Antimicrobials In Patients Research Articles

ISQUA18-2497Can we Improve the Safety of Antimicrobials in Patients with Penicillin Allergy by Using Incident Reported to the National Reporting and Learning System?

ISQUA18-2497Can we Improve the Safety of Antimicrobials in Patients with Penicillin Allergy by Using Incident Reported to the National Reporting and Learning System?

Use of Estimating Equations for Dosing Antimicrobials in Patients with Acute Kidney Injury Not Receiving Renal Replacement Therapy.

Acute kidney injury (AKI) can potentially lead to the accumulation of antimicrobial drugs with significant renal clearance. Drug dosing adjustments are commonly made using the Cockcroft-Gault estimate of creatinine clearance (CLcr). The Modified Jelliffe equation is significantly better at estimating kidney function than the Cockcroft-Gault equation in the setting of AKI. The objective of this study is to assess the degree of antimicrobial dosing discordance using different glomerular filtration rate (GFR) estimating equations. This is a retrospective evaluation of antimicrobial dosing using different estimating equations for kidney function in AKI and comparison to Cockcroft-Gault estimation as a reference. Considering the Cockcroft-Gault estimate as the criterion standard, antimicrobials were appropriately adjusted at most 80.7% of the time. On average, kidney function changed by 30 mL/min over the course of an AKI episode. The median clearance at the peak serum creatinine was 27.4 (9.3–66.3) mL/min for Cockcroft Gault, 19.8 (9.8–47.0) mL/min/1.73 m2 for MDRD and 20.5 (4.9–49.6) mL/min for the Modified Jelliffe equations. The discordance rate for antimicrobial dosing ranged from a minimum of 8.6% to a maximum of 16.4%. In the event of discordance, the dose administered was supra-therapeutic 100% of the time using the Modified Jelliffe equation. Use of estimating equations other than the Cockcroft Gault equation may significantly alter dosing of antimicrobials in AKI.

Antimicrobial Utilization in Wound Infections in Tertiary Care Hospital

To identify the utilization pattern of antimicrobials in patients with suspected wound infections and skin and soft tissue infections (SSTI) according to WHO (World Health Organization) drug utilization indicators.This is a cross-sectional, record based study conducted in a tertiary care hospital after obtaining Institutional Ethical Committee approval. Patients of all ages admitted into N.R.I hospital between June to October 2017 suspected of wound and SSTIs were included in this study. Data of patients was collected from Medical records Department of the hospital. Analysis was done on 100 patients basing on inclusion criteria. Wound infections and SSTIs were found to be more common in males and in age group below 35 yrs. The major co-morbid conditions associated were diabetes and hypertension. Evaluation of prescriptions based on WHO drug utilization indicators showed that a total 201 antimicrobials were prescribed for 100 patients irrespective of positive or negative culture. Among antimicrobials, 31.8% were prescribed by their generic name.42.78 % were in the form of injections. 94.51 % of antimicrobials were in the National list of essential medicines 2015. Average duration of treatment given was for 7±3 days in the hospital. All the patients recovered well and got discharged. None of the patients died during the treatment among these 100 patients. The results obtained will be useful for implementing the modifications in the prescription for betterment of the patients and for the community.

Biomarker-guided antibiotic cessation in sepsis: evidence and future challenges.

Sepsis is a medical emergency, which requires the initiation of broad-spectrum antimicrobial agents as early as possible. In the absence of positive microbiological cultures providing targeted antimicrobial advice, broad-spectrum antibiotics are commonly continued until there is clinical evidence of infection resolution. With an absence of robust evidence to inform when it is safe to stop antimicrobial agents in sepsis, the duration of antimicrobial courses may be longer than is required. Prolonged courses of potent broad-spectrum antimicrobials increase the risk of adverse drug events and contribute to the growing emergence of multidrug resistant pathogens, which is a global public health emergency. The protocolised use of protein biomarkers to guide clinical decision making can be used to help combat excessive durations of antimicrobials in patients with sepsis. This article reviews the current evidence for biomarker-guided antimicrobial discontinuation protocols in sepsis, identifies related evidence gaps and examines future innovation challenges in this field.

