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- Diagnosis and Management of Urinary Tract Infections in the Outpatient Setting: A Review. [JOURNAL ARTICLE]
- JAMA 2014 Oct 22; 312(16):1677-1684.
Urinary tract infection is among the most common reasons for an outpatient visit and antibiotic use in adult populations. The increasing prevalence of antibacterial resistance among community uropathogens affects the diagnosis and management of this clinical syndrome.To define the optimal approach for treating acute cystitis in young healthy women and in women with diabetes and men and to define the optimal approach for diagnosing acute cystitis in the outpatient setting.Evidence for optimal treatment regimens was obtained by searching PubMed and the Cochrane database for English-language studies published up to July 21, 2014.Twenty-seven randomized clinical trials (6463 patients), 6 systematic reviews, and 11 observational studies (252 934 patients) were included in our review. Acute uncomplicated cystitis in women can be diagnosed without an office visit or urine culture. Trimethoprim-sulfamethoxazole (160/800 mg twice daily for 3 days), nitrofurantoin monohydrate/macrocrystals (100 mg twice daily for 5-7 days), and fosfomycin trometamol (3 g in a single dose) are all appropriate first-line therapies for uncomplicated cystitis. Fluoroquinolones are effective for clinical outcomes but should be reserved for more invasive infections. β-Lactam agents (amoxicillin-clavulanate and cefpodoxime-proxetil) are not as effective as empirical first-line therapies. Immediate antimicrobial therapy is recommended rather than delayed treatment or symptom management with ibuprofen alone. Limited observational studies support 7 to 14 days of therapy for acute urinary tract infection in men. Based on 1 observational study and our expert opinion, women with diabetes without voiding abnormalities presenting with acute cystitis should be treated similarly to women without diabetes.Immediate antimicrobial therapy with trimethoprim-sulfamethoxazole, nitrofurantoin, or fosfomycin is indicated for acute cystitis in adult women. Increasing resistance rates among uropathogens have complicated treatment of acute cystitis. Individualized assessment of risk factors for resistance and regimen tolerability is needed to choose the optimum empirical regimen.
- Risk Factors for Drug-Resistant Pathogenes in Community-Acquired Pneumonia in Azerbaijan Republic. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):922A.
Respiratory Infections Posters IISESSION TYPE: Original Investigation PosterPRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PMPURPOSE: Identification of patients with drug-rersistant pathogenes at initial diagnosis is essential for traetment of pneumonia.The purpose of this study was to elucidate clinical features of community-aquired pneumonia(CAP) and to clarify risk factors for drug resistant pathogenes in patients with COPD.METHODS: A prospective observational study was conducted in hospitalized patients with CAP at three centers in Azerbaijan republic.Pathogenes identified as not susceptible to ceftriaxone ,amoxicillin-clavulonic acid ,macrolides,and fluoroquinolones were defined as CAP drug-resistant pathogenes(CAP-DRPs).Microbilogic laboratories in all centers provided possible causative pathogenes,which were cultured in a semiquantitative manner from samples of sputum,tracheobronchial aspitates,bronchalveolar lavage fluid,and blood.Serologic tests were performed to detect antibodies against Mycoplasma pneumoniae and Chlamydophila pneumoniae.Legionella pneumophila serogroup I antigen in urine was tested by immonochromotography.RESULTS: In total, 368 patients with CAP were analized.this observotional study was performed prospectively from January 15 ,2013 through december 25,2013 at one university hospital(a 500-beds),one institution hospital(a 300-beds) and one major community hospital(a 200-beds).All adult patients(>_20 yr) in whom pneumonia had developed during daily community living were included in the study.CAP-DRPs were found in 86(23.4%) patients with CAP.Independents risk factors for CAP-DRPs were almost identical in all three observational study centers.These included prior hospitalization(adjusted odds ratio[AOR],2.57;95% confidence interval[CI],1.45-3.89),previous antibiotic use (AOR),3.85;95% CI,2.14-5.69),use of gastric acid-supressive agents(AOR,2.75;95%CI 1.65-3.95).CONCLUSIONS: The clinical profile of CAP was similar in all three centes of the observational study.However,physicians can predict drug resistance in patients with CAP by taking accoiunt of the cumulative number of risk factors.The superiority of previous use of antibiotics as risk factor may be explain with unrational use of antibiotics by physicions in Azerbaijan republic.CLINICAL IMPLICATIONS: Ewig S,Welte T, Torres A.Rethinking the concepts of community-acquired and health-care associated pneuminia.lancet Infect Dis 2010;10:279-287. Ishida T, Hashimito T,Arita M, Ito I,Osawa M.Etiology of community- acguired pneumonia in hospitalized patients:3-year prospective study in japan.Chest 1998;114:1588-1593.DISCLOSURE: The following authors have nothing to disclose: Alizaman Sadigov, Gulzar Aliyeva, Aynur AgayevaNo Product/Research Disclosure Information.
