Doug Brunk

SAN DIEGO – Adding a simple question to the daily ICU checklist about handwashing before touching patients significantly improved handwashing compliance and was associated with a decreased rate of central line–associated bloodstream infections in a surgical intensive care unit over the course of 6 months.

Photo credit: © Vladimir Voronin/Fotolia.com

"If you look at how people address hand hygiene compliance overall, most of the time it’s with fairly elaborate and expensive educational and marketing campaigns," Dr. Jeremy Pamplin said in an interview after the study was presented during a poster session at the annual congress of the Society of Critical Care Medicine. "Inevitably, you improve hand hygiene compliance for a while. Then the campaign goes away and you start to have fading of the compliance."

As part of a process improvement project, Dr. Pamplin, medical codirector of the 20-bed surgical/trauma ICU at Brooke Army Medical Center, Fort Sam Houston, Tex., and his associates added the following question to their daily ICU checklist: "Has anyone seen anyone else touch the patient without washing their hands in the past 24 hours?" The question was asked during multidisciplinary ICU rounds for every patient, and only "yes" or "no" answers were allowed.

If respondents answered "yes," they were asked to provide the name of the offender, which was recorded. Compliance was measured by a third-party observer and was defined as washing hands or using hand sanitizer prior to touching a patient or the patient’s immediate surroundings.

Dr. Pamplin and his associates collected data for 3 months before and 3 months after this question was added to the ICU checklist. Over that period, the rate of handwashing compliance significantly increased from 69% to 89%, while the rate of central line–associated bloodstream infections decreased from 13.7/1,000 central line days to 2.7/1,000 central line days, an improvement that did not reach statistical significance.

"Before we introduced this question to our checklist, it was very rare for a provider to tell another provider, ‘Hey, I didn’t see you wash your hands,’ " Dr. Pamplin said. "After we introduced this question, people started doing it because we gave leadership and emphasis to it."

This resulted in a change of culture, he continued, "so if nurses, residents, or technicians saw someone walk into the room without washing their hands, they would stop them and say, ‘Hang on a second; you didn’t wash your hands.’ Everyone knows that hand hygiene is an important part of infection control. The hard part is remembering to do it. It’s a rare circumstance that someone gets upset by another health care provider who says, ‘Hey, you forgot to wash your hands.’ Because we have talked about hand hygiene compliance on rounds as a team, it has elevated that component of infection control so that everyone recognizes it as being important."

Dr. Pamplin said that he had no relevant financial disclosures to make.

SAN DIEGO – Adding a simple question to the daily ICU checklist about handwashing before touching patients significantly improved handwashing compliance and was associated with a decreased rate of central line–associated bloodstream infections in a surgical intensive care unit over the course of 6 months.

Photo credit: © Vladimir Voronin/Fotolia.com

"If you look at how people address hand hygiene compliance overall, most of the time it’s with fairly elaborate and expensive educational and marketing campaigns," Dr. Jeremy Pamplin said in an interview after the study was presented during a poster session at the annual congress of the Society of Critical Care Medicine. "Inevitably, you improve hand hygiene compliance for a while. Then the campaign goes away and you start to have fading of the compliance."

As part of a process improvement project, Dr. Pamplin, medical codirector of the 20-bed surgical/trauma ICU at Brooke Army Medical Center, Fort Sam Houston, Tex., and his associates added the following question to their daily ICU checklist: "Has anyone seen anyone else touch the patient without washing their hands in the past 24 hours?" The question was asked during multidisciplinary ICU rounds for every patient, and only "yes" or "no" answers were allowed.

If respondents answered "yes," they were asked to provide the name of the offender, which was recorded. Compliance was measured by a third-party observer and was defined as washing hands or using hand sanitizer prior to touching a patient or the patient’s immediate surroundings.

Dr. Pamplin and his associates collected data for 3 months before and 3 months after this question was added to the ICU checklist. Over that period, the rate of handwashing compliance significantly increased from 69% to 89%, while the rate of central line–associated bloodstream infections decreased from 13.7/1,000 central line days to 2.7/1,000 central line days, an improvement that did not reach statistical significance.

