Duration Of Secondary Prophylaxis Research Articles

Management of infectious disease syndromes in thoracic organ transplants and mechanical circulatory device recipients: a Delphi panel.

Antimicrobial misuse contributes to antimicrobial resistance in thoracic transplant (TTx) and mechanical circulatory support (MCS) recipients. This study uses a modified Delphi method to define the expected appropriate antimicrobial prescribing for the common clinical scenarios encountered in TTx and MCS recipients. An online questionnaire on managing 10 common infectious disease syndromes was submitted to a multidisciplinary Delphi panel of 25 experts from various disciplines. Consensus was predefined as 80% agreement for each question. Questions where consensus was not achieved were discussed during live virtual live sessions adapted by an independent process expert. An online survey of 62 questions related to 10 infectious disease syndromes was submitted to the Delphi panel. In the first round of the online questionnaire, consensus on antimicrobial management was reached by 6.5% (4/62). In Round 2 online live discussion, the remaining 58 questions were discussed among the Delphi Panel members using a virtual meeting platform. Consensus was reached among 62% (36/58) of questions. Agreement was not reached regarding the antimicrobial management of the following six clinical syndromes: (1) Burkholderia cepacia pneumonia (duration of therapy); (2) Mycobacterium abscessus (intra-operative antimicrobials); (3) invasive aspergillosis (treatment of culture-negative but positive BAL galactomannan) (duration of therapy); (4) respiratory syncytial virus (duration of antiviral therapy); (5) left ventricular assist device deep infection (initial empirical antimicrobial coverage) and (6) CMV (duration of secondary prophylaxis). This Delphi panel developed consensus-based recommendations for 10 infectious clinical syndromes seen in TTx and MCS recipients.

Delphipanel on Antimicrobial Stewardship and Management of Clinical Syndromes in Thoracic Organ Transplants and Mechanical Circulatory Device Recipients

<h3>Purpose</h3> Antimicrobial overuse contributes to antimicrobial resistance in lung transplant recipients (LTRs). Guidance on assessment of the quantity and appropriateness of antimicrobial prescribing is required in LTRs for standardized management. This study aims to define the expected appropriate antibiotic prescribing of clinical scenarios in LTRs using a modified Delphi method. <h3>Methods</h3> We developed an online questionnaire to solicit from ISHLT membership and Delphi Panel members regarding the appropriate treatment of 21 common clinical scenarios treated with systemic antimicrobials. Consensus was predefined as 80% agreement on the importance of each metric. The metrics that did not achieve the consensus on questionnaire were presented to an online multidisciplinary Delphi panel consisting of 25 experts from various disciplines (infectious diseases (6), pediatric infectious diseases (1), respirology (8), cardiology (2), cardiothoracic surgery (5), immunology (1) and pharmacy (1)) within ISHLT. An independent non-content expert conducted the panel. <h3>Results</h3> Following the initial online survey, 69 responses were received. Consensus on the antimicrobial management was reached on 20% (20/ 98) of questions related to 21 clinical scenarios. The survey was modified and shortened (based on relevancy, controversy of topic and consensus) to 38 questions in 10 clinical scenarios. Eleven further questions were removed due to redundancy. In total, 27 questions related to 10 clinical scenarios were discussed on-line among the Delphi Panel. Consensus was reached among 77% (21/ 27) of questions. Consensus was not reached regarding the antimicrobial management of the following 6 clinical syndromes: 1) CMV (duration of secondary prophylaxis); 2) <i>Burkholderia cepacia</i> pneumonia (duration of therapy); 3) RSV (duration of therapy); 4) <i>Mycobacterium abscessus</i> (intra operative antimicrobials); 5) <i>Aspergillus</i> (treatment of culture negative BAL but galactomannan BAL +) and 6) LVAD deep infection (initial empirical antimicrobial coverage). <h3>Conclusion</h3> This study resulted in expert consensus for defined levels of appropriate antibiotic prescribing in majority of clinical scenarios assessed in LTRs. These results can be aid in antimicrobial stewardship adjudications in LTRs.