- A Curious Manifestation of Amoxicillin-Induced DRESS Syndrome. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):781A.
Bronchology/Interventional Student/Resident Case Report Posters ISESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Drug rash with eosinophilia and systemic symptoms (DRESS) is an idiosyncratic and potentially life-threatening syndrome. It is a type of delayed hypersensitivity reaction to drugs. We describe a rare manifestation of DRESS syndrome that presented as diffuse alveolar hemorrhage caused by hypersensitivity to amoxicillin.CASE PRESENTATION: A 19-year-old male presented to the emergency department with fevers, morbiliform rash, adenopathy and hepatosplenomegaly 14 days after being started on amoxicillin for symptoms of sinusitis. Initial laboratory studies revealed thrombocytopenia, eosinophilia and transaminitis. His symptoms quickly deteriorated during the first 24 hours of hospitalization to involve respiratory compromise requiring intubation and meeting criteria for acute respiratory distress syndrome. A chest CT scan was remarkable for pulmonary inflitrates with prominent air bronchograms. A bronchoscopy and bronchoalveolar lavage revealed a grossly bloody aspirate and pulmonary eosinophilia. Extensive workup for autoimmune disorders, bacterial, viral, fungal and parasitic infections was unrevealing. A punch biopsy of the skin was compatible with a hypersensitivity reaction as it showed superficial perivascular dermatitis with eosinophil extravasation. DRESS syndrome was diagnosed with rapid regression of symptoms after treatment with high dose methylprednisone was initiated. The patient made a full recovery and was discharged home on day 13 of hospitalization with a very slow steroid taper.DISCUSSION: DRESS syndrome usually presents 2-8 weeks after the initiation of the offending agent. The main culprits are allopurinol, aromatic anticonvulsants and sulfonamides, even though 50 Drugs can induce DRESS1. It has been described as "the great clinical mimicker" as it masquerades as acute severe sepsis. It presents with fever, cutaneous drug eruption, hematological abnormalities and a wide array of internal organ involvement. There has only been a handful of cases of DRESS syndrome as a consequence of amoxicillin. In our case, the most life-threatening manifestation was eosinophilic pneumonitis and diffuse alveolar hemorrhage causing acute respiratory distress syndrome. Pulmonary involvement is present in only 5% of cases of DRESS1. We used the RegiSCAR scoring system developed by Kardaun et al that classifies DRESS cases and a "definite" score gave us the diagnosis2. The main treatments of DRESS are withdrawal of culprit drug and a very slow corticosteroid taper.CONCLUSIONS: Diagnosing DRESS is challenging due to the diversity of cutaneous manifestations and organs involved and as such, there should be a high clinical suspicion for this disease if the introduction of a new drug is followed by a rash, eosinophilia and a sepsis-like syndrome.Reference #1: Cacoub P, Musette P & Descamps V, et al. The DRESS syndrome: a literature review, Am J Med. 2011 Jul;124(7):588-97Reference #2: Kardaun SH, et al. does a DRESS syndrome really exist? Br J Dermatol. 2007;156:609-611DISCLOSURE: The following authors have nothing to disclose: Musa Sharkawi, Noormuhammad AbbasakoorNo Product/Research Disclosure Information.
- A 4-Year-Old With Markedly Reduced Oxygen Affinity Due to a Hemoglobin (Hb) Variant. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):715A.