Microorganisms present after use of Unna’s boot from ulcers venous patient

Model Study: A special analytical observational prospective longitudinal and controlled study of concurrent cohort was conducted from April 2013 to November 2014. Objective: To evaluate the microbiota present in the secretion of venous ulcer patients with “Unna Boot” and their resistance to antimicrobials. Methods: secretion samples were collected from wounds of patients with and without the use of “Unna Boot” and topic therapy during the dressing change and after seven days. The isolated microorganisms were identified and tested for antimicrobial susceptibility: Result: The isolated Gram-positive microorganisms were: S. aureus, E. faecalis, S. haemolyticus and S. xylosus. Gram-negative microorganisms were E. coli, P. aeruginosa, S. plymuthica, P. mirabilis, K. pneumoniae, K. oxytoca, P. stuartii, P. vulgaris, A. hydrophila, S. marcescens, A. baumannii, E. cloacae and Tatumella sp. The growth percentage and the microbiota in the secretion of the ulcer after seven days was not significant between the two types of dressing. The resistance of Gram-positive cocci to antimicrobials in patients using the “Unna Boot” was higher than in patients without boot (p = 0.0093). Conclusion: The number of microorganisms in microbial secretion venous ulcer after dressing change is higher regardless of the type of dressing. The positive cocci increased antimicrobial resistance in patients using the “Unna Boot”.

Evaluation of Antimicrobial use in Ventilated Patients in Coronary Care Unit of a Tertiary Care Hospital

In developing countries, excess and indiscriminate use of antibiotics in community and hospital settings can lead to adverse effects primary to prolongation of therapy, harbour antibiotic resistance bacteria, rise in health expenditures and decrease quality of life. Antimicrobial resistance in the intensive care unit (ICU) has emerged as an important problem in this scenario. Recent studies revealed that antibiotic use is roughly ten times larger in ICU than in general wards. Research studies are required to gain suitable information concerning the use of antimicrobials (AMA) in ventilated patients which helps in improving the prescribing pattern of antimicrobial and also in executing infection control strategies in the therapy modification of such patients. There is barely limited data on antibiotic prescribing pattern in ventilated patients from India hence this study was carried out with an objective to know more about the antibiotic prescribing pattern and to analyze rationality among the prescriptions. This retrospective study was conducted in the Coronary care unit (CCU) of tertiary care hospital in South India from June 2014 to December 2014. The prescribing pattern of antimicrobials in patients aged between 10-90 years was studied. Total 33 AMA preparations were used either single or in combination. In the study, the commonly used AMAs were beta-lactam antibiotics, particularly ceftriaxone, levofloxacin followed by piperacillin + tazobactam (extended –spectrum penicillins + s-lactamase inhibitor) as single or combination therapy. Combination of AMAs was used in 54.3% of patients. In order to achieve good outcome right use of antibiotic at right time and right dose is required, based on general AMAs prescribing pattern and susceptibility pattern of pathogens, which aid to minimize the irrational employ of antibiotics and extra pressure for resistance.

Impact of Antibiotic Stewardship Program on Prescribing Pattern of Antimicrobials in Patients of Medical Intensive Care Unit.