"Before we introduced this question to our checklist, it was very rare for a provider to tell another provider, ‘Hey, I didn’t see you wash your hands,’ " Dr. Pamplin said. "After we introduced this question, people started doing it because we gave leadership and emphasis to it."

This resulted in a change of culture, he continued, "so if nurses, residents, or technicians saw someone walk into the room without washing their hands, they would stop them and say, ‘Hang on a second; you didn’t wash your hands.’ Everyone knows that hand hygiene is an important part of infection control. The hard part is remembering to do it. It’s a rare circumstance that someone gets upset by another health care provider who says, ‘Hey, you forgot to wash your hands.’ Because we have talked about hand hygiene compliance on rounds as a team, it has elevated that component of infection control so that everyone recognizes it as being important."

Dr. Pamplin said that he had no relevant financial disclosures to make.

SAN DIEGO – Adding a simple question to the daily ICU checklist about handwashing before touching patients significantly improved handwashing compliance and was associated with a decreased rate of central line–associated bloodstream infections in a surgical intensive care unit over the course of 6 months.

Photo credit: © Vladimir Voronin/Fotolia.com

"If you look at how people address hand hygiene compliance overall, most of the time it’s with fairly elaborate and expensive educational and marketing campaigns," Dr. Jeremy Pamplin said in an interview after the study was presented during a poster session at the annual congress of the Society of Critical Care Medicine. "Inevitably, you improve hand hygiene compliance for a while. Then the campaign goes away and you start to have fading of the compliance."

As part of a process improvement project, Dr. Pamplin, medical codirector of the 20-bed surgical/trauma ICU at Brooke Army Medical Center, Fort Sam Houston, Tex., and his associates added the following question to their daily ICU checklist: "Has anyone seen anyone else touch the patient without washing their hands in the past 24 hours?" The question was asked during multidisciplinary ICU rounds for every patient, and only "yes" or "no" answers were allowed.

If respondents answered "yes," they were asked to provide the name of the offender, which was recorded. Compliance was measured by a third-party observer and was defined as washing hands or using hand sanitizer prior to touching a patient or the patient’s immediate surroundings.

Dr. Pamplin and his associates collected data for 3 months before and 3 months after this question was added to the ICU checklist. Over that period, the rate of handwashing compliance significantly increased from 69% to 89%, while the rate of central line–associated bloodstream infections decreased from 13.7/1,000 central line days to 2.7/1,000 central line days, an improvement that did not reach statistical significance.

"Before we introduced this question to our checklist, it was very rare for a provider to tell another provider, ‘Hey, I didn’t see you wash your hands,’ " Dr. Pamplin said. "After we introduced this question, people started doing it because we gave leadership and emphasis to it."

This resulted in a change of culture, he continued, "so if nurses, residents, or technicians saw someone walk into the room without washing their hands, they would stop them and say, ‘Hang on a second; you didn’t wash your hands.’ Everyone knows that hand hygiene is an important part of infection control. The hard part is remembering to do it. It’s a rare circumstance that someone gets upset by another health care provider who says, ‘Hey, you forgot to wash your hands.’ Because we have talked about hand hygiene compliance on rounds as a team, it has elevated that component of infection control so that everyone recognizes it as being important."

Dr. Pamplin said that he had no relevant financial disclosures to make.

SAN DIEGO – Administering enoxaparin to patients with acute burn injuries at a dosage of less than 30 mg every 12 hours often leads to subtherapeutic anti-Xa levels that are associated with an increase in risk of venous thromboembolism, according to results from a single-center study.

The finding suggests that enoxaparin dosing should be individualized for this patient population, Hsin Lin, Pharm.D., said in an interview during a poster session at the annual congress of the Society of Critical Care Medicine. "Most of the published enoxaparin dosing regimens we see are not for burn patients," said Dr. Lin, a pharmacist at the University of Utah Burn Trauma Center, Salt Lake City. "Burn patients are hypermetabolic. One dose does not fit everyone."