Pediatric CasesSESSION TYPE: Affiliate Case Report SlidePRESENTED ON: Monday, October 27, 2014 at 03:15 PM - 04:15 PMINTRODUCTION: Child with hypoxemia, not caused by hypoventilation, V/Q mismatch, shunting, or diffusion limitation.CASE PRESENTATION: A 4 year old boy presented with fever and exertional dyspnea, without cough or respiratory distress, SpO2 85% in room air, which improved to 92% on 2LPM oxygen. Chest radiograph (CXR) showed bronchial thickening without focal infiltrate; heart size and vascularity were normal. Hb value was normal. He was discharged home on azithromycin and amoxicillin when stable in room air. Two days later, pediatrician sent him to ER for SpO2 85%, unchanged CXR. Review of systems: no history of excercise tolerance, problems at high altitudes, or decreased activity. Immunizations up to date. Paternal family history of Thalassemia. Prior surgery for coarctation repair in infancy. During hospitalization, lungs were clear to auscultation; rest of exam was normal without signs of clubbing or cyanosis. SpO2 ranged 87-92% in room air. Interestingly, SpO2 of patient's father was 92%. Paternal grandmother and aunt reportedly have low oxygen saturations during doctors' visits. Studies during hospitalization included bubble ECHO and chest CT angiogram, which were normal. ABG was unsuccessful. Hemoglobin electrophoresis showed Hb A 75, Hb V 22. DNA analysis was consistent with heterozygous Hb Bassett.DISCUSSION: Hb Bassett is an abnormal Hb variant with a markedly reduced oxygen affinity, decreased Bohr effect, and low subunit cooperativity. It has an amino acid substitution (α94Asp-->Ala) at the α1:β2 contact region, where the key conformational changes associated with oxygenation and deoxygenation of Hb molecule take place. This dimer interface plays a major role in the allosteric activity of Hb by forming an inter-subunit hydrogen bond/salt bridge that links and stablizes the two αβ dimers in both the T- and R- state. In Hb Bassett, replacement of the aspartate residue by alanine abolishes significant α1:β2 hydrogen bond interactions resulting in reduced stability of Hb Bassett relative to normal Hb, R-state more destabilized than T-state due to loss of a greater number of inter-subunit interactions in the R-state. The allosteric equilibrium is therefore expected to favor the relatively stable T-state Hb Bassett, giving rise to low oxygen affinity.CONCLUSIONS: Hb binding affinity for oxygen should be considered when all four causes of hypoxemia are ruled out.Reference #1: Abdulmalik O, et al. Characterization of hemoglobin Bassett (α94AspàAla), a variant with very low oxygen affinity. Am J Hematol 2004;77(3):268-276.DISCLOSURE: The following authors have nothing to disclose: Diana Chen, Mustafa BseikriNo Product/Research Disclosure Information.
- Chronic Granulomatous Disease Complicated With Dissemination of BCG Vaccine. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):688A.
Pediatric Global Case ReportsSESSION TYPE: Global Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Chronic granulomatous disease is caused by a deficiency of phagocyte microbicidal function, due to the inability to produce hydrogen peroxide and superoxide anion. The most common form is X-linked and presented with recurrent pulmonary infections.CASE PRESENTATION: A male patient a one year and nine months old, presented with febriles syndrome treated with multiple antibiotics such as clabulanic amoxicillin due to reoccurrent infection in the whole respiratory system; anemia, axillary adenopathy, without symptoms of recovery. For this reason he was referred to our hospital for diagnosis and treatment. At admission, his general condition was bad, with the following BM16.5 kg/m2, the patient is between 50-25 percentile growth. Presented: asthenia, decreased appetite, fever syndrome with records of 38 °, oxygen