Days Of Metronidazole Research Articles

42. A Pharmacist-Led Intervention to Decrease Anaerobic Coverage for Hospitalized Patients with Community-Acquired Pneumonia

BackgroundCommunity-acquired pneumonia (CAP) is frequently mis-categorized as aspiration pneumonia, prompting the addition of anaerobic coverage to the antibiotic regimen. In our institution, this usually takes the form of adding metronidazole to ceftriaxone. The 2019 American Thoracic Society and Infectious Diseases Society of America CAP guidelines recommend anaerobic coverage only for hospitalized patients with a suspected lung abscess or empyema. The objective of this study was to determine if a pharmacist-led workflow could increase adherence to the 2019 CAP guideline recommendations by limiting anaerobic coverage to those rare occasions.MethodsThe hospital antimicrobial stewardship committee approved a pharmacist workflow and guidance document which outlines criteria to evaluate appropriateness of anaerobic coverage for hospitalized patients with CAP and no other indications for antibiotics. If anaerobic coverage is not indicated, the pharmacist submits a standardized message to the treating provider via the electronic medical record, recommending discontinuation of metronidazole. This workflow was implemented on October 3, 2019. Metronidazole days of therapy (DOT) per 1000 patient days in quarters 1 through 4 of 2019 and quarter 1 of 2020 were collected as well as percent acceptance of documented pharmacist interventions from October 3, 2019 until March 31, 2020.ResultsBetween October 3, 2019 and March 31, 2020, a total of 221 interventions were made by pharmacists to discontinue metronidazole in hospitalized CAP patients where anaerobic coverage was not indicated. Out of those 221 interventions, 164 (74%) were accepted by providers and only 57 (26%) were rejected.The DOT per 1000 patient days of metronidazole was assessed for the three quarters prior to our intervention and the two quarters after the intervention. Compared to the three quarters prior, metronidazole DOT per 1000 patient days decreased by 26.6% for the two quarters following implementation of the pharmacist-led intervention (Figure 1).Figure 1: Metronidazole DOT per 1000 patient days from January 1, 2019 through March 31, 2020. Vertical line indicates when pharmacist workflow was implemented. ConclusionA pharmacist antimicrobial stewardship intervention at our institution increased adherence to CAP guidelines and decreased unnecessary antibiotic exposure in hospitalized CAP patients when anaerobic coverage was not indicated.Disclosures All Authors: No reported disclosures

S1831 Intestinal Amebiasis: A Crohn's Mimicker

INTRODUCTION: Amebiasis is caused by Entamoeba histolytica (E. histolytica), an intestinal protozoan endemic in tropical and subtropical regions. Amebic colitis shares similar clinical symptoms and endoscopic findings with Crohn’s disease and may be easily unrecognized and misdiagnosed. We present a case of intestinal amebiasis due to E. histolytica in an immunocompetent patient which was initially managed as Crohn’s disease. CASE DESCRIPTION/METHODS: A 53-year-old, previously healthy man presented with a six-month history of intermittent hematochezia, urgency and watery diarrhea (several times daily), accompanied by mild crampy lower abdominal pain. He denied fever, weight loss, or recent medication use. He had 6 same-sex sexual partners in the year prior to presentation but denied having unprotected intercourse. An active duty service member, he had recently moved from South Korea, and had been stationed in Italy, Turkey and Germany prior to that. Physical examination was unremarkable. Complete blood count, hemoglobin, electrolytes and liver enzymes were within normal limits. Recent HIV testing was negative. Colonoscopy demonstrated a large ulcer in the cecum and 4 deep ulcers (up to 15mm in size) in the ascending colon. In the rectum, there were several ulcers less than 1cm in size. Biopsies were taken at each location. The remainder of the colon and 15cm of the visualized terminal ileum appeared normal. The patient was empirically started a budesonide taper starting at 9mg daily for presumed Crohn’s disease. The endoscopic biopsies showed colonic ulceration with many trophozoites consistent with E. histolytica. The patient was contacted within two weeks of his colonoscopy. He reported his symptoms had not worsened, but he continued to have urgency, hematochezia and diarrhea. Budesonide was discontinued and he started 10 days of metronidazole, followed by 10 days of paromomycin. Within one week his symptoms resolved completely and he remains asymptomatic at 4 month follow-up. DISCUSSION: Amebic colitis may be misdiagnosed as Crohn’s disease due to the low incidence of invasive amebiasis in industrialized countries and the shared similar clinical and endoscopic features. Amebiasis is an emerging parasitic infection, particularly among men who have sex with men. Amebiasis should be ruled out prior to corticosteroid administration, to avoid complications such as colonic strictures, perforation and extra intestinal abscesses.Figure 1.: Acute colitis with ulcer. High-power view of a section from ascending colon shows colonic mucosa with cryptitis and acute inflammation in lamina propria and areas of necroinflammatory debris (ulcer).Figure 2.: Ulcer with Entamoeba histolytica. High-power view of colonic ulcer with abundant Entamoeba histolytica with small round eccentric nuclei with open chromatin and ingested erythrocytes in the cytoplasm.Figure 3.: Cecal ulcer. Colonoscopy demonstrated a large ulcer in the cecum (approximately 15mm) and several small ulcers in the ascending colon and rectum.

