Duration Of Intravenous Antibiotic Treatment Research Articles

Experience of managing acute osteomyelitis in a district general hospital

Introduction A cute Osteomyelitis (AO) is a suppurative bone infection caused by haematogenous spread within the metaphysis of long bones. Unlike septic arthritis, children with AO are usually systemically well and the classic text book description of fever, swelling and limp is often absent. Prompt diagnosis and treatment is important to avoid complications such as growth arrest, septic arthritis and chronic infection. Objective 1) To review the clinical presentation and value of laboratory and radiological investigations in diagnosing Acute Osteomyelitis; 2) To review current treatment of Acute Osteomyelitis and follow up of patients for complications. Method We retrospectively reviewed case notes of 12 children who were diagnosed with acute osteomyelitis over a two year period. Results Temperature of 38 degrees and above was present only in one third of patients whereas loss of function and pain were present in all the patients. Recent infection or trauma was present in most of the cases. An elevated ESR (>35 in 10 patients) and high platelet count (>400 in 11 patients) were the most consistent laboratory results. CRP was less than 15 in 3 patients. Blood cultures were negative in all but one case where group B streptococcus was isolated in a neonate from blood and aspiration of joint. MRI was helpful in confirming equivocal diagnosis. Bone scan when done in 4 cases helped in diagnosing AO. Flucloxacillin was an effective antibiotic in the majority except for neonatal osteomyelitis. 6 children received antibiotics for 42 days, 1 child for 5 days and 1 for 70 days, the rest received antibiotics for 14 days. Intravenous antibiotic treatment duration was very variable and was guided by resolution of inflammatory markers to normal levels. Antibiotics was started on the 12th day of presentation for a baby and 3 en had complications where one child required a sequestrectomy, one developed a Brodie9s abscess and one developed chronic recurrent multifocal osteomyelitis. Conclusions Acute osteomyelitis still remains a difficult diagnosis. A high index of suspicion together with a combination of clinical signs, laboratory and radiological tests are essential to facilitate prompt diagnosis and treatment to avoid long term complications. Good team working, information sharing and communication with our orthopaedic colleagues is essential to reduce morbidity and improve quality of care.

Length of Intravenous Antibiotic Therapy and Treatment Failure in Infants With Urinary Tract Infections

The goal was to determine the association between short-duration (< or =3 days) and long-duration (> or =4 days) intravenous antibiotic therapy and treatment failure in a cohort of young infants hospitalized with urinary tract infections (UTIs). We conducted a retrospective cohort study of infants <6 months of age who were hospitalized with UTIs between 1999 and 2004 at 24 children's hospitals in the Pediatric Health Information System. Our main model adjusted for all covariates, propensity scores, and clustering according to hospital to evaluate the effect of short versus long courses of inpatient intravenous antibiotic therapy on treatment failure, defined as readmission because of UTI within 30 days. Of the 12,333 infants who met the inclusion criteria, 240 (1.9%) experienced treatment failure. The treatment failure rates were 1.6% for children who received short-course intravenous antibiotic treatment and 2.2% for children who received long-course treatment. Treatment courses varied substantially across hospitals and with patient-level characteristics. After multivariate adjustment, including propensity scores, there was no significant association between treatment group and outcomes, with an odds ratio for long versus short treatment of 1.02 (95% confidence interval: 0.77-1.35). Known presence of genitourinary abnormalities, but not age, predicted treatment failure. Treatment failure for generally healthy young infants hospitalized with UTIs is uncommon and is not associated with the duration of intravenous antibiotic treatment. Treating more infants with short courses of intravenous antibiotic therapy might decrease resource use without affecting readmission rates.

Acute haematogenous osteomyelitis in children: is there any evidence for how long we should treat?

Despite diagnostic and therapeutic advances, acute haematogenous osteomyelitis in children continues to cause significant morbidity and disease burden. The molecular epidemiology of causal organisms has wide geographic variation, but regardless of cause children often require several weeks of inpatient parenteral antibiotic therapy. This review focuses on antibiotic treatment and length of antibiotic therapy. Currently there is no international and little local consensus regarding the route or duration for antibiotic treatment of acute haematogenous osteomyelitis in children. Although there are encouraging data from review papers and case series, no randomized controlled trial has been conducted to show good evidence for shorter courses of parenteral antibiotic treatment. Prospective studies show effective treatment for a wide variety of antibiotic agents, but there are few comparative studies. Overall treatment for 4-6 weeks is considered standard therapy, but the laboratory or clinical parameters that would determine the decision to switch to oral therapy remain undefined. Evidence-based data about the route and duration of intravenous antibiotic treatment for acute haematogenous osteomyelitis in children are still limited to observational and retrospective studies. A randomized controlled trial will provide much needed data.