desaturation, with a 92 % to 21 % FiO2, respiratory rate of 36 per minute. Physical examination presented: right axillary lymphadenopathy, mobile, painless, hard elastic 1cm diameter, crepitant widespread rales and rhonchi in both lung fields and Other symptoms such as, increased rate of breathing, breathlessness and wheezing. Treatment was initiated with Clarithromycin and Amoxicillin clavulanic. TB empirical first-line treatment is added. He continued, febrile with records of 38-39 ° C, with antipyretics and physical means. Added access nonproductive cough and increased respiratory compromise adding retractions, and tachypnea. Background: Fully vaccinated. From month of life was treated for recurrent respiratory tract infections. Five months olds requiring hospitalization for acute pneumonia record. Laboratory results: anemia, increased erythrocyte sedimentation rate, hyperglycemia, and mild oxygen desaturation. Serological tests, toxoplasmosis, HIV, EBV, parvovirus, CMV, Mycoplasma, Bartonella, Brucella, Leptosipirosis, all negative. Dosage IgA and IgG slightly above its normal value, IgE 541.6 Ul/ml. Elevation of gamma globulin. DNA- antibody, ANCAs, and Rheumatoid Factor negative. Thorax CT: multiple images of lymph nodes in the mediastinum Observed in lung parenchyma patchy areas of airspace occupation distributed in both lungs and cavitated images in the lower lobes. Axillary lymphadenopathy. Upper abdomen no abnormalities. Normal Echocardiogram. Ocular Fundus, right eye net edges whitish lesions without macular involvement Faced with suspected diagnosis of TB specific studies are requested: Gastric Lavage, Lymph Node and Cerebrospinal Fluid: Negative smear and culture. Blood cultures for mycobacteria: Negatives. Tuberculin Skin Test: Negative.Were raised various differential diagnosis: Infectious diseases such as tuberculosis, toxoplasmosis, aspergillosis, staphylococci sepsis, tuberculosis being the entity that most compatible with the characteristics presented by the patient, although the bacillus was not found by the methods referred. Immunological diseases: Wiskott Aldrich immunodeficiency. Severe combined immunodeficiency disease is a group with deficiency of humoral and cellular immunity caused by various genetic mutations and associated enzyme deficiencies. The most common form is X-linked early onset in the first months of life, and is presented as severe mucocutaneous candidiasis, dissemination of BCG vaccine, persistent diarrhea, lung infections, meningitis, septicemia. Complement deficiency can start at different ages. C3 deficiencies present with sino-pulmonary infections by encapsulated bacteria, pneumococcus, Neisseria meningitidis, Haemophilus influenza. Autoimmune disease Systemic lupus erythematosus, polyangiitis, Wegener's granulomatosis.CONCLUSIONS: The patient remained febrile despite therapy instituted and showed no improvement in respiratory symptoms so it is referred to a specialist center for studies to detect diseases of the immune system. Resulting poor response in nitroblue tetrazolium (NBT) test, it was assumed as a chronic granulomatous disease complicated with dissemination of BCG (Bacille Calmette-Guerin) vaccine , given that the child was vaccinated at birth. Treatment was started with interferon gamma, TB drugs, Trimethoprim-sulfamethoxazole and Itraconazol, and showed significant improvement 40 days after starting treatment.Reference #1: Chronic granulomatous disease, Current Opinion in Immunology, Volume 15, October 2003, Pages 578-584, P G Heyworth, and col.DISCLOSURE: The following authors have nothing to disclose: Gabriela Manonelles, Vanina MartinNo Product/Research Disclosure Information.
- Solitary Pulmonary Nodule in an Immunosuppressed Patient With Non-Hodgkin Lymphoma: An Unusual Situation. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):635A.