A Randomized Controlled Trial of Ceftriaxone and Doxycycline, With or Without Metronidazole, for the Treatment of Acute Pelvic Inflammatory Disease.

Anaerobic organisms are important pathogens in acute pelvic inflammatory disease (PID). The currently recommended PID regimen of a single dose of ceftriaxone and doxycycline for 14 days has limited anaerobic activity. The need for broader anaerobic coverage is unknown and concerns have been raised about metronidazole tolerability. We conducted a randomized, double-blind, placebo-controlled trial comparing ceftriaxone 250 mg intramuscular single dose and doxycycline for 14 days, with or without 14 days of metronidazole in women with acute PID. The primary outcome was clinical improvement at 3 days following enrollment. Additional outcomes at 30 days following treatment were the presence of anaerobic organisms in the endometrium, clinical cure (absence of fever and reduction in tenderness), adherence, and tolerability. We enrolled 233 women (116 to metronidazole and 117 to placebo). Clinical improvement at 3 days was similar between the 2 groups. At 30 days following treatment, anaerobic organisms were less frequently recovered from the endometrium in women treated with metronidazole than placebo (8% vs 21%, P < .05) and cervical Mycoplasma genitalium was reduced (4% vs 14%, P < .05). Pelvic tenderness was also less common among women receiving metronidazole (9% vs 20%, P < .05). Adverse events and adherence were similar in each treatment group. In women treated for acute PID, the addition of metronidazole to ceftriaxone and doxycycline was well tolerated and resulted in reduced endometrial anaerobes, decreased M. genitalium, and reduced pelvic tenderness compared to ceftriaxone and doxycycline. Metronidazole should be routinely added to ceftriaxone and doxycycline for the treatment of women with acute PID. NCT01160640.

2366. PCR Followed by Toxin EIA for the Diagnosis of C. difficile Infection

BackgroundIn June 2017 for the diagnosis of Clostridioides difficile infection (CDI), Renown Health transitioned from utilizing polymerase chain reaction (PCR) to a two-step algorithm of PCR followed by toxin enzyme immunoassay (EIA) if PCR was positive. Providers were encouraged to forgo treatment in patients that were PCR-positive and EIA-negative as recent literature suggests this may indicate colonization rather than infection. The purpose of this study was to assess the impact of implementation of the two-step algorithm for the diagnosis of CDI on antibiotic usage and patient outcomes.MethodsThis was a retrospective quasi-experimental study of adult inpatients at Renown Regional and South Meadows Medical Centers that were PCR positive before and after implementation of a two-step algorithm for the diagnosis of CDI. The pre-implementation period was defined between May 8, 2016 and May 7, 2017, and the post-implementation period was May 8, 2017 to May 7, 2018. Patients were excluded if they were admitted to a pediatric ward, tested for CDI at an outside facility, or if results were available following discharge. The primary outcome was inpatient days of metronidazole and non-parenteral vancomycin per PCR positive patient. Secondary outcomes included defined daily doses of therapy, proportion of untreated patients, time to resolution of diarrhea, all-cause in-hospital mortality, 30-day recurrence, all-cause 30-day readmission, length of stay, and 30-day CDI-related complications. CDI-related complication was a composite of ICU care, megacolon, ileus, surgical intervention. It was calculated that 242 patients were required to achieve at least 80% power to detect a 30% difference in antibiotic days between pre- and post-implementation of two-step C. difficile testing. Wilcoxon two-sample test was used for continuous data, and χ 2 or Fisher exact test were used for categorical data.ResultsSee figures.ConclusionIncorporation of C. difficile toxin EIA to PCR for the diagnosis of CDI resulted in a significant reduction in non-parenteral vancomycin and metronidazole days of therapy. Patient outcomes were not adversely affected by the addition of toxin EIA. The results suggests that toxin EIA may help differentiate between C. difficile colonization and active infection. Disclosures All authors: No reported disclosures.