Rising concerns about antimicrobial resistance and inadequate development of effective new anti-infective drugs have stimulated universal efforts to strengthen infection-control interventions. Antimicrobial stewardship is a rational, systematic approach to promote the optimal selection, dosing, and duration of therapy for antimicrobial agents throughout the course of their use in order to improve the outcomes. Since in Shree Krishna Hospital (SKH), Antibiotic Stewardship Program (ASP) was first implemented in 2013, this study was planned to assess any change in antimicrobial use before and after implementation of ASP and to study the rate and pattern of antimicrobial use in medical ICU. A cross-sectional study was conducted in 12 bedded medical intensive care unit, over a period of two years from October 2014 to October 2016 at SKH. Permission was taken from Institutional Human Research Ethics Committee. Total 150 case files i.e., 75 from year 2012 and 75 from year 2015 were retrieved from medical record section of the hospital. Appropriateness of prescriptions was decided on the basis of appropriateness of choice, dose, frequency and duration of antimicrobial agents. Data were analysed by using descriptive statistics. There were 68.67% males and the mean (±SD) age was 57.11 (±16.83) years. Majority of the patients were suffering from respiratory conditions. The most common group of drugs prescribed in MICU was β-lactam antibiotics + β-lactamase inhibitors during 2012 as well as 2015. Total 139 patients i.e., 69 (92%) patients in 2012 and 70 (93.33%) patients in 2015 were given antimicrobial for therapeutic purpose. During the year 2015, 67 (89.33%) antimicrobial prescriptions were adhering to antibiotic policy of SKH. Appropriateness of prescriptions had significantly improved in 2015 in MICU (p-value=0.031). In-depth analysis of the study revealed a positive impact of ASP and antibiotic policy. Implementation of ASP in year 2013, brought an effective increase in the appropriate use of antimicrobials.

Efficacy of Local Antimicrobials in the Non-Surgical Treatment of Patients With Periodontitis and Diabetes: A Systematic Review.

Patients with diabetes present a worse response to periodontal treatment. Local antimicrobials as an adjunct to scaling and root planing (SRP) provide additional benefits in the treatment of periodontitis in healthy patients. This review aims to evaluate the effects of local antimicrobials as an adjunct to SRP, compared with SRP alone, on periodontal clinical parameters of patients with chronic periodontitis (CP) and diabetes mellitus (DM). Only randomized controlled trials with: 1) at least 6 months of follow-up; 2) SRP, in combination with local antimicrobials; and 3) patients with periodontitis and DM were considered eligible. MEDLINE, EMBASE, and LILACS databases were searched for articles published up to January 2016. Random-effects meta-analyses were conducted for clinical attachment level (CAL), probing depth (PD), bleeding on probing, and gingival index change after treatment. Of 153 papers potentially relevant to this review, six were included. The majority of trials showed a significant PD reduction and CAL gain associated with use of local antimicrobials in patients with type 1 and type 2 DM. Only studies that included well-controlled patients and applied antimicrobials at the deepest sites or sites with baseline PD ≥5 mm presented significant PD reduction and CAL gain. In patients with DM and CP, use of local antimicrobials as an adjunct to SRP may result in additional benefits compared with SRP alone in PD reduction and CAL gain, especially in well-controlled individuals and deep sites.

Empirical antimicrobial therapy for probable v. directed therapy for possible ventilator-associated pneumonia in critically injured patients.

Ventilator-associated pneumonia (VAP) has recently been classified as possible or probable. Although direct attributable mortality has been difficult to prove, delay in instituting appropriate therapy has been reported to increase morbidity and mortality. Recent literature suggests that in possible VAP, instituting directed therapy while awaiting microbiological culture does not prejudice outcome compared with best-guess empirical therapy. To ascertain outcomes of directed v. empirical therapy in possible and probable VAP, respectively. Endotracheal aspirates were obtained from patients with suspected VAP. Those considered to have possible VAP were given directed therapy following culture results, whereas patients with more convincing evidence of VAP were classed as having probable VAP and commenced on empirical antimicrobials based on microbiological surveillance. Pneumonia was suspected in 106 (36.8%) of 288 patients admitted during January - December 2014. Of these, 13 did not fulfil the criteria for VAP. Of the remaining 93 (32.2%), 31 (33.3%) were considered to have probable and 62 (66.7%) possible VAP. The former were commenced on empirical antimicrobials, with 28 (90.3%) receiving appropriate therapy. Of those with possible VAP, 34 (54.8%) were given directed therapy and in 28 (45.2%) no antimicrobials were prescribed. Of the latter, 24 recovered without antimicrobials and 4 died, 3 from severe traumatic brain injury and 1 due to overwhelming intra-abdominal sepsis. No death was directly attributable to failure to treat VAP. No significant difference in mortality was found between the 34 patients with possible VAP who were commenced on directed therapy and the 31 with probable VAP who were commenced on empirical antimicrobials (p=0.75). Delaying antimicrobial therapy for VAP where clinical doubt exists does not adversely affect outcome. Furthermore, this policy limits the use of antimicrobials in patients with possible VAP following improvement in their clinical condition despite no therapy.

