The efficacy of daptomycin versus vancomycin for methicillin-resistant Staphylococcus aureus bloodstream infection in patients with impaired renal function.

BACKGROUND: Concerns regarding the efficacy of daptomycin for methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections in patients with impaired renal function are reflected in a recent package insert change by the Food and Drug Administration (FDA). However, this decision was based on a small subgroup analysis and it is unclear if this is a true association. METHODS: We conducted a retrospective cohort study of patients with MRSA bacteremia treated at a tertiary hospital from 2001 to 2011 and who received either vancomycin or daptomycin. We used propensity score and multivariable logistic regression to assess the outcome of treatment failure, via blinded adjudication, in daptomycin- vs vancomycin-treated subjects and the interaction with renal function. RESULTS: One hundred fifty patients were analyzed, 100 in the vancomycin arm and 50 in the daptomycin arm. The average age was 61 years, and 60% were men. Of patients treated with daptomycin or vancomycin, 29 (58%) and 51 (51%), respectively, had an estimated glomerular filtration rate (GFR) <50 mL/minute/1.73 m(2). Compared with vancomycin, the usage of daptomycin in patients was not significantly associated with treatment failure in patients with a GFR >50 mL/minute/1.73 m(2) (odds ratio [OR], 0.45; 95% confidence interval [CI], .11 -1.79), nor in patients with a GFR of <50 mL/minute/1.73 m(2) (OR, 0.46; 95% CI, .11 -1.94). There was no significant interaction between them (P = .54). CONCLUSIONS: In patients with MRSA bacteremia, daptomycin efficacy was not affected by GFR level and was similar to vancomycin's efficacy. Although our sample size was small, it was larger than than the one used by the FDA. However, smaller differences may be significant with a larger sample size.

Activity groups for people with schizophrenia: a randomized controlled trial.

BACKGROUND: UK guidelines recommend that patients with schizophrenia are offered access to social activities, however, the impact of such interventions have not been examined in a large randomized trial. AIMS: To investigate the effect of an activity group intervention on mental health and global functioning 12 months after randomization compared to standard care alone. METHODS: Secondary analysis of data from the MATISSE study. Primary outcomes were global functioning, assessed using the Global Assessment of Functioning (GAF), and mental health symptoms measured using the Positive and Negative Syndrome Scale (PANSS). RESULTS: About 140 participants were randomized to activity groups and 137 to standard care alone. Follow-up data were collected from 242 (87%) participants. Mental health improved significantly among those offered activity groups (change in PANSS score = -6.0, 95% CI -2.3 to -9.8) but global functioning did not (change in GAF score = 0.8, 95% CI -1.7 to 3.3). No significant differences were found between treatment arms. CONCLUSIONS: Offering activity groups to patients with schizophrenia was not associated with any additional clinical benefits. There was poor uptake and attendance at activity groups. Interventions that aim to improve negative symptoms may be useful in enabling engagement in psychosocial interventions.

Surgical care improvement project in the value-based purchasing era: more harm than good?

The Surgical Care Improvement Project (SCIP) started in 2006 as a core measure to reduce perioperative morbidity and mortality, with many measures addressing perioperative antibiotic usage and timing. However, measures are often rolled out without consideration of their full impact, causing confusion, frustration, and possibly patient harm. We have provided examples of each. The institution of SCIP has markedly increased the compliance to its measures but little evidence shows that it provides any substantial benefit to patients, whereas this improved compliance comes at the cost of significant time, money, and staff resources. Despite this, several SCIP measures, which are currently incorporated into quality contracts, will be tied to Medicare reimbursement in 2013 under value-based purchasing, with third-party payers likely following suit. This may lead to inappropriate lower compensation of hospitals providing good care with questionable effects on patient outcomes.

Relationship between price paid for off-trade alcohol, alcohol consumption and income in England: a cross-sectional survey.

AIMS: In order to examine the potential impact of an increase in the minimum price per unit of alcohol to 50 pence ($0.78), we examined drinking patterns and household incomes of people who purchase alcohol in England at above and below this price. METHODS: Cross-sectional survey of 515 members of the public in seven towns and cities in the south of England. The primary outcome was whether the participant had purchased alcohol at <50 p/unit. The main exposures were annual household income and alcohol consumption, measured using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). RESULTS: The median price paid per unit of alcohol was 53.1 pence (range 16.4-297.0 pence). Those buying alcohol at <50 p/unit had a mean AUDIT-C score of 6.2 compared with 5.5 among those buying alcohol at above this price. The odds ratio (OR) of a person on low income with high-risk drinking purchasing alcohol at <50 p/unit was 1.29 [95% confidence interval (CI) = 0.82-1.79] compared with all other study participants. The OR of a person on low income with low-risk drinking purchasing alcohol below this price was 0.51 (95% CI = 0.30-0.87) compared with all other participants. CONCLUSIONS: These data suggest that an increase in the minimum price of alcohol to 50 pence price per unit is only likely to disproportionately affect people on low incomes if their alcohol consumption is excessive.