Sarcina as an Unknown Culprit of Esophageal Strictures

Sarcina ventriculi is a gram positive organism that is well known to veterinarians, however the exact pathogenicity in humans is not well delineated. Several cases of human disease have been described including emphysematous gastritis, gastric ulcers and perforation, and recently esophageal pneumatosis. Here we present a case of Sarcina-associated esophageal stricture. A 65 year old woman with metastatic breast cancer and history of Schatzki ring presented with two months of progressive dysphagia. Imaging with x-ray fluoroscopy revealed an irregularly short segment stricture at the mid to distal esophagus. Esophagogastroduodenoscopy (EGD) showed a benign appearing stenosis at 32 cm that measured 3 mm in diameter and gastric ulcers. She underwent subsequent dilation under fluoroscopy with a Savary dilator up to 12 mm and was medically managed with a proton pump inhibitor. Esophageal biopsies revealed acute and chronic inflammation with rare large tetrads of bacterial cocci, morphologically consistent with Sarcina organisms. In light of Sarcina presence, she was treated with 7 days of metronidazole and ciprofloxacin. An esophageal stent was placed after serial dilation failed to improve symptoms. Unfortunately, her hospital course was complicated by acute pulmonary embolisms, hemorrhagic gastropathy, and persistent vomiting resulting in subsequent removal of the stent. Ultimately, the patient transitioned to palliative comfort care due to overall poor prognosis. Sarcina ventriculi is a well described pathogen in veterinary medicine, but its role in human disease is not as well understood. Human presentation has varied widely from gastrointestinal symptoms of nausea, vomiting, epigastric pain to emphysematous gastritis complicated by gastric perforation. EGD findings have also varied but common themes have emerged including luminal findings of retained food residue and mucosal findings of erosion and gastric ulcers. While most reported cases of Sarcina pathology have been gastric in location, very few have been esophageal. Studies of the esophageal microbiome did not identify Sarcina in patients with normal histology, which suggests that in contrast to gastric sites the organism is more likely to be a pathogen. Compared to previous esophageal pathology reported, we report a case of Sarcina that occurred in the setting of stasis as a result of esophageal stricture. It will be important to further assess the importance of Sarcina in the pathogenesis of esophageal diseases.Figure: EGD findings of severe esophageal stricture.Figure: Purple Sarcina cocci in characteristic tetrads (long arrows) are present in the luminal aspect of this gastric biopsy. Notice the large size of the organisms in comparison to the luminal bacilli (arrowheads) in the background. There is mild acute inflammation, demonstrated by the intraepithelial neutrophils (short arrows), in the adjacent gastric epithelium. Hematoxylin and eosin (H&E) stain, original magnification 600x.Figure: Esophagus squamous mucosa with luminal Sarcina organisms (long arrows). Arrowhead points to background bacilli for size comparison. H&E 600x.

PTH-010 Rises In both White Cell Count and Crp at Day 3 Predict Failure of Treatment with Metronidazole in C.Difficile Infection

IntroductionC.difficile infection (CDI) is the most serious cause of hospital-acquired diarrhoea. Factors predicting outcome are unclear. We have assessed possible biomarkers of failure to respond to metronidazole in a prospective...