Cancer Global Case ReportsSESSION TYPE: Global Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: The carcinoid tumor is a rare neoplasm of enterochromaffin cells. Its main location is in the intestine, more often in the appendix. Carcinoid tumors may or may not produce the carcinoid syndrome, characterized by various clinical symptoms such as tachycardia, flushing and paraesthesia, all related to serotonin secretion by the tumor. We report a case of a patient in use of adjuvant chemotherapy after diagnosis of non-Hodgkin's lymphoma that presented in exam chest ray routine circumscribed pulmonary nodule. After long follow-up, it was opted for surgical resection of the lesion, being diagnosed carcinoid tumor of the lung.CASE PRESENTATION: MAF, female, 68 years old, housewife, resident in the interior of Rio de Janeiro, Brazil. Was presented for the first time to our service with clinical cough, yellowish scanty expectoration and low fever of 37.8°. She was treated with prednisone 30 mg daily, omeprazole, acyclovir , sulfametozaxol-trimethoprim and ondansetron. Reported a previous diagnosis, received eighteen months prior this consultation, of non-Hodgkin's lymphoma, obtained through biopsy of inguinal lymph node. Chest radiography showed pulmonary nodule with soft tissue density of 1.8 cm in diameter, without calcification and well delimited in the left lower lobe that was first identified three years prior. This lesion had been accompanied by another service of pneumology and oncology in a conservative way. Was treated for the infection with a more enlarged approach, using amoxicillin-clavulonate and clarithromycin, because of her underlying disease and continuous use of systemic corticosteroids. Complete regression of symptoms occurred with absolute improvement. The nodulation remained present in later radiographys. Requested chest CT which showed lobulated nodule with well-defined borders in the medial basal segment of the left lower lobe, near the thoracic aortic wall, measuring 2.0 cm, with intense enhancement after contrast infusion. The examination of inflammatory tests after treatment of the infection were in low titles: CRP of 6mm and ESR of 10mm. Normal conventional lung function test. In this moment, the oncology service decided, in relation to the treatment of the lymphoma, the addition of rituximab to the treatment regimen. It was made screening for infectious diseases with no data suggesting underlying disease. Despite nonreactive Mantoux test, as the same was held on corticosteroids use, it was requested bronchoscopy. Collected material, with results of direct examination and culture negative for tuberculosis and fungi, as well as negative oncotic cytology. In regards of epidemiological risks, the absence of etiological definition and risks inherent in the use of rituximab, it was decided to introduce prophylactic isoniazid for prevention of possible masked TB. In the monitoring of the non-Hodgkin lymphoma, PET scan was requested to re-estage, which revealed absence of signs of disease activity. On the other hand, the previously identified lung injury exhibited growth, evidenced by increasing its dimensions in relation to previous studies. Because of this, she was referred to thoracic surgery. Due to difficult surgical access, it was decided to approach the nodule via videothorascoscopy, being perfomed a lung segmentectomy. Retrieved tissue containing a nodule of 3 cm in diameter, which was diagnosed after examination as typical carcinoid tumor. The surgery was uneventful and the patient is currently asymptomatic on follow -up.DISCUSSION: Despite the carcinoid tumor usually require large surgical excision, segmentectomy was performed due to the limitations of the patient and the peculiar location of the lesion. As histopathological study revealed that the surgical margins were free of lesions and PET-scan showed no metabolic activity in other sites, we considered the segmentectomy a proper treatment of the condition founded.CONCLUSIONS: The involvement of more than one different type of neoplasm sequentially is uncommon. There are no reports in the literature that non-Hodgkin lymphoma may predispose carcinoid tumor and vice versa. In elderly, frail or patients with comorbidities, segmentectomy can assume similar healing criteria of the lobectomy.Reference #1: SAVIVA, E. V.; DESCOURT, R. Focus on treatment of lung carcinoid tumor. Onco Targets Ther. 2013Reference #2: TRAVIS, W.D. Advances in neuroendocrine lung tumors. Oxford Journals Medicine. Annals of Oncology 2010Reference #3: REKHTMAN, N. Neuroendocrine Tumors of the Lung - An Update. Arch Pathol Lab Med. 2010DISCLOSURE: The following authors have nothing to disclose: Gilmar Zonzin, Vitório Puntel, Silvio Guerra, Vinicius Agostinho, Mariana Silva, Priscila Virgens, Marina FariaNo Product/Research Disclosure Information.
- Don't Smooch That Pooch! A Rare Case of Pasteurella multocida Pneumonia in an Elderly Woman. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):146A.