Dr. Lin and her associates evaluated the effectiveness of a protocol for graduated enoxaparin dosing with concurrent monitoring to achieve a peak anti-Xa level of 0.2-0.4 U/mL in 84 patients with acute burn injuries who received venous thromboembolism (VTE) prophylaxis with an initial dosage of 30 mg subcutaneously twice daily. They adjusted the dosages until patients obtained therapeutic levels or until they were discharged. About 1 month later, the patients were interviewed by telephone to determine if any VTE events had occurred.

The median age of patients was 39 years, their median body mass index was 27 kg/m2, and their injuries covered a median of 15% of body surface area.

Of the 84 patients, 64 showed initial anti-Xa levels below target (0.2 U/mL), and their enoxaparin dosage was then increased. In 15 patients, the target anti-Xa level was never reached before discharge. Of 69 patients who had appropriate anti-Xa levels, 1 had a deep vein thrombosis during the hospital stay, 1 developed pulmonary embolism 1 month after discharge, 2 died of non-VTE causes, and 5 were unable to be reached by telephone.

There were no episodes of abnormal hemorrhage, thrombocytopenia, or heparin allergy documented.

Dr. Lin reported that the median final enoxaparin dosage required to achieve therapeutic anti-Xa levels was 40 mg every 12 hours, ranging from 20 to 70 mg. Linear regression analysis revealed that the final enoxaparin dosage correlated with total body surface area and weight.

"Enoxaparin dose adjustment was associated with a low incidence of VTE events, and there was no hemorrhagic bleeding–related complication," Dr. Lin said. "In patients with acute burn injury, routine monitoring of anti-Xa levels is recommended."

Dr. Lin said that she had no relevant financial disclosures to make.

SAN DIEGO – Administering enoxaparin to patients with acute burn injuries at a dosage of less than 30 mg every 12 hours often leads to subtherapeutic anti-Xa levels that are associated with an increase in risk of venous thromboembolism, according to results from a single-center study.

The finding suggests that enoxaparin dosing should be individualized for this patient population, Hsin Lin, Pharm.D., said in an interview during a poster session at the annual congress of the Society of Critical Care Medicine. "Most of the published enoxaparin dosing regimens we see are not for burn patients," said Dr. Lin, a pharmacist at the University of Utah Burn Trauma Center, Salt Lake City. "Burn patients are hypermetabolic. One dose does not fit everyone."

Dr. Lin and her associates evaluated the effectiveness of a protocol for graduated enoxaparin dosing with concurrent monitoring to achieve a peak anti-Xa level of 0.2-0.4 U/mL in 84 patients with acute burn injuries who received venous thromboembolism (VTE) prophylaxis with an initial dosage of 30 mg subcutaneously twice daily. They adjusted the dosages until patients obtained therapeutic levels or until they were discharged. About 1 month later, the patients were interviewed by telephone to determine if any VTE events had occurred.

The median age of patients was 39 years, their median body mass index was 27 kg/m2, and their injuries covered a median of 15% of body surface area.

Of the 84 patients, 64 showed initial anti-Xa levels below target (0.2 U/mL), and their enoxaparin dosage was then increased. In 15 patients, the target anti-Xa level was never reached before discharge. Of 69 patients who had appropriate anti-Xa levels, 1 had a deep vein thrombosis during the hospital stay, 1 developed pulmonary embolism 1 month after discharge, 2 died of non-VTE causes, and 5 were unable to be reached by telephone.

There were no episodes of abnormal hemorrhage, thrombocytopenia, or heparin allergy documented.

Dr. Lin reported that the median final enoxaparin dosage required to achieve therapeutic anti-Xa levels was 40 mg every 12 hours, ranging from 20 to 70 mg. Linear regression analysis revealed that the final enoxaparin dosage correlated with total body surface area and weight.

"Enoxaparin dose adjustment was associated with a low incidence of VTE events, and there was no hemorrhagic bleeding–related complication," Dr. Lin said. "In patients with acute burn injury, routine monitoring of anti-Xa levels is recommended."

Dr. Lin said that she had no relevant financial disclosures to make.

SAN DIEGO – Administering enoxaparin to patients with acute burn injuries at a dosage of less than 30 mg every 12 hours often leads to subtherapeutic anti-Xa levels that are associated with an increase in risk of venous thromboembolism, according to results from a single-center study.