Community Acquired Clostridium difficile Ileitis in a Patient with Crohnʼs Disease and Ileostomy

Purpose: Background: Clostridium difficile is linked with antibiotic-associated colitis. Antibiotic use, hospitalization, older patients, and long-term care facility residents are recognized as main risk factors. Community-acquired cases are increasing and underdiagnosed. We report a case of a community acquired Clostridium difficile infection of the ileum in a patient with Crohn's disease who underwent total colectomy. Case presentation: The patient is 41-year-old woman with a history of myelodysplastic syndrome and Crohn's disease, which was diagnosed at age 23; she underwent proctocolectomy with ileostomy in 1998. She subsequently underwent resection of a part of her distal small bowel secondary to obstruction. She presented to the ER with 5 days of increasing ileostomy bag output and diffuse abdominal pain, accompanied by intermittent nausea. Patient had been treated with steroids, aminosalicylates, and 6-mercaptopurine on different occasions, but she was not on any treatment for her Crohn's at time of this presentation. She was not on antibiotics and had not used antibiotics recently. On physical exam, the patient had diffuse abdominal tenderness, no guarding or rebound and had hyperactive bowel sounds. Laboratory data showed no white count elevation. A basic metabolic panel was normal. KUB and CT of the abdomen showed a left peri-stomal hernia without evidence of obstruction and no small bowel thickening. A sample of the patient's iejunostomy effluent tested positive for C. difficile toxin by enzyme immunoassays (EIAs). Treatment was initiated with rehydration, and she was started on metronidazole. Over the course of her stay (3 days), she reported a gradual decrease in the ostomy output and it returned to baseline. She was discharged home to complete 10 days of metronidazole. Conclusion:C. difficile is third most common cause of infectious diarrhea in patients aged 75 years and older seen by general practitioners according to the Intestinal Infectious Disease Survey in England. Clostridium difficile enteritis is a rare infection and associated with a higher mortality rate (60- 80%) than that reported with C. difficile colitis 10-30%. Kim et al. found only 56 cases of C. difficile enteritis had been reported between 1980 to 2010. With a reported increase in the incidence of community acquired infections, we believed that this is the first case of community acquired small bowel C. difficile infection, and given that previous articles have suggested C. difficile enteritis has a more severe clinical course than colitis, clinical awareness especially in patients with IBD, early diagnosis and treatment are imperative.

Tu1529 Endoscopic Colon Biopsies From Patients With Chronic Clostridium Difficile Infection Have No Characteristic Histologic Abnormalities

Clostridium difficile infection is a common cause of hospital- and community-acquired diarrhea, often occurring after antibiotic treatment for a separate infection. Recommended therapy for acute C. difficile colitis is 10 days of metronidazole or vancomycin. The incidence and virulence of C. difficile is increasing, as is the rate of refractory infection, which we refer to as “chronic C. difficile infection” (CCDI). The histologic findings in acute C. difficile colitis are well documented and include focal surface epithelial necrosis with a neutrophilic infiltrate early in the disease, and complete mucosal necrosis with pseudomembrane formation in the late phase (Fig.

Delayed Etiologic Diagnosis of Meningitis in an Extremely Low Birth Weight Newborn

Delayed Etiologic Diagnosis of Meningitis in an Extremely Low Birth Weight Newborn

Traveling Internationally: Avoiding and Treating Travelers' Diarrhea

Traveling Internationally: Avoiding and Treating Travelers' Diarrhea

The concept of personal drugs in the undergraduate pharmacology practical curriculum.

