Can a multifaceted educational intervention targeting both nurses and physicians change the prescribing of antibiotics to nursing home residents? A cluster randomized controlled trial.

OBJECTIVES: To assess the impact of a multifaceted educational intervention concerning treatment of infections in the nursing home setting. METHODS: We used a cluster randomized controlled trial. Fifty-eight nursing homes in Sweden were randomly assigned either to educational intervention or control. The intervention consisted of small educational group sessions with nurses and physicians, feedback on prescribing, presentation of guidelines and written materials. The primary outcome was the proportion of quinolones prescribed for lower urinary tract infection (UTI) in women. Secondary outcomes were for all infections: number of UTIs per resident, proportion of recorded infections treated with an antibiotic, proportion of infections handled by physicians as 'wait and see', and for lower UTI in women, proportion of nitrofurantoin. RESULTS: Of the 58 nursing homes, 46 completed the study. A total of 702 and 540 infections were recorded pre- and post-intervention. The proportion of quinolones decreased significantly in the intervention and control groups, by -0.196 (9/93 to 36/123) and -0.224 (4/66 to 31/109), respectively [95% confidence interval (CI) -0.338, -0.054 and -0.394, -0.054], but the difference between intervention and control groups was not significant, with an absolute risk reduction of 0.028 (95% CI -0.193, 0.249). The changes in proportion of infections treated with antibiotics and proportion of infections handled by physicians as 'wait and see' was significant in comparison with controls: -0.124 (95% CI -0.228, -0.019) and 0.143 (95% CI 0.047, 0.240). No intervention effect could be seen for the other outcomes. CONCLUSIONS: The educational intervention had no effect on the primary outcome, but decreased the overall prescribing of antibiotics.

Infections and antibiotic prescribing in Swedish nursing homes: a cross-sectional study.

The aim of this study was to present and assess the treatment of infections in Swedish nursing homes. It included 58 nursing homes with 3002 residents. During 3 months, nurses in the nursing homes recorded all infections requiring a physician's opinion. Of the 889 infectious episodes, 84% were treated with antibiotics. Many of the antibiotics were issued after indirect contact with the physician (38%). Indications for antibiotics were in 55% of the cases urinary tract infections (UTI), in 17% skin and soft-tissue infections and in 15% respiratory tract infections (RTI). The most common antibiotics were penicillins (38%), followed by quinolones (23%) and trimethoprim (18%). For the major indication, lower UTI in women, half of the cases were not treated according to the recommendations. The main concerns were length of treatment and overprescribing of quinolones. For the second major diagnosis, pneumonia, the high use of doxycycline could be questioned. Continuing education on infections and their treatment in nursing homes is needed. Training should preferably include both physicians and nurses as a high proportion of antibiotics is issued without direct contact with the physician.

Sequestration of plant-derived phenolglucosides by larvae of the leaf beetle Chrysomela lapponica: thioglucosides as mechanistic probes.

Feeding larvae of Chrysomela lapponica (Coleoptera: Chrysomelidae) acquire characteristic O-glucosides from the leaves of their food plants. The glucosides are selectively channeled from the gut to the defensive gland. Subsequent enzymatic transformations generate a blend of different defensive compounds, e.g., salicylaldehyde and two series of 2-methylbutyl and isobutyryl esters. By using systematically modified and hydrolysis-resistant thioglucosides as structural mimics of the plant-derived glucosides, e.g., salicin and its o-, m-, and p-isomers 1, 2, and 3; o-, m-, and p-cresols 5, 6, 7; along with thioglucosides of 2-phenylethanol 9 and (3Z)-hexenol 10, we demonstrated that the larvae of C. lapponica are able to sequester a broad range of structurally different thioglucosides with comparable efficiency. This sharply contrasts with the sequestration habitus previously observed in Chrysomela populi and Phratora vitellinae, which secrete almost pure salicylaldehyde and posses a highly specific transport mechanism for salicin (Kuhn et al., Proc. Natl. Acad. Sci. USA 101:13808-13813, 2004). Also, neither C. lapponica nor C. populi sequester in their gland the thioglucoside of 8-hydroxygeraniol, the mimic of the glucoside specifically transported by larvae secreting iridoid monoterpenes (Phaedon cochleariae, Gastrophysa viridula). Accordingly, leaf beetle larvae possess selective membrane carriers in their gut and their defensive systems that match the orientation of the functional groups of glucosides from their food plants probably by embedding the substrate in a network of hydrogen bonds inside the membrane carriers. The synthesis and the spectroscopic properties of the test compounds along with a comparative evaluation of the transport capabilities of larvae of C. populi and C. lapponica are described.

Efficacy and safety of high-dose budesonide/formoterol (Symbicort) compared with budesonide administered either concomitantly with formoterol or alone in patients with persistent symptomatic asthma.

