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2.
Heart Lung ; 45(6): 538-543, 2016.
Article in English | MEDLINE | ID: mdl-27601213

ABSTRACT

PURPOSE: To determine if treating bronchoalveolar lavage (BAL) culture-positive patients with antifungal therapy impacted mortality compared to not treating due to presumed colonization. METHODS: We conducted a retrospective study of immunocompetent, critically ill adult patients from 2010 to 2014. Patients with a BAL culture-positive for Candida or unspeciated yeast and a clinical suspicion of pneumonia were included. The treatment group received an antifungal agent for at least 5 days, and the control group received either no antifungal therapy or an antifungal agent for less than 48 h. Recruitment occurred in a 2:1 ratio of untreated versus treated patients. RESULTS: Seventy-five patients were included. In-hospital mortality was similar between treated and untreated groups (24% vs. 26%, P = 0.85). Length of stay and duration of mechanical ventilation also did not differ between the two groups. CONCLUSION: We did not observe a difference in mortality or clinical outcomes in patients treated with antifungal agents. Presumptive antifungal therapy for BAL-positive Candida or yeast in immunocompetent patients did not result in improved clinical outcomes.


Subject(s)
Antifungal Agents/therapeutic use , Critical Illness , Immunocompromised Host , Pneumonia, Ventilator-Associated/drug therapy , Adult , Female , Hospital Mortality/trends , Humans , Male , Middle Aged , Pneumonia, Ventilator-Associated/microbiology , Pneumonia, Ventilator-Associated/mortality , Prognosis , Respiration, Artificial/adverse effects , Retrospective Studies , United States/epidemiology
3.
Hosp Pharm ; 50(9): 789-97, 2015 Oct.
Article in English | MEDLINE | ID: mdl-26912920

ABSTRACT

BACKGROUND: Optimal dosing of vancomycin in morbidly obese patients (>100 kg and at least 140% of their ideal body weight) has not been determined. Conventional dosing strategies have led to the observation of supratherapeutic trough concentrations (>20 mcg/mL). OBJECTIVE: To evaluate the effectiveness of a new vancomycin dosing protocol in morbidly obese patients in achieving therapeutic trough concentrations between 10 and 20 mcg/mL and to determine patient-specific factors influencing the trough concentration attained. METHODOLOGY: A single-center, retrospective chart review included morbidly obese adult patients with a pharmacy-to-dose vancomycin consult and at least 1 trough concentration obtained at steady state. Patients were excluded if they had a creatinine clearance (CrCl) less than 35 mL/min or unstable renal function, were not dosed according to the revised protocol, or received vancomycin prior to initiation of the protocol. RESULTS: Of the 48 patients included, 17 (35.4%) achieved a therapeutic vancomycin trough concentration. Subtherapeutic concentrations (<10 mcg/mL) were observed in 27 patients (56.3%) and supratherapeutic concentrations were observed in 4 (8.3%) patients. Age less than 45 years and CrCl greater than 100 mL/min were associated with subtherapeutic trough concentrations. CONCLUSION: This study demonstrates that the revised vancomycin dosing protocol led to the attainment of therapeutic trough concentrations in 35.4% of patients. The majority had subtherapeutic concentrations, which increases the risk of treatment failures and resistance. Further study is needed to determine the optimal dosing strategy in this patient population.

4.
J Clin Microbiol ; 51(12): 4126-9, 2013 Dec.
Article in English | MEDLINE | ID: mdl-24088861

ABSTRACT

Staphylococcus aureus is a common cause of bacteremia, with a substantial impact on morbidity and mortality. Because of increasing rates of methicillin-resistant Staphylococcus aureus, vancomycin has become the standard empirical therapy. However, beta-lactam antibiotics remain the best treatment choice for methicillin-susceptible strains. Placing patients quickly on the optimal therapy is one goal of antimicrobial stewardship. This retrospective, observational, single-center study compared 33 control patients utilizing only traditional full-susceptibility methodology to 22 case patients utilizing rapid methodology with CHROMagar medium to detect and differentiate methicillin-resistant and methicillin-susceptible Staphylococcus aureus strains hours before full susceptibilities were reported. The time to targeted therapy was statistically significantly different between control patients (mean, 56.5 ± 13.6 h) and case patients (44.3 ± 17.9 h) (P = 0.006). Intensive care unit status, time of day results emerged, and patient age did not make a difference in time to targeted therapy, either singly or in combination. Neither length of stay (P = 0.61) nor survival (P = 1.0) was statistically significantly different. Rapid testing yielded a significant result, with a difference of 12.2 h to targeted therapy. However, there is still room for improvement, as the difference in time to susceptibility test result between the full traditional methodology and CHROMagar was even larger (26.5 h). This study supports the hypothesis that rapid testing plays a role in antimicrobial stewardship by getting patients on targeted therapy faster.