Influence of clinical presentation, site, and extent of venous thrombosis on decision about duration of anticoagulation: Data from the international, prospective, observational WHITE study

BackgroundLow attention has generally been dedicated to the influence of clinical presentation, extent of venous thrombosis and presence of residual vein obstruction (RVO) on the decision about the duration of secondary prophylaxis after a first venous thromboembolism (VTE). AimThis study aimed at investigating the role of the mentioned VTE characteristics on the therapeutic decision using the information collected in the international, prospective, observational WHITE study. Results1240 patients were recruited by 79 clinical centers in 7 countries (China, Czechia, Poland, Portugal, Russia, Slovakia, and Tunisia). 35 patients had as index event a pulmonary embolism (PE) without a deep vein thrombosis (DVT), and all continued anticoagulation. We focused on the 1205 subjects with DVT. The treatment decision differed among countries; altogether, more than 85% of patients with proximal (with or without distal) DVT continued a prophylactic treatment with anticoagulants, or antithrombotics; 34% of patients with isolated distal DVT stopped treatment, and more than 85% of patients with a PE associated to a DVT continued treatment. At multivariable analysis, the presence of proximal DVT, signs of post-thrombotic syndrome (PTS), residual vein obstruction (RVO), maintenance <180 days and concomitant diseases was associated with increased probability to continue secondary prophylaxis. ConclusionThe presentation as proximal DVT (with or without PE) or isolated PE influenced the treating physicians' decision in favor of extension of secondary prophylaxis, together with the presence of concomitant diseases and local conditions which may increase the risk of post-thrombotic syndrome.

Evaluation of Knowledge Regarding Rheumatic Fever and Its Prevention among Doctors at a Tertiary Cardiac Care Unit

Background: Rheumatic heart disease is one of the most frequent types of acquired heart disease, and it is one of the leading causes of morbidity and death. Awareness of doctors regarding rheumatic fever and how to prevent it is important for primary and secondary prevention. Objective: The study aimed to assess the knowledge of rheumatic fever and its prevention and the association of knowledge with cardiology working experience among local doctors working at a tertiary cardiac care unit. Methodology: It was a cross-sectional study conducted at the department of cardiology of a national institute of cardiovascular disease and its satellite centers, Karachi, Pakistan from Dec 2020 to Jun 2021. Doctors of age more than 25 years of either gender were included in the study. A self-administered questionnaire, circulated through emails was used to collect data on age, gender, designation, total years of experience, and years of experience in the cardiac unit and 10 questions to assess the knowledge regarding rheumatic fever and its prevention. Based on the correct response the doctors were categorized as either having adequate knowledge or inadequate knowledge regarding various aspects of rheumatic fever. Data was entered and analyzed using SPSS version 21. Results: A total of 225 participants were approached, out of which 200 responded and completed the survey (88.8%). The mean age of the doctors was 37.40+6.55 years. Most of the participants were males (87.5%). About 82% of the doctors had adequate knowledge about the mechanism of rheumatic fever. A large proportion of participants answered correctly about prophylaxis post-surgery (58%). Doctors with more than 2 years of experience in the cardiology department had better knowledge about the mechanism (p=0.017), diagnosis (p=0.005), post-surgery prophylaxis (p=0.005), duration of secondary prophylactic treatment (p=0.03), drug of choice for secondary prophylaxis (p=0.026) as compared to doctors with up to 2 years of experience in the cardiology department. Conclusion: Knowledge regarding the duration of secondary prophylaxis and primary prophylaxis was low among doctors. Years of working experience in the cardiology unit was a significant factor in the knowledge of the mechanism, diagnosis and recurrence of RF and it is also associated with duration and drugs of secondary prophylaxis.

FACTORS LEADING TO POOR ADHERENCE TO SECONDARY PROPHYLAXIS OF RHEUMATIC FEVER

Objectives: The objective of this study was to determine the level of adherence and possible barriers to secondary prophylaxis among patients with Rheumatic heart disease (RHD).&#x0D; Methodology: It is a cross-sectional study conducted at the largest tertiary care cardiac center of Karachi, Pakistan. We included patients with RHD, based on transthoracic echocardiography and adherence to the secondary prophylaxis and possible barriers were assessed using a structured questionnaire.&#x0D; Results: Among total of 195 patients 66.7% (130) were female, mean age was 32.25 ± 13.78 years. Rural residents were 51.3% (100) and 59.5% (116) of the patients were illiterate. Benzathine Penicillin injection was prescribed to 56.4% (110) patients, out of them 70.0% (77) of the patients were counseled regarding duration of secondary prophylaxis. The most common reason for non-adherence was reported to be a painful injection (19.1%).&#x0D; Conclusion: Majority of the RHD patients are not being prescribed and effectively counseled regarding secondary prophylaxis. Low adherence to the secondary prophylaxis was observed and the common reasons for non-adherence were painful injection, non-availability of nearby health facility, friends/family advising them otherwise, allergic reaction, and patients feeling sick and unable to take injection.