Infectious Disease Cases IISESSION TYPE: Affiliate Case Report SlidePRESENTED ON: Wednesday, October 29, 2014 at 11:00 AM - 12:15 PMINTRODUCTION: Pasteurella multocida is a Gram-negative coccobacillus that colonizes the naso-oropharynx of many domestic mammals. Zoonotic transmission to humans most commonly occurs after animal bites resulting in soft-tissue and skin infections, but pulmonary infections are possible. We report a rare case of pasteurella pneumonia in an elderly woman from kissing her pet dog.CASE PRESENTATION: An 88 year-old nonsmoking woman with a history of well-controlled chronic obstructive pulmonary disease presented with a persistent nonpurulent cough, night sweats, and a weight loss of 12 lbs over 1 month. Physical examination and vital signs were unremarkable. A CT scan of the chest revealed multilobar tree-in-bud opacities associated with patchy areas of consolidation. Multiple sputum cultures were unremarkable and were negative for acid fast bacilli. A bronchoalevolar lavage was performed and cultures grew P. multocida. On further questioning, the patient revealed that she kisses her pet dog daily and her pet dog had a chronic cough as well. The patient and the dog (after veterinary consultation) were treated with amoxicillin-clavulanate for 2 weeks. The patient was advised to avoid kissing her pets. At 3 month follow up there was resolution of the pulmonary infiltrates on a CT scan and she reported no respiratory symptoms in herself or the pet dog.DISCUSSION: Respiratory tract infection from P. multocida is rare, and the actual incidence is likely under-reported. Cases of pneumonia have been reported and the likely mechanism of transmission is by direct inhalation of contaminated aerosols or oral exposure to animal secretions. In the reported literature, pasteurella pneumonia is most frequently found in elderly patient with underlying lung disease that reside with cats and dogs. The treatment of choice for P. multocida infection is ampicillin-sulbactam if intravenous therapy is needed or oral amoxicillin-clavulanate.CONCLUSIONS: We describe a rare case of a zoonotic transmission of pasteurella pneumonia. A history of animal exposure should alert the physician to consider Pasteurella multocida as a potential pulmonary pathogen. Our case further highlights that advising patients to avoid kissing pets can prevent zoonotic transmission of infections, especially in elderly patients with chronic lung diseases.Reference #1: Klein NC, Cunha BA. Pasteurella multocida pneumonia. Semin Respir Infect 1997;12(1):54-56.Reference #2: Marinella MA. Community-Acquired Pneumonia Due to Pasteurella multocida. Respir Care 2004;49(12):1528 -1529.DISCLOSURE: The following authors have nothing to disclose: Nikunj Bhatt, Angeline LazarusNo Product/Research Disclosure Information.
- Compassionate Use of Bedaquiline in the Treatment of Extensively Drug-Resistant Pulmonary Tuberculosis. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):132A.
Infectious Disease Case Report PostersSESSION TYPE: Affiliate Case Report PosterPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Extensively Drug Resistant Tuberculosis (XDR-TB), is uncommon in developed countries with only 63 cases reported in the US between 1993-2011. Treatment is tailored to culture sensitivities with second line anti-tuberculosis (anti-TB) drugs. We report the first case in United States of compassionate use of bedaquiline for the treatment of pulmonary XDR-TB.A 30 year-old man, former smoker, with diabetes, presented with fevers and hemoptysis one month after immigrating to New York from a high incidence country. His chest x-ray revealed bilateral cavitary upper lobe infiltrates (Figure 1). Sputum smears for acid-fast bacilli were positive as were cultures for Mycobacterium Tuberculosis. He was empirically started on first-line anti-TB drugs, and his regimen was modified as results from susceptibility testing became available eventually revealing XDR-TB. He was ultimately treated with pyrazinamide, ethionamide, paraminosalycilic acid, cycloserine, capreomycin, amoxicillin/clavulanic, meropenem and linezolid. As a result of multiple adverse effects from his XDR-TB treatment, especially linezolid induced demyelinating peripheral neuropathy, bedaquiline was obtained through a compassionate use program in order to maintain an effective treatment regimen for XDR-TB after the discontinuation of linezolid. He tolerated bedaquiline well experiencing only mild transaminitis and successfully completed his XDR-TB treatment.DISCUSSION: Three cases in the literature pertain to the compassionate use of bedaquiline. In each of these cases, bedaquiline was added in place of a fourth agent in a treatment regimen when there were no additional options remaining. QTC prolongation and increased risk of death have been noted in patients receiving bedaquiline. High incidences of nausea (35.3% vs. 25.7%) and hepatotoxicity (8.8% vs. 1.9%) have also been reported with bedaquiline when compared to placebo.Bedaquiline is a novel agent for the treatment of Pre-XDR or XDR Tuberculosis. In our patient bedaquiline was added to an effective XDR regimen to ameliorate the side effect profile in order to allow for the successful completion of therapy. Reference #1: CDC, Trends in Tuberculosis - United States, 2011. MMWR, 2012. 61(11): p. 181-185. Reference #2: Tiberi, S., et al., Bedaquiline in MDR/XDR-TB cases: first experience on compassionate use. Eur Respir J, 2014. 43(1): p. 289-92. Reference #3: Diacon, A.H., et al., The diarylquinoline TMC207 for multidrug-resistant tuberculosis. N Engl J Med, 2009. 360(23): p. 2397-405.The following authors have nothing to disclose: Melissa Lesko, Mauricio Danckers Degregori, Rosemary Adamson, Eric LeibertNo Product/Research Disclosure Information.