Subject(s)
Anti-Bacterial Agents/therapeutic use , Bacteremia/diagnosis , Bacteriological Techniques/methods , Blood/microbiology , Methicillin Resistance , Staphylococcal Infections/diagnosis , Staphylococcus aureus/isolation & purification , Adult , Anti-Bacterial Agents/pharmacology , Bacteremia/drug therapy , Bacteremia/microbiology , Culture Media/chemistry , Humans , Male , Middle Aged , Retrospective Studies , Staphylococcal Infections/drug therapy , Staphylococcal Infections/microbiology , Staphylococcus aureus/drug effects , Time Factors , Treatment Outcome
5.
AIDS Res Hum Retroviruses ; 28(8): 798-805, 2012 Aug.
Article in English | MEDLINE | ID: mdl-22011066

ABSTRACT

HIV increases risk of non-Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL). The effect of HIV on presentation, treatment, and outcomes of NHL and HL in routine care in the combination antiretroviral therapy (cART) merits further characterization. We performed a retrospective analysis of HIV-infected patients with NHL and HL receiving care at the University of North Carolina at Chapel Hill from January 1, 2000 until December 31, 2010. Statistical analyses were conducted using SAS, version 9.2 (SAS Institute Inc). Sixty-five HIV-infected patients with NHL and HL were identified. Patients with non-CNS NHL and HL presented with advanced disease (85% stage III or IV) and adverse prognostic features. Patients completed 87% of planned chemotherapy cycles, and 68% of patients completed stage-appropriate therapy. Dose reduction, interruption, and/or delay occurred during more than 25% of administered cycles in 64% of patients. Infectious complications, febrile neutropenia, and myelosuppression accounted for 78% of deviations from planned cumulative dose and dose intensity. Primary CNS lymphoma (PCNSL) was associated with poor prognosis, but 2-year overall survival was 66% for all non-CNS lymphoma. Among patients surviving at least 2 years, 75% had CD4 count >200 cells/µl and 79% had HIV viral load <400 copies/ml at last follow-up. Despite advanced disease and difficulty tolerating chemotherapy with optimal cumulative dose and dose intensity, most patients with non-CNS HIV-associated lymphoma survived more than 2 years after diagnosis, the majority with suppressed HIV RNA.


Subject(s)
Antineoplastic Combined Chemotherapy Protocols/therapeutic use , HIV Infections/complications , Lymphoma, AIDS-Related/diagnosis , Adult , Antiretroviral Therapy, Highly Active , Female , Follow-Up Studies , HIV , HIV Infections/drug therapy , Humans , Lymphoma, AIDS-Related/drug therapy , Lymphoma, AIDS-Related/virology , Male , Middle Aged , North Carolina , Prognosis , Retrospective Studies , Survival Analysis , Treatment Outcome
6.
Pharmacotherapy ; 30(3): 304-22, 2010 Mar.
Article in English | MEDLINE | ID: mdl-20180613

ABSTRACT

The rates of major adverse coronary events, including recurrent ischemic events and death, in patients with coronary artery disease (CAD) have been shown to be significantly increased in patients with depression. In addition, health care costs are higher and health-related quality of life is lower in depressed patients with CAD. Several pathophysiologic mechanisms have been proposed for the association of increased events seen in this population. Studies have focused on antidepressants (specifically, selective serotonin reuptake inhibitors and mirtazapine), psychotherapy (cognitive behavioral therapy and interpersonal psychotherapy), and a wide range of other nonpharmacologic interventions. Pharmacologic and nonpharmacologic treatments are known to improve depressive symptoms in patients with CAD, but their effects on outcomes such as mortality and hospital admissions remain controversial. If treatment of depression is warranted, strategies should include sertraline or citalopram, with or without cognitive behavioral therapy, based on the known efficacy and safety of the drugs in this population. Nonpharmacologic therapy such as aerobic exercise has been shown to improve not only depression but also cardiovascular health. When selecting an appropriate antidepressant, clinicians should consider their patients' comorbid conditions and the potential for drug interactions, and treatment should be frequently monitored. Screening for depression in patients with cardiac disease should be instituted on a routine basis by using either case-finding or symptom-triggered approaches. Based on the high prevalence of depression and its known adverse effects in patients with CAD, future research is needed to help determine the role of antidepressants and nonpharmacologic strategies in improving outcomes in patients with both comorbidities.


Subject(s)
Coronary Artery Disease/complications , Depression/complications , Depression/drug therapy , Depressive Disorder/complications , Depressive Disorder/drug therapy , Antidepressive Agents/adverse effects , Antidepressive Agents/therapeutic use , Behavior Control , Coronary Artery Disease/prevention & control , Coronary Artery Disease/therapy , Depression/diagnosis , Depression/therapy , Depressive Disorder/diagnosis , Depressive Disorder/therapy , Drug Interactions , Drug Monitoring , Exercise , Humans , Psychotherapy , Quality of Life , Risk-Taking , Treatment Outcome
7.
J Chem Ecol ; 34(6): 702-7, 2008 Jun.
Article in English | MEDLINE | ID: mdl-18506531

ABSTRACT

Chemical communication plays an important role in mediating social interactions of many taxa, particularly arthropods. Many individuals communicate information about their reproductive status to potential mates through distance and/or contact pheromones, an ability that may be advantageous to both signalers and receivers. In this paper, we describe tests of two hypotheses on the role of distance communication in the reproductive behaviors of crayfish (Orconectes quinebaugensis). First, we hypothesized that male crayfish would show stronger attraction towards virgin females (females with no viable sperm) than towards non-virgin females because of the fitness costs (to males) associated with sperm competition. Second, we hypothesized that female crayfish should show differential responses to mature male signals depending on their own sexual history: virgin females should be more strongly attracted to male signals than should non-virgin females because they must mate at least once to be able to fertilize eggs in the spring. Data from two Y-maze experiments yielded support for both hypotheses: males were attracted to signals from virgin females, but not to signals from non-virgins. Likewise, virgin females were attracted to signals from males, but non-virgin females were not. We discuss our data in the context of the potential costs and benefits of mate searching and suggest that distance chemical communication of sexual status may be particularly advantageous when the costs of mate searching are high.


Subject(s)
Animal Communication , Astacoidea/physiology , Sexual Behavior, Animal/physiology , Animals , Female , Fertilization , Male
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