DIABETIC FOOT INFECTIONS;

Objective: (1) To evaluate the effects of G-CSF in eliminating infection in diabetic foot wound (2) Tocompare the effects with conventional diabetic foot management. Design: Prospective, open, randomized comparativestudy. Setting: Medical&amp;Surgical Department of Allied, DHQ Hospital &amp; Nawaz Medicare Faisalabad. Period: FromJan 2000 to Nov 2000 Patients &amp; Methods: Fifty diabetic patients with foot infections were included in this study. Themean age was 52 years ranging from 27 to 60 years. They were divided into two equal groups(Group A and Group B).Results: The male patients were 41(82%) and female 9(18%). Forty six percent of patients were on oral hypoglycaemicdrugs, and 54% on insulin. The trauma preceding infection was 20%, Peripheral neuropathy 94% and peripheralvascular disease 34%. Thirty two percent of patients were smoker. Group A were subjected to G-CSF ( Neupogen )therapy (n=25) subcutanously daily for 5days in addition to conventional measures. Whereas patients in Group Breceived only conventional therapy. Both groups received similar antibiotic and insulin treatment. G-CSF therapy wasassociated with earlier eradication of pathogens from the infected ulcer (median 5 [range 2-11] vs11 [6-31] days in thegroup B; (p=&lt;O.000I), quicker resolution of cellulitis (6 vs l4 days; p&lt;O.0001), shorter hospital stay (8 vsl6 days;p&lt;O.000l), and a shorter duration of intravenous antibiotic treatment (7 vs l4 days ;p—0.0001).No G-CSF treatedpatient needed surgery, whereas three patients in group B underwent toe amputation and six had extensivedebridement under anaesthesia (p=0.00 1). G-CSF therapy was generally well tolerated. Conclusion: Granulocytecolony stimulating factor (G-CSF) may be used as a good adjuvant therapy along with conventional measures for themanagement of diabetic foot infection, as it promotes the healing of diabetic foot ulcer/cellulitis and consequentlyprevents many hazardous complications like amputation of limbs, long hospital stays, extensive and prolonged antibioticuse and last but not the least the total misery of the patients.

An economic evaluation of a European cohort from a multinational trial of linezolid versus teicoplanin in serious Gram-positive bacterial infections: the importance of treatment setting in evaluating treatment effects

In a recent multinational trial, hospital resource use and total cost of treatment were compared between linezolid and teicoplanin for severe Gram-positive bacterial infections among 227 European hospitalised patients. The results show that the linezolid group had a 3.2-day (6.3 for linezolid versus 9.5 for teicoplanin groups) shorter mean intravenous antibiotic treatment duration. Certain baseline variables, particularly the inpatient location at enrolment and the presence of outpatient/home parenteral antibiotic therapy (OHPAT), had substantial effects on length of stay (LOS) and cost of treatment. After adjusting for the between-treatment difference in these two variables and other baseline variables, the results showed non-significant shorter LOS and lower mean total cost of treatment for the linezolid group among patients with no access to OHPAT.

Rifampicin and sodium fusidate reduces the frequency of methicillin-resistant Staphylococcus aureus (MRSA) isolation in adults with cystic fibrosis and chronic MRSA infection

Nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA) to patients with cystic fibrosis (CF) frequently results in chronic respiratory tract carriage. This is an increasing problem, adds to the burden of glycopeptide antibiotic use in hospitals, and represents a relative contraindication to lung transplantation. The aim of this study was to determine whether it is possible to eradicate MRSA with prolonged oral combination antibiotics, and whether this treatment is associated with improved clinical status. Adult CF patients (six male, one female) with chronic MRSA infection were treated for six months with rifampicin and sodium fusidate. Outcome data were examined for six months before treatment, on treatment and after treatment. The patients had a mean age of 29.3 (standard deviation=6.3) years and FEV 1 of 36.1% (standard deviation=12.7) predicted. The mean duration of MRSA isolation was 31 months. MRSA isolates identified in these patients was of the same lineage as the known endemic strain at the hospital when assessed by pulsed-field gel electrophoresis. Five of the seven had no evidence of MRSA during and for at least six months after rifampicin and sodium fusidate. The proportion of sputum samples positive for MRSA was lower during the six months of treatment (0.13) and after treatment (0.19) compared with before treatment (0.85) ( P<0.0001). There was a reduction in the number of days of intravenous antibiotics per six months with 20.3±17.6 on treatment compared with 50.7 before treatment and 33.0 after treatment ( P=0.02). There was no change in lung function. Gastrointestinal side effects occurred in three, but led to therapy cessation in only one patient. Despite the use of antibiotics with anti-staphylococcal activity for treatment of respiratory exacerbation, MRSA infection persists. MRSA can be eradicated from the sputum of patients with CF and chronic MRSA carriage by using rifampicin and sodium fusidate for six months. This finding was associated with a significant reduction in the duration of intravenous antibiotic treatment during therapy.

Randomised placebo-controlled trial of granulocyte-colony stimulating factor in diabetic foot infection

Diabetic foot infections cause substantial morbidity and mortality. Neutrophil superoxide generation, a crucial part of neutrophil bactericidal activity, is impaired in diabetes. Granulocyte-colony stimulating factor (G-CSF) increases the release of neutrophils from the bone marrow and improves neutrophil function. We assessed G-CSF as adjuvant therapy for the treatment of severe foot infections in diabetic patients. 40 diabetic patients with foot infections were enrolled in a double-blind placebo-controlled study. On admission, patients were randomly assigned G-CSF (filgrastim) therapy (n = 20) or placebo (n = 20) for 7 days. Both groups received similar antibiotic and insulin treatment. Neutrophils from the peripheral blood of these participants and from healthy controls were stimulated with opsonised zymosan, and superoxide production was measured by a spectrophotometric assay (reduction of ferricytochrome C). G-CSF therapy was associated with earlier eradication of pathogens from the infected ulcer (median 4 [range 2-10] vs 8 [2-79] days in the placebo group; p = 0.02), quicker resolution of cellulitis (7 [5-20] vs 12 [5-93] days; p = 0.03), shorter hospital stay (10 [7-31] vs 17.5 [9-100] days; p = 0.02), and a shorter duration of intravenous antibiotic treatment (8.5 [5-30] vs 14.5 [8-63] days; p = 0.02). No G-CSF-treated patient needed surgery, whereas two placebo recipients underwent to amputation and two had extensive debridement under anaesthesia. After 7 days' treatment, neutrophil superoxide production was significantly higher in the G-CSF group than in the placebo group (16.1 [4.2-24.2] vs 7.3 [2.1-11.5] nmol per 10(6) neutrophils in 30 min; p < 0.0001). G-CSF therapy was generally well tolerated. G-CSF treatment was associated with improved clinical outcome of foot infection in diabetic patients. This improvement may be related to an increase in neutrophil superoxide production.

Pediatric Hematogenous Osteomyelitis: New Trends in Presentation, Diagnosis, and Treatment.

The character of acute hematogenous osteomyelitis (AHO) in North American children has changed significantly during the past several decades. Although the typical clinical picture of established acute osteomyelitis in children (illness, dehydration, and an acutely painful limb) is still seen, more subtle presentations appear more frequently. Children often present with subacute osteomyelitis. Less common variants include Brodie's abscess, subacute epiphyseal osteomyelitis, and chronic recurrent multifocal osteomyelitis. Some patients present with a bone lesion that may be confused with other disease entities, including neoplasms. Biopsy is often needed to clarify the diagnosis. With the trend toward more invasive procedures in the neonatal intensive care unit, neonatal osteomyelitis is also seen more frequently. Advances in imaging technology, particularly improvements in technetium bone scanning and the advent of magnetic resonance imaging, have contributed to more precise diagnosis and better management of AHO. With the increased concern about medical economics, the recent trend toward decreasing the duration of intravenous antibiotic treatment of these infections appears to be appropriate as long as certain criteria are met. Neither surgery nor antibiotics alone will be associated with successful treatment in all cases, and this fact may explain the rare but continued morbidity that is still seen in children with AHO.