The finding suggests that enoxaparin dosing should be individualized for this patient population, Hsin Lin, Pharm.D., said in an interview during a poster session at the annual congress of the Society of Critical Care Medicine. "Most of the published enoxaparin dosing regimens we see are not for burn patients," said Dr. Lin, a pharmacist at the University of Utah Burn Trauma Center, Salt Lake City. "Burn patients are hypermetabolic. One dose does not fit everyone."

Dr. Lin and her associates evaluated the effectiveness of a protocol for graduated enoxaparin dosing with concurrent monitoring to achieve a peak anti-Xa level of 0.2-0.4 U/mL in 84 patients with acute burn injuries who received venous thromboembolism (VTE) prophylaxis with an initial dosage of 30 mg subcutaneously twice daily. They adjusted the dosages until patients obtained therapeutic levels or until they were discharged. About 1 month later, the patients were interviewed by telephone to determine if any VTE events had occurred.

The median age of patients was 39 years, their median body mass index was 27 kg/m2, and their injuries covered a median of 15% of body surface area.

Of the 84 patients, 64 showed initial anti-Xa levels below target (0.2 U/mL), and their enoxaparin dosage was then increased. In 15 patients, the target anti-Xa level was never reached before discharge. Of 69 patients who had appropriate anti-Xa levels, 1 had a deep vein thrombosis during the hospital stay, 1 developed pulmonary embolism 1 month after discharge, 2 died of non-VTE causes, and 5 were unable to be reached by telephone.

There were no episodes of abnormal hemorrhage, thrombocytopenia, or heparin allergy documented.

Dr. Lin reported that the median final enoxaparin dosage required to achieve therapeutic anti-Xa levels was 40 mg every 12 hours, ranging from 20 to 70 mg. Linear regression analysis revealed that the final enoxaparin dosage correlated with total body surface area and weight.

"Enoxaparin dose adjustment was associated with a low incidence of VTE events, and there was no hemorrhagic bleeding–related complication," Dr. Lin said. "In patients with acute burn injury, routine monitoring of anti-Xa levels is recommended."

Dr. Lin said that she had no relevant financial disclosures to make.

SAN DIEGO – Administering enoxaparin to patients with acute burn injuries at a dosage of less than 30 mg every 12 hours often leads to subtherapeutic anti-Xa levels that are associated with an increase in risk of venous thromboembolism, according to results from a single-center study.

The finding suggests that enoxaparin dosing should be individualized for this patient population, Hsin Lin, Pharm.D., said in an interview during a poster session at the annual congress of the Society of Critical Care Medicine. "Most of the published enoxaparin dosing regimens we see are not for burn patients," said Dr. Lin, a pharmacist at the University of Utah Burn Trauma Center, Salt Lake City. "Burn patients are hypermetabolic. One dose does not fit everyone."

Dr. Lin and her associates evaluated the effectiveness of a protocol for graduated enoxaparin dosing with concurrent monitoring to achieve a peak anti-Xa level of 0.2-0.4 U/mL in 84 patients with acute burn injuries who received venous thromboembolism (VTE) prophylaxis with an initial dosage of 30 mg subcutaneously twice daily. They adjusted the dosages until patients obtained therapeutic levels or until they were discharged. About 1 month later, the patients were interviewed by telephone to determine if any VTE events had occurred.

The median age of patients was 39 years, their median body mass index was 27 kg/m2, and their injuries covered a median of 15% of body surface area.

Of the 84 patients, 64 showed initial anti-Xa levels below target (0.2 U/mL), and their enoxaparin dosage was then increased. In 15 patients, the target anti-Xa level was never reached before discharge. Of 69 patients who had appropriate anti-Xa levels, 1 had a deep vein thrombosis during the hospital stay, 1 developed pulmonary embolism 1 month after discharge, 2 died of non-VTE causes, and 5 were unable to be reached by telephone.

There were no episodes of abnormal hemorrhage, thrombocytopenia, or heparin allergy documented.

