Secular trends in the appropriateness of empirical antibiotic treatment in patients with bacteremia: a comparison between three prospective cohorts.

The objective of this study was to explore whether the percentage of inappropriate empirical antibiotic treatment in patients with bacteremia changed over time and to understand the factors that brought on the change. Three prospective cohorts of patients with bacteremia in three different periods (January 1st, 1988 to December 31st, 1989; May 1st, 2004 to November 30, 2004; May 1st, 2010 to April 30, 2011) were compared. Analysis was performed on a total of 811 patients. In 2010-2011, 55.9% (76/136) of patients with bacteremia received inappropriate empirical treatment, compared with 34.5% (170/493) and 33.5% (55/164) in the first and second periods, respectively, in a significant upward trend (p = 0.001). Resistance to antibiotics increased significantly during the study period. The following variables were included in the multivariate analysis assessing risk factors for inappropriate empirical treatment: study period (third period) [odds ratio, OR = 2.766 (95% confidence interval, CI, 1.655-4.625)], gender (male) [OR = 1.511 (1.014-2.253)], pathogen carrying extended-spectrum beta-lactamases [OR = 10.426 (4.688-23.187)], multidrug-resistant Acinetobacter baumannii [OR = 5.428 (2.181-13.513)], and skin/soft infections [OR = 3.23 (1.148-9.084)]. A model excluding microbiological data included: gender (male) [OR = 1.648 (1.216-2.234)], study period (third period) [OR = 2.446 (1.653-3.620)], hospital-acquired infection [OR = 1.551 (1.060-2.270)], previous use of antibiotics [OR = 1.815 (1.247-2.642)], bedridden patient [OR = 2.019 (1.114-3.658)], and diabetes mellitus [OR = 1.620 (1.154-2.274)]. We have observed a worrisome increase in the rate of inappropriate empirical treatment of bacteremia. We need tools that will allow us better prediction of the pathogen and its susceptibilities during the first hours of managing a patient suspected of a severe bacterial infection.

Presentation of infection in older patients--a prospective study.

BACKGROUND: Traditional wisdom suggests that infections in older patients have atypical presentation, including blunted febrile response. Data are scarce. DESIGN: We analyzed data from a prospectively collected database on presentation of infection in 4,308 patients, and compared the presentation of older patients (≥ 75 years) versus adults (< 75 years). SETTINGS: Single tertiary medical center. PARTICIPANTS: Patients admitted with suspected bacterial infection during 2002-2004 and 2010-2011. MEASUREMENTS: We evaluated clinical presentation on day of admission, including vital signs and laboratory parameters. RESULTS: No difference in fever values as a presenting sign of infection was found between older patients and adults (median fever 38.3°C, interquartile range [IQR] 37.4-39.0°C; and 38.4°C, IQR 37.3-39.0°C, respectively, P = 0.08). Median leukocyte count was significantly higher in older patients (median 11.60, IQR 8.30-15.72 in older patients; 10.84, 7.50-15.00 in adults, P < 0.001). Presentation with septic shock, acute renal failure, and reduced consciousness was significantly more common in older patients. These findings were also consistent in the subgroups of bacteremic patients and patients with microbiologically documented infection. CONCLUSION: Elevated fever and leukocytosis were found to be at least equally common in older patients compared to younger adults as part of the presentation of infection.

Medications and glucose-6-phosphate dehydrogenase deficiency: an evidence-based review.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is the most common human enzyme defect and one of the most common genetic disorders worldwide, with an estimated 400 million people worldwide carrying a mutation in the G6PD gene that causes deficiency of the enzyme. Although drug-induced haemolysis is considered the most common adverse clinical consequence of G6PD deficiency, significant confusion exists regarding which drugs can cause haemolytic anaemia in patients with G6PD deficiency. In the absence of consensus among physicians, patients are subject to conflicting advice, causing uncertainty and distress. In the current review we aimed, by thorough search of the medical literature, to collect evidence on which to base decisions either to prohibit or allow the use of various medications in patients with G6PD deficiency. A literature search was conducted during May 2009 for studies and case reports on medication use and G6PD deficiency using the following sources: MEDLINE (1966-May 2009), PubMed (1950-May 2009), the Cochrane database of systematic reviews (2009), and major pharmacology, internal medicine, haematology and paediatric textbooks. After assessing the literature, we divided medications into one of three groups: medications that should be avoided in individuals with G6PD deficiency, medications that were considered unsafe by at least one source, but according to our review can probably be given safely in normal therapeutic dosages to individuals with G6PD deficiency as evidence does not contravene their use, and medications where no evidence at all was found to contravene their use in G6PD-deficient patients. It is reasonable to conclude that, over time, many compounds have been wrongly cited as causing haemolysis because they were administered to patients experiencing an infection-related haemolytic episode. We found solid evidence to prohibit only seven currently used medications: dapsone, methylthioninium chloride (methylene blue), nitrofurantoin, phenazopyridine, primaquine, rasburicase and tolonium chloride (toluidine blue). Regarding all other medications, our review found no evidence to contravene their use in normal therapeutic doses to G6PD-deficient patients. There is a need for evidence-based global consensus regarding medication use in G6PD-deficient patients.