Opportunities to improve antimicrobial use in paediatric intensive care units: a nationwide survey in Spain

Improving antimicrobial use is a complex process that requires an accurate assessment of ongoing problems and barriers. Paediatric intensive care units (PICU) have seldom been assessed from this perspective. Two Internet-based, self-administered surveys were conducted nationwide in Spain between January and February 2014. The first survey aimed to assess those characteristics of Spanish PICUs that could influence antimicrobial prescribing or antimicrobial stewardship. The second survey targeted Spanish PICU physicians and pursued to assess their attitudes and perceptions regarding antimicrobial resistance and antimicrobial use. Information about 29/39 contacted PICUs was obtained. A total of 114/206 (55.3%) paediatric intensivists responded. PICUs were heterogeneous regarding years since foundation, number of beds, type of patients admitted and staffing. Only 11 (37.9%) PICUs had available e-prescribing systems. Procalcitonin was available in 24 (89.1%) PICUs, but there were no procalcitonin-based protocols in 14 (60.9%) of them. Half of surveyed PICUs had implemented antimicrobial stewardship activities. Ninety-eight of the 114 PICU physicians (86%) who participated considered that antimicrobial resistance was a significantly relevant problem for their daily and that improving antimicrobial use in their PICU should be a priority (103; 90.4%). The main perceived problems regarding antimicrobial use were the excessive use of antimicrobials in patients with nonconfirmed infections and excessive use of broad-spectrum antimicrobials. The most valued antimicrobial stewardship interventions were the implementation of protocols to guide antimicrobial therapy. Spanish PICU doctors are aware of the relevance of the problem of antimicrobial resistance and the need to improve antimicrobial use. Targeted interventions should take into account their difficulties and preferences when feasible.

Efficacy of early switch from intravenous to oral antimicrobials in patients with aspiration pneumonia: A prospective observational study.

Previous reports have documented the efficacy of an early switch from intravenous to oral antimicrobials in community-acquired pneumonia, but not aspiration pneumonia. Therefore, we assessed the feasibility and efficacy of these newly developed criteria for community-acquired pneumonia in patients with aspiration pneumonia. This prospective observational study included consecutive patients admitted with aspiration pneumonia over a 10-month period at St. Luke's International Hospital; we excluded patients that required intensive care. The criteria for an early switch were stability of vital signs (temperature ≤ 38 °C; respiratory rate ≤ 24 breaths/min; pulse rate ≤ 100 beats/min for >24 h) and a successful swallow evaluation (repetitive saliva swallowing test score ≥ 2; modified water swallowing test score ≥ 4). Our primary endpoint was successful completion of antimicrobial treatment 30 days after the switch, without reversion to intravenous antimicrobials. Our anticipated success rate was set as 60-75%, based on a previous study. Of the 70 patients admitted with aspiration pneumonia, 32 (45.7%) were excluded, and 38 (54.3%) met the inclusion criteria. Of these 38 patients, 29 (76.3%) met the switch criteria. The median duration of hospital stay for the included patients was 16 (5-30) days and 30 (12-68) days, respectively (P=0.03). Among patients who met the switch criteria, 26 (89.7%) completed oral treatment successfully while 3 (10.3%) reverted to intravenous antimicrobials. Approximately 75% of patients met the switch criteria; of these, nearly 90% underwent safe conversion to oral therapy. These results demonstrate the efficacy and feasibility of our switch criteria.

Role of Antimicrobial Prophylaxis During Treatment of Adults with Acute Leukemia

Patients with acute leukemia (AL) are at high risk for developing bacterial, viral and fungal infections during chemotherapy. Because these infections cause considerable morbidity and mortality, prevention is attractive. In recent decades, several trials have established the benefit of prophylactic antimicrobials in patients with AL. Administration of prophylactic fluoroquinolone, acyclovir and triazole is recommended in neutropenic patients with AL by both the USA and European national guidelines. The potential for antimicrobial resistance as a long-term consequence of prophylaxis, however, is a concern. The recent development of nonculture-based diagnostic tests for invasive fungal infections has made early diagnosis and targeted treatment a promising future strategy as an alternative to mold-active prophylaxis.