Dr. Lin reported that the median final enoxaparin dosage required to achieve therapeutic anti-Xa levels was 40 mg every 12 hours, ranging from 20 to 70 mg. Linear regression analysis revealed that the final enoxaparin dosage correlated with total body surface area and weight.

"Enoxaparin dose adjustment was associated with a low incidence of VTE events, and there was no hemorrhagic bleeding–related complication," Dr. Lin said. "In patients with acute burn injury, routine monitoring of anti-Xa levels is recommended."

Dr. Lin said that she had no relevant financial disclosures to make.

SAN DIEGO – Administering enoxaparin to patients with acute burn injuries at a dosage of less than 30 mg every 12 hours often leads to subtherapeutic anti-Xa levels that are associated with an increase in risk of venous thromboembolism, according to results from a single-center study.

The finding suggests that enoxaparin dosing should be individualized for this patient population, Hsin Lin, Pharm.D., said in an interview during a poster session at the annual congress of the Society of Critical Care Medicine. "Most of the published enoxaparin dosing regimens we see are not for burn patients," said Dr. Lin, a pharmacist at the University of Utah Burn Trauma Center, Salt Lake City. "Burn patients are hypermetabolic. One dose does not fit everyone."

Dr. Lin and her associates evaluated the effectiveness of a protocol for graduated enoxaparin dosing with concurrent monitoring to achieve a peak anti-Xa level of 0.2-0.4 U/mL in 84 patients with acute burn injuries who received venous thromboembolism (VTE) prophylaxis with an initial dosage of 30 mg subcutaneously twice daily. They adjusted the dosages until patients obtained therapeutic levels or until they were discharged. About 1 month later, the patients were interviewed by telephone to determine if any VTE events had occurred.

The median age of patients was 39 years, their median body mass index was 27 kg/m2, and their injuries covered a median of 15% of body surface area.

Of the 84 patients, 64 showed initial anti-Xa levels below target (0.2 U/mL), and their enoxaparin dosage was then increased. In 15 patients, the target anti-Xa level was never reached before discharge. Of 69 patients who had appropriate anti-Xa levels, 1 had a deep vein thrombosis during the hospital stay, 1 developed pulmonary embolism 1 month after discharge, 2 died of non-VTE causes, and 5 were unable to be reached by telephone.

There were no episodes of abnormal hemorrhage, thrombocytopenia, or heparin allergy documented.

Dr. Lin reported that the median final enoxaparin dosage required to achieve therapeutic anti-Xa levels was 40 mg every 12 hours, ranging from 20 to 70 mg. Linear regression analysis revealed that the final enoxaparin dosage correlated with total body surface area and weight.

"Enoxaparin dose adjustment was associated with a low incidence of VTE events, and there was no hemorrhagic bleeding–related complication," Dr. Lin said. "In patients with acute burn injury, routine monitoring of anti-Xa levels is recommended."

Dr. Lin said that she had no relevant financial disclosures to make.

SAN DIEGO – Administering enoxaparin to patients with acute burn injuries at a dosage of less than 30 mg every 12 hours often leads to subtherapeutic anti-Xa levels that are associated with an increase in risk of venous thromboembolism, according to results from a single-center study.

The finding suggests that enoxaparin dosing should be individualized for this patient population, Hsin Lin, Pharm.D., said in an interview during a poster session at the annual congress of the Society of Critical Care Medicine. "Most of the published enoxaparin dosing regimens we see are not for burn patients," said Dr. Lin, a pharmacist at the University of Utah Burn Trauma Center, Salt Lake City. "Burn patients are hypermetabolic. One dose does not fit everyone."

Dr. Lin and her associates evaluated the effectiveness of a protocol for graduated enoxaparin dosing with concurrent monitoring to achieve a peak anti-Xa level of 0.2-0.4 U/mL in 84 patients with acute burn injuries who received venous thromboembolism (VTE) prophylaxis with an initial dosage of 30 mg subcutaneously twice daily. They adjusted the dosages until patients obtained therapeutic levels or until they were discharged. About 1 month later, the patients were interviewed by telephone to determine if any VTE events had occurred.