P4335The incidence of acute rheumatic fever in indigenous adults in the Northern Territory, South Australia and Western Australia

Abstract Background Worldwide, knowledge of the contemporary incidence of acute rheumatic fever (ARF) in Indigenous adult populations is limited, with little understanding of patterns of ARF recurrence according to age and geographical location. This has created uncertainty in the development of rheumatic heart disease (RHD) guidelines surrounding the appropriate duration of antibiotic prophylaxis for these patients. Purpose This study aimed to describe the incidence rates of ARF in Indigenous Australian adults, analyse patterns of recurrence according to sex, age and geographical location, and assess adherence to secondary prophylaxis. Methods ARF episodes in Indigenous adults, aged 18 years and older, recorded within three Australian jurisdictions (Northern Territory, South Australia and Western Australia) ARF registers, diagnosed between 2007 to 2017, were included. Poisson and negative binomial regression were used to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI) for first and recurrent episodes according to age, sex and remoteness. Adherence rates to secondary prophylaxis was described in the 12 months preceding recurrent ARF episodes in the Northern Territory. Results 481 episodes were analysed. The incidence of ARF episodes in these jurisdictions from 2007 to 2017 was relatively constant. The overwhelming burden of disease occurred in remote areas (105 episodes per 100,000 people). An increased rate occurred in females (IRR 2.34, 95% CI 1.81–3.03). The 18–24 year olds had the highest incidence rates (115 episodes per 100,000 people). High rates of recurrence were also observed in those aged 25–34 years (96 episodes per 100,000 people). Adherence to secondary prophylaxis in those having a recurrent episode was only achieved in 10% of cases. Conclusions The incidence of ARF remains very high amongst adult Indigenous Australians. Adherence to secondary prophylaxis continues to play a role in recurrent episodes. RHD guidelines should take into account remoteness as a significant risk factor when deciding the duration of secondary prophylaxis.

PRIMARY AND SECONDARY THROMBOPHILIА: PATHOGENESIS, CLINICAL PRESENTATION, APPROACHES TO THROMBOTIC COMPLICATIONS PREVENTION AND TREATMENT

Introduction: Thrombophiliа is a predisposition to arterial or venous thrombotic complications as a result of congenital or acquired hemostatic system defects. Thrombophilia increases risk of fatal complications, disability of patients. The assessment of the risk of thrombotic complications makes it possible to prescribe adequate primary or secondary prophylaxis. However, there is no systematic information about estimation risk of thrombosis in various types of thrombophilia and conduction primary and secondary prophylaxis of thrombotic complications, choosing treatment. The aim: Analysis and arrangement information regarding pathogenesis, clinical features, approaches to diagnosis, risk assessment, primary and secondary prevention and peculiarities of thrombotic complications treatment in patients with thrombophilia. Materials and methods: There were used methods: content analysis, method of systemic approach. An analysis of the results of clinical trials, the review of articles in the field of hemostasis was conducted. Conclusions: Patients with deficiency of Pt C, S, antithrombin III deficiency and homozygous factor V Leiden mutation, malignancy, antiphospholipid syndrome, surgical interventions, pregnancy, usage of oral contraceptive pills (OCP s) and hormone replacement therapy (HRT) have the highest risk of thrombotic complications. The type of thrombophilia determinates the choice of anticoagulants, necessity for primary prophylaxis and the duration of secondary prophylaxis.

Factors influencing the duration of secondary prophylaxis in AIDS patients coinfected with Penicillium marneffei: a retrospective analysis