Skin Testing, Graded Challenge and Desensitization to the Tetracycline Class of Antimicrobials in Patients with Hypersensitivity Reactions

S U N D A Y 396 Pretreatment with IVIG and Corticosteroids for Contrast Media Induced Severe Adverse Drug Reaction Thao Nguyen N. Tran, Colleen Adkins, Vuong A. Nayima, DO, John T. Anderson, MD, James Ryan Bonner, MD, FAAAAI; UAB Internal Medicine Residency Birmingham, Birmingham, AL, University of Alabama at Birmingham, Birmingham, AL, University of Alabama Birmingham, Birmingham, AL, Alabama Allergy & Asthma Center, Birmingham, AL. RATIONALE: Contrast media (CM) is known to cause severe adverse drug reactions (ADR) including delayed reactions such as SJS/TEN and leukocytoclastic vasculitis (LCV). Pretreatment for subsequent administration is not standardized. Here we present a patient with history of severe delayed ADR to CM in whom pretreatment with IVIG and corticosteroids successfully reduced her reactions to repeated exposure. METHODS: Our patient is a 67 yo female with reported history of SJS to CM who presented with acute coronary syndrome requiring cardiac intervention. For two days prior to catheterization, she was treated following a previously published protocol (Hebert and Bogle) with IVIG 200mg/kg and prednisone 60mg daily. RESULTS: Hours after CM exposure, the patient developed a nonblanching purpuric rash on bilateral feet clinically consistent with mild LCV. Protocol was adjusted, changing steroids to methylprednisolone 40mg q6hrs with continuation of IVIG. Due to the necessity of repeat coronary angiography, IVIG and IV steroids were continued until 2 days post repeat catheterization. Thereafter she was transitioned to oral prednisone with one week taper. No further ADRs were observed. CONCLUSIONS: While history suggested SJS, our patient’s subsequent reaction was more consistent with LCV. The improvement of the LCVand lack of recurrence after repeat CM challenge suggests administering IVIG and steroids may be an effective option for preventing severe delayed ADR to CM in patients with a history of severe LCV.

Prescribing Pattern of Antimicrobials in Patients during Post-Operative Period – An Observational Study

Background: Understanding prescribing pattern of antimicrobials in postoperative period will provide data pertaining to efficacy of prophylaxis during post surgical period and economic burden faced by patients. This data will help local authorities formulate practical guidelines to ensure their rational prescription. Our aim was to evaluate the type and dosage schedule of antimicrobials used in post-operative patients and to estimate the cost of antimicrobials in these patients. Materials and Methods: This is a prospective observational study conducted by the Department of Original Research Article Revathi et al.; BJMMR, 5(10): 1213-1219, 2015; Article no.BJMMR.2015.137 1214 Pharmacology at R.L. Jalappa Hospital and Research Centre attached to Sri Devaraj Urs Medical College between April and September 2013. All patients above the age of 18 years undergoing surgical procedures in the departments of Orthopedics, Surgery and ENT and hospitalised were included. Results: There were 500 patients, 351 males and 149 females. The mean age and duration of stay was 43.15±16.8 years and 6.7±3.1 days respectively. Types of surgeries were, fracture fixation (31.8%), head and neck (18.2%), soft tissue extremities (18.0%), abdominal (9.4%) and others (22.6%). All patients received antimicrobials prophylactically. 72% of the patients received antimicrobials for more than 24 hours. Commonly prescribed antimicrobials were cephalosporins (54.6%) and aminoglycosides (22.3%). The daily defined dose (DDD) /1000 patient days) was highest for aminoglycoside amikacin (296.96±63.5). Conclusion: All patients received prophylactic antimicrobials and more than seventy percent were continued with the antimicrobials in the post operative period to prevent surgical site infection. However use of third generation cephalosporins was extensive, which may result in the development of resistance to these agents in the near future.