I have read the thought provoking research letter by Dr Parmar and Jadav on The concept of personal drugs in the undergraduate pharmacology practical curriculum.[1] I have the following comments to share with the readership of the IJP. The concept of P-drug for the undergraduate practical curriculum is a good instrument to promote the practice of rational therapeutics with the objective to promote use of cost effective, safe and suitable medicines. However, the concept needs to be utilized in its right perspective so that it does not leave enough to question its utility. In selecting a P-drug for acute amoebic dysentery so far as the drug group is concerned, nitroimidazoles may be the choice. However, choosing a drug among this group will require utilization of certain criteria. Therefore, using the criteria of efficacy, safety, suitability and affordability [Table 1], one may conclude that tinidazole is a better choice to be a P-drug (along with a luminal amoebicide-vide infra). This is because of its suitability i.e., once or twice daily intake) and comparable cost of a course of treatment (3 days for tinidazole v/s 7-10 days of metronidazole). The authors have ignored the suitability factor. It is one of the important criteria for selecting a P-drug. It not only includes patient-related conditions, which preclude the use of selected drug, but also the convenience of dosage form and dosage schedule.[2] Adherence to treatment is improved by creating a good doctor-patient relationship, giving necessary drug related information to the patient and most importantly, prescribing a few drugs with a simple dosage schedule (one or two times a day).[2] Table 1 Comparison of nitroimidazoles in acute amoebic dysentery[4] It is difficult to agree with the authors' proposition of ignoring the advice of clinical teachers in selecting P-drug. Medical teachers have gained expertise from long standing practice and medical students learn greatly from these experts. In fact they may provide vital information to the students about the use of existing drugs and this will help them a lot in selecting their own P-drugs. Furthermore, authors' recommendation of use of a luminal amoebicide AFTER a course of nitroimidazole is contrary to the text book recommendation of its concurrent use.[4,5] Is a P-drug concept different from the principle of choosing a ‘drug’ of choice? The drug of choice for roundworm infestation is selected by using same criteria [Table 2]. Table 2 Criteria of selection of a suitable antihelminthic agent[3–4] It is clear that albendazole is a drug of choice because of convenience of single dose, comparable efficacy, safety and cost. It can also be considered to be a P-drug for roundworm infestation.

The concept of personal drugs in the undergraduate pharmacology practical curriculum

I have read the thought provoking research letter by Dr Parmar and Jadav on The concept of personal drugs in the undergraduate pharmacology practical curriculum.[1] I have the following comments to share with the readership of the IJP. The concept of P-drug for the undergraduate practical curriculum is a good instrument to promote the practice of rational therapeutics with the objective to promote use of cost effective, safe and suitable medicines. However, the concept needs to be utilized in its right perspective so that it does not leave enough to question its utility. In selecting a P-drug for acute amoebic dysentery so far as the drug group is concerned, nitroimidazoles may be the choice. However, choosing a drug among this group will require utilization of certain criteria. Therefore, using the criteria of efficacy, safety, suitability and affordability [Table 1], one may conclude that tinidazole is a better choice to be a P-drug (along with a luminal amoebicide-vide infra). This is because of its suitability i.e., once or twice daily intake) and comparable cost of a course of treatment (3 days for tinidazole v/s 7-10 days of metronidazole). The authors have ignored the suitability factor. It is one of the important criteria for selecting a P-drug. It not only includes patient-related conditions, which preclude the use of selected drug, but also the convenience of dosage form and dosage schedule.[2] Adherence to treatment is improved by creating a good doctor-patient relationship, giving necessary drug related information to the patient and most importantly, prescribing a few drugs with a simple dosage schedule (one or two times a day).[2] Table 1 Comparison of nitroimidazoles in acute amoebic dysentery[4] It is difficult to agree with the authors' proposition of ignoring the advice of clinical teachers in selecting P-drug. Medical teachers have gained expertise from long standing practice and medical students learn greatly from these experts. In fact they may provide vital information to the students about the use of existing drugs and this will help them a lot in selecting their own P-drugs. Furthermore, authors' recommendation of use of a luminal amoebicide AFTER a course of nitroimidazole is contrary to the text book recommendation of its concurrent use.[4,5] Is a P-drug concept different from the principle of choosing a ‘drug’ of choice? The drug of choice for roundworm infestation is selected by using same criteria [Table 2]. Table 2 Criteria of selection of a suitable antihelminthic agent[3–4] It is clear that albendazole is a drug of choice because of convenience of single dose, comparable efficacy, safety and cost. It can also be considered to be a P-drug for roundworm infestation.