Objective To explore the factors affecting the duration of secondary prophylaxis for penicilliosis marneffei in patients with acquired immunodeflciency syndrome (AIDS).Methods A retrospective analysis was conducted.The study included 92 adult patients with AIDS and penicilliosis mameffei which were confirmed at the Guangxi Centers for Disease Control and Prevention/Medecins Sans Frontieres clinic.The patients were divided into two groups based on the counts of CD4+ T cells at the time of discontinuation of secondary prophylaxis with itraconazole.The patients with a CD4+ lymphocyte count ＞ or =200 × 106 cells/L at the discontinuation of secondary prophylaxis were assigned to Group Ⅰ,and those with a CD4+ lymphocyte count ranging from 100 × 106 to 200 × 106 cells/L to Group Ⅱ.The treatment duration and clinical outcome were compared between the two groups,and factors which might affect the duration of secondary prophylaxis,including organ involvement,complications,antifungal regimen,antiviral treatment timing,and so on,were assessed.The SPSS 13.0 ~ftware package was used for statistical analysis.Results All the 92 patients received highly active antiretroviral therapy (HAART).No significant difference was observed in the sex ratio,age,follow up duration,number of organs involved,occurrence of complications,composition and duration of antifungal treatment regimens between the two groups (all P ＞ 0.05).The duration of secondary prophylaxis was significantly shorter in Group Ⅱ than in Group Ⅰ (8.13 ± 5.13 vs.12.44 ± 9.51 months,P＜0.05).The commencement of HAART after the treatment of penicilliosis,coinfection with other pathogens or mycobacterium tuberculosis were associated with a longer duration of secondary prophylaxis,and the influence degree of these factors decreased in order,whereas the commencement of HAART before the treatment of penicilliosis was associated with a shorter secondary prophylaxis (P ＜ 0.05).Conclusions For AIDS/PSM patients receiving HAART,secondary prophylaxis could be discontinued 3 to 6 months after the CD4 +lymphocyte count restores to 100 × 106 cells/L or more.The duration of secondary prophylaxis may be extended by the commencement of HAART after the treatment of penicilliosis,coinfection with other pathogens or mycobacterium tuberculosis,but shortened by the commencement of HAART before the treatment of penicilliosis. Key words: Acquired immunodeficiency syndrome; Penicilliosis marneffei; Antiretroviral therapy,highly active; Chemoprevention

Secondary prophylaxis in adolescent and adult haemophiliacs.

Progressive arthropathy of large joints of the limbs (knees, ankles, elbows), resulting from recurrent joint bleeds and subsequent long-term degenerative phenomena, is one of the main causes of morbidity and of deterioration of quality of life in adult severe hemophiliacs. While primary prophylaxis (i.e. the regular continuous long-term infusion of factor concentrates started before the age of two years and/or after no more than one joint bleed) is nowadays considered the gold standard for preserving joint function in patients with severe haemophilia, the benefits of secondary prophylaxis (i.e., all the long-term regular treatments not fulfilling the criteria of primary prophylaxis) are still controversial. In this review we present the literature data on secondary prophylaxis, focusing on adolescent and adults haemophiliacs along with clinical experience in Italy. On the whole, the more recently published studies suggest the effectiveness of early and delayed secondary prophylaxis. However, a number of questions are still unanswered, including the optimal dose, dosing interval and duration of secondary prophylaxis. Only large, prospective, long-term, possibly randomized studies will help to definitively assess the clinical impact of this strategy in adolescent and adult hemophiliacs.

Extension of anticoagulation after venous thromboembolism

Whereas every clinician agrees on the need for anticoagulation initially after the diagnosis of venous thromboembolism (VTE), the opinions regarding optimal duration of secondary prophylaxis differ. The decision is complicated by the large number of identified risk factors associated with the risk of recurrence. In addition consideration has to be taken to the risk factors for bleeding and individual patient preferences. Data from long-term follow-up studies up to a decade indicate that some risk factors for recurrence decline and others seem to gain importance with time. In this review data has been extracted from the most illustrative trials to highlight controversies but also where there is consensus in order to give the clinician some support for the individual decisions on extension of anticoagulation after VTE.

An Australian guideline for rheumatic fever and rheumatic heart disease: an abridged outline

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are diseases of poverty. They occur at world-record rates in Indigenous Australians, yet individual cases are often poorly managed, and most jurisdictions with high rates of these diseases do not have formal control strategies in place. New Australian guidelines formulated in 2005 by the National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand for diagnosis and management of ARF and RHD are a valuable resource for clinicians and policymakers. Key recommendations of the guidelines include: New diagnostic criteria for ARF in high-risk populations, including Indigenous Australians, which include echocardiographic evidence of subclinical valvular disease, and polyarthralgia or aseptic monoarthritis as major manifestations. Clear guidance about treatment of ARF. Non-steroidal anti-inflammatory drugs should be withheld until the diagnosis is confirmed, and corticosteroids may be an option in severe acute carditis. Most cases of chorea do not require medication, but use of carbamazepine or sodium valproate is recommended if medication is needed. Clear guidance about dose, dosing frequency and duration of secondary prophylaxis. Benzathine penicillin G is the preferred medication for this purpose. Establishment of a coordinated control program for all regions of Australia where there are populations with high prevalence of ARF and RHD. Key elements and indicators for evaluation are recommended. Active screening and legislated notification of ARF and RHD, where possible. Development of a structured care plan for all patients with a history of ARF or with established RHD, to be recorded in the patient's primary health care record.