- Free antibiotic and vaccination programmes in community pharmacies of Miami-Dade County, FL, USA. [JOURNAL ARTICLE]
- J Antimicrob Chemother 2014 Oct 19.
Some community pharmacies provide prescribed oral antibiotics for free to incentivize customers. This can influence prescribing practices and may increase inappropriate antibiotic use. Thus, pleas to incorporate education and/or vaccinations into these initiatives have been made by the CDC and IDSA. This study aims to investigate the prevalence and characteristics of free antibiotic programmes (FAPs) and free vaccination programmes (FVPs) offered by community pharmacies within a major US county. Additionally, we evaluated the association between FAP location and proximate socioeconomic status.A telephone survey was administered to all community pharmacies in operation and located in Miami-Dade County, FL, USA (n = 668). Population characteristics at the five-digit ZIP code level were acquired from the 2010 US Census and American Communities Survey. An independent t-test, Kruskal-Wallis and logistic regression were used for statistical analysis.A total of 660 community pharmacies agreed to the telephone survey (response rate = 98.8%). FAPs were present in 6.8% of pharmacies (n = 45) and none incorporated an educational component targeted at patients or prescribers. Ciprofloxacin and amoxicillin were offered by all FAPs and 84.4% provided up to a 14 day supply (n = 38). Thirty-four of 72 ZIP codes had an FAP and those with a programme had larger populations and higher incomes (P ≤ 0.05). Family income ≥$75 000 (P = 0.0002) was an independent predictor of FAP availability. None of the surveyed pharmacies offered a FVP.Frequently provided by chain pharmacies and located in areas of higher income, FAPs within Miami-Dade County offer broad-spectrum antibiotics for long durations without additional education to patients or prescribers.
- First- and second-line Helicobacter pylori eradication with modified sequential therapy and modified levofloxacin-amoxicillin-based triple therapy. [JOURNAL ARTICLE]
- Ann Gastroenterol 2014; 27(4):357-361.
Helicobacter pylori (H. pylori) treatment remains a challenge for physicians. Although highly effective, the standard sequential therapy fails in a certain number of patients. Moreover, the cure rate following a levofloxacin-amoxicillin second-line triple therapy seems to be decreasing. We tested the efficacy of modified 10-day sequential therapy, and an intensified levofloxacin-amoxicillin regimen as first- and second-line therapy respectively.In this prospective, open label, multicenter, pilot study H. pylori-infected patients received a first-line modified 10-day sequential therapy regimen including rabeprazole 20 mg, and amoxicillin 1 g for the first 3 days, followed by rabeprazole 20 mg, clarithromycin 250 mg, and metronidazole 250 mg, for the remaining 7 days, all drugs given thrice daily. An 8-day therapy regimen with rabeprazole 20 mg, levofloxacin 250 mg, and amoxicillin 1 g, all thrice daily, was administered a second-line therapy.A total of 99 and 15 patients were enrolled for first- and second-line therapy. The eradication rates were 85.9% (95% CI 80-93) and 93.4% (95% CI 88-98) according to ITT and PP analyses following modified sequential therapy, and 60% (95% CI 35-86) and 64.3% (95% CI 39-89) following the intensified second-line therapy.A modified sequential 3- plus 7-day regimen with thrice daily drug administration failed to achieve very high eradication rate at ITT analysis. The intensified second-line regimen achieved disappointingly low eradication rate. Novel levofloxacin-free second-line therapies are urged in Italy.