Kernberg and Clarkin 1992). The project has involved teaching a group of self-selected trainees and faculty the manualized therapy (Kernberg et al. 1989); taping each of the twice-weekly therapy sessions over a period of 2 years; and rating (1) each therapist's adherence to the manual (Koenigsberg et al. 1985), (2) each therapist's skill, and (3) patient change. The patients are women with borderline personality disorder, between 20 and 40 years of age, diagnosed by DSM-III-R criteria (American Psychiatric Association 1987), SCID-II (Spitzer et al. 1987), and a self-report questionnaire for level of personality organization. At regular intervals, the patients are evaluated for symptom status, change in BPD criteria, and functioning. The therapists are evaluated for adherence to the manual and level of therapeutic skill. In teaching and carrying out the manualized therapy, it became clear that a critical moment in the treatment was the setting up of the treatment contract. A study was organized to look systematically at the adherence of the therapists to the model of treatment with regard to this initial phase of the therapy.