Subclinical carditis in rheumatic fever: A systematic review

Objective Subclinical carditis (SCC) – pathological valvular regurgitation detected on echocardiography that is not evident clinically – has been reported in acute rheumatic fever (ARF), but its significance is unknown. We aimed to review the existing literature on the prevalence and outcome of SCC in ARF. Methods We conducted a systematic literature review using MEDLINE. Results Prevalences of SCC in ARF ranged from 0% (in one study only) to 53% in 23 articles. The weighted pooled prevalence of SCC in ARF was 16.8% (95%CI 11.9 to 21.6). This increased slightly to 18.1% (95%CI 11.1 to 25.2) by analysing only the 10 studies that applied full World Health Organization criteria for SCC diagnosis. The weighted pooled prevalence of persistence or deterioration of SCC 3 to 23 months after ARF diagnosis was 44.7% (95%CI 19.3 to 70.2) from 11 articles. Conclusion SCC is relatively common in ARF. Although some studies suggest that SCC lesions may persist or deteriorate, the available data are insufficient and of poor quality, so no confident conclusions can be drawn about the prognosis of SCC. Until better studies are conducted, clinicians will have to make management decisions that are not evidence-based. These decisions will have important practical implications for the use of echocardiography acutely and during follow-up, diagnosis of ARF, and duration of secondary prophylaxis in patients with SCC.

Post-thrombotic syndrome, recurrence, and death 10 years after the first episode of venous thromboembolism treated with warfarin for 6 weeks or 6 months.

The influence of the duration of anticoagulant therapy after venous thromboembolism (VTE) on the long-term morbidity and mortality is unclear. To investigate the long-term sequelae of VTE in patients randomized to different duration of secondary prophylaxis. In a multicenter trial comparing secondary prophylaxis with vitamin K antagonists for 6 weeks or 6 months, we extended the originally planned 2 years follow-up to 10 years. The patients had annual visits and at the last visit clinical assessment of the post-thrombotic syndrome (PTS) was performed. Recurrent thromboembolism was adjudicated by a radiologist, blinded to treatment allocation. Causes of death were obtained from the Swedish Death Registry. Of the 897 patients randomized, 545 could be evaluated at the 10 years follow-up. The probability of developing severe PTS was 6% and any sign of PTS was seen in 56.3% of the evaluated patients. In multivariate analysis, old age and signs of impaired circulation at discharge from the hospital were independent risk factors at baseline for development of PTS after 10 years. Recurrent thromboembolism occurred in 29.1% of the patients with a higher rate among males, older patients, those with permanent triggering risk factor - especially with venous insufficiency at baseline - signs of impaired venous circulation at discharge, proximal deep vein thrombosis, or pulmonary embolism. Death occurred in 28.5%, which was a higher mortality than expected with a standardized incidence ratio (SIR) of 1.43 (95% CI 1.28-1.58), mainly because of a higher mortality than expected from cancer (SIR 1.83; 95% CI 1.44-2.23) or from myocardial infarction or stroke (SIR 1.28; 95% CI 1.00-1.56). The duration of anticoagulation did not have a statistically significant effect on any of the long-term outcomes. The morbidity and mortality during 10 years after the first episode of VTE is high and not reduced by extension of secondary prophylaxis from 6 weeks to 6 months. A strategy to reduce recurrence of VTE as well as mortality from arterial disease is needed.

Spontaneous Arterial Dissection.

There is no controlled study for the best treatment or management of cervico-cerebral artery dissection (CAD). Rationale initial empiric treatment in acute CAD to prevent secondary embolism is partial thromboplastin time (PTT)-guided anticoagulation by intravenous heparin followed by anticoagulation with warfarin. Carotid surgery for treatment of CAD is not recommended anymore with the possible exception of persisting severe stenosis of the proximal internal carotid artery (ICA). There could be use of carotid angioplasty by balloon dilatation and stenting in selected cases of severe cerebral hemodynamic impairment by bilateral CAD. Duration of secondary prophylaxis by anticoagulation is best guided by Doppler sonography follow-up, and should be continued until normalization of blood flow or until at least 1 year after the vessel is occluded. There is no evidence that pseudoaneurysms increase the risk for embolic complication, and there is no evidence for surgery or continuation of anticoagulation in patients with pseudoaneurysms. Caution should be recommended for exercises that involve excessive head movements (eg, bungee jumping, trampoline jumping, and chiropractic maneuvers). The patient should be informed that recurrent rate is low in nonfamilial cases. Doppler sonography is a low-cost and high-sensitivity method for patients at risk.