Ameboma

61 Hispanic male with a history of hypercholestorolemia was referred to our clinic for a screening colonoscopy. He denied any complaints of weight loss, diarrhea, abdominal pain, hematochezia, melena fever, chills or fatigue. He was originally from South America, but had been in the U.S. for over five years. Our patient had no abnormal labaratory findings. On colonoscopy he was found to have a 2 cm ulcerated, friable flat mass with exudate in the ascending colon just outside the cecum. Histology revealed an ameboma which was described as severe active chronic inflammation with an exudate fragment showing trophozoites with erythrophagocytosis. The patient was treated with 10 days of metronidazole followed by 10 days of paromomycin. Intestinal amebiasis is caused by the protozoan Entamoeba Hystolytica. Worldwide 30–50 million symptomatic infections occur. It is the third most common parasitic cause of death. In the United states most of the cases are seen in immigrants from developing countries and travelers. Infection begins with ingestion of cysts from fecally contaminated water or food. Excystation occurs in the small bowel where trophozoites emerge. Ninety percent of patients colonized by E. Hystolytica spontaneously clear the infection by one year. Most patients are asymptomatic, however invasive intestinal amebiasis may mimic inflammatory bowel disease, malignancy and malsbsorptive illnesses. Extraintestinal manifestations are uncommon. They include liver abscesses, pleuropulmonary disease, cerebritis and pericarditis. Diagnosis is made by serologic and stool examinations.Microscopic examination of the stool has a low sensitivity 30–60%. A high false positive rate exists secondary to non pathogenic entamoebas which are morphologically identical to and more common then entamoeba hystolytica.ELISA stool antigen test which detects adherence lectin antigen has a sensitivity of 87% and a specificity of greater than than 90%. Seum antibody tests are most useful for extraintestinal disease when organisms are not found in the stool. Antibodies are detectable by the first week of infection and may persist for years. Up to 25% of uninfected patients in endemic regions are positive. An Ameboma is an unususual manifestation of entamoeba hystolytica. In immigrants from developing countries with atypical colonic masses one must consider entamoeba hystolytica as part of their differential diagnosis.

Pseudomembranous colitis presenting as an isolated colonic stricture

Dear Editor: Pseudomembranous colitis (PMC) is an increasingly common complication secondary to antibiotic use in hospitalised patients. Antibiotic therapy alters the gastrointestinal flora, resulting in an overgrowth of the toxin-producing organism Clostridium difficile, which is the causative organism in PMC. There is a wide spectrum of acute disease severity ranging from mild diarrhoea to toxic megacolon, and the vast majority of infectious colitis episodes resolve with antibiotic therapy, although some require surgery. Longterm complications are rare. We describe a case of symptomatic PMC presenting as an emergency to hospital with symptoms secondary to an isolated stricture and continuing colitis 2 years after antibiotic treatment. A 68-year-old man was admitted to the hospital with a 2year history of abdominal pain and bloody diarrhoea. Over the previous 6 months he reported a weight loss of 3 stone. In the 3 weeks before admission, his symptoms had become progressively worse. He had a history of antibiotic therapy with flucloxacillin for paronychia 2 years previously, and the symptoms of pain and diarrhoea commenced shortly after. There was a family history of Crohn's disease. Abdominal examination was unremarkable. An abdominal X-ray showed a loaded ascending and transverse colon. C. difficile toxin was detected in stool samples. He was treated with 10 days of metronidazole, 400 mg orally three times per day, but the bloody diarrhoea continued. A Gastrograffin enema showed a 20-cm stricture in his sigmoid colon. Colonoscopy revealed inflammation of the sigmoid colon with a membranous appearance typical of pseudomembranous colitis. The stricture was seen but the scope could not pass through. Biopsies of the stricture were taken. These confirmed pseudomembranous colitis. A Hartmann's procedure and closed mucus fistula was performed with removal of the strictured, inflamed segment. Histopathology of the sigmoid colon showed florid pseudomembranous colitis. The patient's recovery was uncomplicated. PMC is characterised by acute severe diarrhoea usually following antibiotic therapy. This leads to replacement of normal colonic flora by the enteric pathogen C. difficile. Cases that are not associated with antibiotic therapy have been reported but are rare. Macroscopically, a pseudomembrane covers the inflamed oedematous mucosa of the large bowel. Most infections respond to oral metronidazole or vancomycin therapy and the duration of symptoms are short. The history of our patient suggests that untreated symptomatic infections with C. difficile can be long-standing—2 years in our case. The authors can find no reported cases of such prolonged continuous symptoms, although unusual cases may have relapsing symptoms over a number of years. In a paper by Miller et al., a series of 40 cases was reviewed. Four of these had chronic diarrhoea for 9 to 12 months after antibiotic therapy [1]. Int J Colorectal Dis (2007) 22:1293–1294 DOI 10.1007/s00384-006-0170-1