Antibiotic Resistance, Part 1: Gram-positive Pathogens

Antibiotics have been instrumental in reducing mortality and morbidity associated with bacterial infections. However, antibiotic resistance has been increasing at an alarming rate due to overuse and inappropriate utilization. The emergence of resistance in Streptococcus pneumoniae, Staphylococcus aureus and enterococci is of concern. The increasing incidence of resistance in these pathogens has led to increased morbidity, mortality and health care costs. Understanding mechanisms of resistance and current patterns of resistance found in gram-positive organisms is important when prescribing antimicrobials in patients. A collaborative effort to promote the appropriate prescribing of antimicrobial agents must be undertaken to preserve currently available antibiotics.

Impacto del cobre en la reducción de infecciones intrahospitalarias, mortalidad y gasto en antimicrobianos en una Unidad de Cuidados Intensivo de adultos

We conducted a clinical trial to determine the impact of coating surfaces with copper in reducing hospital-acquired infections, mortality associated with nosocomial infections and antimicrobial costs in the UCI. The study took place at Carlos Van Buren Hospital, Valparaíso, Chile. No differences in the frequency of nosocomial infections were found. Not in rates of ventilator-associated pneumonia (p = 0.9), nor in catheter- associated urinary tract infection (p = 0.9) or in central venous catheter associated bacteremia (p = 0.3). There were no differences in infection-free survival (p = 0.9). There were less costs of antimicrobials in patients in which copper was used. The fact that the sample size was not completed could explain that no significant differences in infections were found. The use of copper as a surface in the ICU showed no statistically significant differences in rates of nosocomial infections during the study period, however, these results could be related to the sample size.

Efectividad de un programa para mejorar el uso de antibióticos en niños internados en un hospital pediátrico de tercer nivel de atención en Argentina

Inadequate antibiotic use is associated with an increased emergence of resistant microorganisms, higher morbidity and mortality rates, and an impact on public health. To assess the effectiveness of a program aimed at improving the use of antimicrobials in patients hospitalized at Hospital Garrahan. Prospective, longitudinal, before and after study with no control group. From November 1st, 2010 to June 30th, 2011. Patients receiving parenteral antibiotics were included. Newborn infants, burned patients and those receiving prophylactic antibiotics were excluded. The periods before and after implementing discussion and monitoring workshops for antibiotic prescription and distributing treatment guidelines were compared. An univariate analysis and a multiple logistic regression study were performed (STATA 8.0). In the pre-intervention period,376 patients were included; of them, 35.6% had received inadequate treatment. The multiple regression analysis showed that the endpoints for inadequate antibiotic use were acute lower respiratory tract infection (OR: 3.80; 95% CI: 1.35-3.26; p=0.04), fever without a source in hospitalized patients (OR: 5.55; 95% CI: 2.43-12.6; p < 0.01), and febrile neutropenia (OR: 0.29; 95% CI: 0.10-0.7; p < 0.01). In the post-intervention period, 357 patients were included; 21.5% had received inadequate treatment. A reduction in inadequate antibiotic prescription was observed compared to the pre-intervention period (p < 0.01). The multiple regression analysis showed that endpoints for inadequate use were skin and soft tissue infections (OR: 0.33; 95% CI: 0.13-0.93; p = 0.035), and febrile neutropenia (OR: 0.48; 95% CI: 0.220.94; p= 0.04). The program was effective and allowed to improve antibiotic prescription practices in hospitalized children.

Granulocyte Transfusions for Children with Infection and Neutropenia or Granulocyte Dysfunction