OBJECTIVE AND BACKGROUND: Budesonide/formoterol 160/4.5 microg, two inhalations bd, is an effective and well-tolerated maintenance therapy for patients not controlled on inhaled corticosteroids alone. The authors assessed the efficacy and safety of a higher dose of budesonide/formoterol in patients with persistent symptomatic asthma. METHODS: This was a 24-week, double-blind, double-dummy randomized study. Budesonide/formoterol 320/9 microg, two inhalations bd (1280/36 microg/day), was compared with corresponding doses of budesonide during weeks 1-12 and budesonide plus formoterol via separate inhalers during weeks 1-24. Efficacy was assessed during weeks 1-12; the primary variable was morning PEF. Safety was assessed over weeks 1-24. RESULTS: Patients (n=456; aged 12-79 years) had a mean reversibility in FEV1 of 28% and mean pre-study inhaled corticosteroid dose of 1038 microg/day. Mean morning PEF increased by 37 L/min and 36 L/min with budesonide/formoterol and budesonide plus formoterol, respectively, versus an increase of 5 L/min with budesonide (P<0.001 for both vs. budesonide). Budesonide/formoterol increased time to first mild exacerbation (P<0.005) versus budesonide. Budesonide/formoterol and budesonide plus formoterol had similar efficacy. All treatments were well tolerated and the incidence of class-related adverse events was similarly low in all groups. Changes in serum potassium and plasma cortisol were comparable across treatments. CONCLUSIONS: High-dose budesonide/formoterol (320/9 microg, two inhalations bd) is effective and well tolerated in patients with persistent symptomatic asthma. The findings also support the safety of regular high-dose formoterol (36 microg/day).

Functional analysis and localisation of a delta-class glutathione S-transferase from Sarcoptes scabiei.

The mite Sarcoptes scabiei causes sarcoptic mange, or scabies, a disease that affects both animals and humans worldwide. Our interest in S. scabiei led us to further characterise a glutathione S-transferase. This multifunctional enzyme is a target for vaccine and drug development in several parasitic diseases. The S. scabiei glutathione S-transferase open reading frame reported here is 684 nucleotides long and yields a protein with a predicted molecular mass of 26 kDa. Through phylogenetic analysis the enzyme was classified as a delta-class glutathione S-transferase, and our paper is the first to report that delta-class glutathione S-transferases occur in organisms other than insects. The recombinant S. scabiei glutathione S-transferase was expressed in Escherichia coli via three different constructs and purified for biochemical analysis. The S. scabiei glutathione S-transferase was active towards the substrate 1-chloro-2,4-dinitrobenzene, though the positioning of fusion partners influenced the kinetic activity of the enzyme. Polyclonal antibodies raised against S. scabiei glutathione S-transferase specifically localised the enzyme to the integument of the epidermis and cavities surrounding internal organs in adult parasites. However, some minor staining of parasite intestines was observed. No staining was seen in host tissues, nor could we detect any antibody response against S. scabiei glutathione S-transferase in sera from naturally S. scabiei infected dogs or pigs. Additionally, the polyclonal sera raised against recombinant S. scabiei glutathione S-transferase readily detected a protein from mites, corresponding to the predicted size of native glutathione S-transferase.

Selective transport systems mediate sequestration of plant glucosides in leaf beetles: a molecular basis for adaptation and evolution.

Chrysomeline larvae respond to disturbance and attack by everting dorsal glandular reservoirs, which release defensive secretions. The ancestral defense is based on the de novo synthesis of monoterpene iridoids. The catabolization of the host-plant O-glucoside salicin into salicylaldehyde is a character state that evolved later in two distinct lineages, which specialized on Salicaceae. By using two species producing monoterpenes (Hydrothassa marginella and Phratora laticollis) and two sequestering species (Chrysomela populi and Phratora vitellinae), we studied the molecular basis of sequestration by feeding the larvae structurally different thioglucosides resembling natural O-glucosides. Their accumulation in the defensive systems demonstrated that the larvae possess transport systems, which are evolutionarily adapted to the glycosides of their host plants. Minor structural modifications in the aglycon result in drastically reduced transport rates of the test compounds. Moreover, the ancestral iridoid-producing leaf beetles already possess a fully functional import system for an early precursor of the iridoid defenses. Our data confirm an evolutionary scenario in which, after a host-plant change, the transport system of the leaf beetles may play a pivotal role in the adaptation on new hosts by selecting plant-derived glucosides that can be channeled to the defensive system.

Budesonide and mesalazine in active Crohn's disease: a comparison of the effects on quality of life.

OBJECTIVES: Controlled ileal release budesonide and slow release mesalazine are both used to treat mild to moderate active Crohn's disease, although data show that budesonide is more effective in inducing remission. When comparing different treatment options, the effects of agents on health-related quality of life must be considered as well as efficacy. In this study, we sought to compare the effects of budesonide and mesalazine on the health-related quality of life of patients with active Crohn's disease. METHODS: The study included 182 patients with Crohn's Disease Activity Index scores between 200 and 400. Patients were randomized in a double blind, double dummy, multicenter study to receive 9 mg of budesonide, once daily (n = 93), or 2 g of mesalazine, b.i.d. (n = 89), for 16 wk. Quality of life was assessed at baseline and after 2, 4, 8, 12, and 16 wk of treatment using the Psychological General Well-Being index. In addition, a physician's global evaluation was used to assess how symptoms affected patients' normal activities. RESULTS: Patients treated with budesonide experienced significantly greater improvement in Psychological General Well-Being scores than the group treated with mesalazine after 2, 8, 12, and 16 wk. All components of this index showed greater improvements in the budesonide-treated group than in the mesalazine group at 12 and 16 wk. The physician's global evaluation showed significantly greater improvements in the budesonide group than in the mesalazine group at all visits. CONCLUSION: Budesonide (9 mg once daily) improves health-related quality of life to a greater extent than mesalazine (2 g b.i.d.) in patients with mild to moderate active Crohn's disease.