Changes in the diagnosis and management of bacterial vaginosis following clinical research

It has become common practice to offer patients attending public sexual health clinics participation in research studies. We investigated the premise that clinician involvement in research leads to improvements in clinical practice within a sexual health service in Melbourne, Australia. Retrospective case note reviews were conducted of 100 cases of bacterial vaginosis (BV) during three time periods; 2000, 2002 and 2004. The first and second reviews were conducted 2 years before and immediately prior to a cross-sectional study of BV at Melbourne Sexual Health Centre. The third review was conducted immediately after study completion. Diagnostic criteria and treatment for BV were recorded. Clinicians were divided into high and low recruiters, according to the percentage of eligible patients that they recruited into the cross-sectional study. No audited cases were enrolled in the study. Significant improvements in the use of Amsel's criteria occurred between the second and third audit periods (51 to 65%, P = 0.04) but not between the first and second audits (51% for both, P = 1.0). The improvement was seen in high-recruiting clinicians (P = 0.02) but not low-recruiting clinicians (P = 0.75). Although treatment with 7 days of metronidazole or vaginal clindamycin increased for all clinicians between the first and second audit periods (8 to 18%, P = 0.04), it was greater between the second and third audit periods (18 to 72%, P < 0.01). No difference was observed between high- and low-recruiting clinicians. Introduction of research was temporally associated with improved clinical practice in high-recruiting clinicians only.

Recent trends in diagnosis and treatment of Clostridium difficile in a tertiary care facility

With the prevalence of antibiotic use, the diagnosis and management of Clostridium difficile disease requires assessment. In a retrospective review, patients with a positive culture, toxin, or both during 1 year were identified. Recent literature was reviewed. Results of culture and toxin, prior antibiotic use, antibiotic treatment history and cost were analyzed. Of 592 patients tested, 101 were positive; 96 of 101 were available for review. Of those positive tested for both, 45% were positive for toxin and culture. Sixty-two of 96 were treated with antibiotics; metronidazole was used in 90%. Ten of 62 antibiotic treatments were changed (mean 3 days). Ten days of metronidazole is 1/200th the cost of vancomycin. In 55% of the positive cases in which culture and toxin were obtained, one test was negative. As metronidazole's efficacy and cost compares favorably with vancomycin, metronidazole is the drug of choice. Any changes made to antibiotic regimens occurred prior to the 6 days recommended in the literature.

Presentation and antimicrobial treatment of acute orofacial infections in general dental practice.

Information on the presentation of orofacial infections and the use of antimicrobial agents in general dental practice in the United Kingdom was obtained using a postal questionnaire. Six hundred dentists were randomly selected and a total of 340 replies were received, giving a response rate of 57%. The dental practitioners estimated that acute infection was present in only a minority (approximately 5%) of patients. A total of seven different antibiotics were prescribed, in a variety of regimens, for the treatment of bacterial infection. However, the majority of dentists (46-62%) preferred a 5-day course of penicillin (250 mg, qid) for bacterial conditions other than acute ulcerative gingivitis, for which most practitioners (89%) prescribed 3 days of metronidazole (200 mg, tid). Nystatin was the most frequently selected anticandidal agent and topical acyclovir the most popular therapy for Herpes simplex infection.