Transfusions of granulocytes can be used as an adjunct therapy to antimicrobials in patients with infection and neutropenia or granulocyte dysfunction. However, there is a lack of strong clinical evidence to support the use of this treatment strategy, particularly in children. We retrospectively reviewed the medical records of children who received granulocytes at our institution from April 2009 to October 2012, with emphasis on primary indication for the transfusion and clinical outcome in terms of infection. The patients had granulocyte dysfunction or severe neutropenia, defined as absolute neutrophil count (ANC) < 500 cells/mm3 due to chemotherapy or hematopoietic stem cell transplant (HSCT), and reasonable hope for bone marrow recovery or engraftment. Eighteen children received granulocytes during 20 distinct episodes: 62% (n = 13) for acute infection, 29% (n = 5) for unresolved chronic infection during the time of HSCT, and 9% (n = 2) for other clinical conditions such as typhilitis and appendectomy. Overall, 92% (n = 12) of the episodes of acute infection had complete or partial resolution, as determined by review of vital signs, physical exam findings and discontinuation of antimicrobials. A substantial number (46%) of children who received granulocytes for acute infection developed respiratory adverse events, but all of these recovered. We conclude that granulocyte transfusions continue to be primarily used in neutropenic patients with acute infections, and that its use in this group of patients is reasonable. However, a prospective randomized clinical trial is needed to evaluate safety and whether the use of granulocytes is superior to antimicrobial-only therapy.

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Introduction: No study has examined the differences in time to antimicrobials between patient locations at the time of severe sepsis and septic shock onset and its impact on outcomes. This study aimed to compare the time from onset of severe sepsis or septic shock to antimicrobial administration between patients in the emergency department (ED), intensive care unit (ICU), and all other hospital units. Secondary objectives were (1) to compare the rate of antimicrobial administration within one hour of disease onset between the ED, ICU, and all other hospital units, and (2) to determine the impact of location on mortality and length of stay. Methods: A retrospective chart review was conducted over a 3-year period. Adult patients identified with severe sepsis or septic shock who received antimicrobial therapy were included. Time from disease onset to administration of the first antimicrobial was calculated. Descriptive statistics and bivariate analysis were undertaken to determine the timing of antimicrobial administration. Results: A total of 386 subjects were included in the final analysis; 321 from the ED, 12 from the ICU, and 53 from all other hospital units. Patients in the ED had a median time to antimicrobial administration of 145 minutes after identification of severe sepsis or septic shock, compared with 120 minutes for the patients in the ICU and 144 minutes for patients in other hospital units (p=0.78). Patients in the ED were less likely to receive antimicrobials within one hour of onset (10%), as compared to those in the ICU (25%) and in all other hospital units (27%); p<0.05. Overall mortality was 27%. Patients in the ICU and all other hospital units had a higher rate of mortality, compared to patients in the ED (50%, 40%, and 24%, respectively; p=0.01). Patients in the ICU and all other hospital units also had longer hospital stays after sepsis onset as compared to patients in the ED (21, 22, and 15 days, respectively; p=0.03). Conclusions: There are significant delays associated with the administration of antimicrobials in patients with severe sepsis or septic shock, regardless of location at the time of disease onset. Subjects in the ED are more likely to experience delays of at least one hour as compared to those in the ICU and all other hospital units.

Clinical and microbiological effects of systemic antimicrobials combined to an anti‐infective mechanical debridement for the management of aggressive periodontitis: a 12‐month randomized controlled trial

To compare the 1-year clinical and microbiological outcomes of an enhanced anti-infective therapy with versus without systemic antimicrobials in patients with generalized aggressive periodontitis (GAP). In this 12-month randomized, double-blinded, placebo-controlled trial, 35 individuals assigned to a control (n=17) or test group (n=18) received full-mouth supra and subgingival ultrasonic debridement followed by scaling and root planing with chlorhexidine rinsing, brushing, and irrigation. Subjects received either amoxicillin (AMX, 500mg) + metronidazole (MET, 250mg) or placebos, TID for 10days. Subgingival samples were obtained and analysed for their composition by checkerboard. Data were subjected to non-parametric tests. Both therapeutic protocols resulted in similar significant clinical improvement for most parameters at 1 year (p<0.01). The AMX + MET group exhibited shallower residual pockets than the placebo (p=0.05). Most periodontal pathogens decreased, whereas beneficial bacteria increased in counts in both groups over time (p<0.0012). High levels of some periodontal and other microbial pathogens were associated with disease persistence regardless treatment. The enhanced anti-infective mechanical therapy is comparable with its combination with systemic AMX+MET for most clinical parameters and for maintaining low levels of periodontal pathogens for up to 1 year after treatment of GAP.