The median age of patients was 39 years, their median body mass index was 27 kg/m2, and their injuries covered a median of 15% of body surface area.

Of the 84 patients, 64 showed initial anti-Xa levels below target (0.2 U/mL), and their enoxaparin dosage was then increased. In 15 patients, the target anti-Xa level was never reached before discharge. Of 69 patients who had appropriate anti-Xa levels, 1 had a deep vein thrombosis during the hospital stay, 1 developed pulmonary embolism 1 month after discharge, 2 died of non-VTE causes, and 5 were unable to be reached by telephone.

There were no episodes of abnormal hemorrhage, thrombocytopenia, or heparin allergy documented.

Dr. Lin reported that the median final enoxaparin dosage required to achieve therapeutic anti-Xa levels was 40 mg every 12 hours, ranging from 20 to 70 mg. Linear regression analysis revealed that the final enoxaparin dosage correlated with total body surface area and weight.

"Enoxaparin dose adjustment was associated with a low incidence of VTE events, and there was no hemorrhagic bleeding–related complication," Dr. Lin said. "In patients with acute burn injury, routine monitoring of anti-Xa levels is recommended."

Dr. Lin said that she had no relevant financial disclosures to make.

SAN DIEGO – Administering enoxaparin to patients with acute burn injuries at a dosage of less than 30 mg every 12 hours often leads to subtherapeutic anti-Xa levels that are associated with an increase in risk of venous thromboembolism, according to results from a single-center study.

The finding suggests that enoxaparin dosing should be individualized for this patient population, Hsin Lin, Pharm.D., said in an interview during a poster session at the annual congress of the Society of Critical Care Medicine. "Most of the published enoxaparin dosing regimens we see are not for burn patients," said Dr. Lin, a pharmacist at the University of Utah Burn Trauma Center, Salt Lake City. "Burn patients are hypermetabolic. One dose does not fit everyone."

Dr. Lin and her associates evaluated the effectiveness of a protocol for graduated enoxaparin dosing with concurrent monitoring to achieve a peak anti-Xa level of 0.2-0.4 U/mL in 84 patients with acute burn injuries who received venous thromboembolism (VTE) prophylaxis with an initial dosage of 30 mg subcutaneously twice daily. They adjusted the dosages until patients obtained therapeutic levels or until they were discharged. About 1 month later, the patients were interviewed by telephone to determine if any VTE events had occurred.

The median age of patients was 39 years, their median body mass index was 27 kg/m2, and their injuries covered a median of 15% of body surface area.

Of the 84 patients, 64 showed initial anti-Xa levels below target (0.2 U/mL), and their enoxaparin dosage was then increased. In 15 patients, the target anti-Xa level was never reached before discharge. Of 69 patients who had appropriate anti-Xa levels, 1 had a deep vein thrombosis during the hospital stay, 1 developed pulmonary embolism 1 month after discharge, 2 died of non-VTE causes, and 5 were unable to be reached by telephone.

There were no episodes of abnormal hemorrhage, thrombocytopenia, or heparin allergy documented.

Dr. Lin reported that the median final enoxaparin dosage required to achieve therapeutic anti-Xa levels was 40 mg every 12 hours, ranging from 20 to 70 mg. Linear regression analysis revealed that the final enoxaparin dosage correlated with total body surface area and weight.

"Enoxaparin dose adjustment was associated with a low incidence of VTE events, and there was no hemorrhagic bleeding–related complication," Dr. Lin said. "In patients with acute burn injury, routine monitoring of anti-Xa levels is recommended."

Dr. Lin said that she had no relevant financial disclosures to make.

SAN DIEGO – Administering enoxaparin to patients with acute burn injuries at a dosage of less than 30 mg every 12 hours often leads to subtherapeutic anti-Xa levels that are associated with an increase in risk of venous thromboembolism, according to results from a single-center study.

The finding suggests that enoxaparin dosing should be individualized for this patient population, Hsin Lin, Pharm.D., said in an interview during a poster session at the annual congress of the Society of Critical Care Medicine. "Most of the published enoxaparin dosing regimens we see are not for burn patients," said Dr. Lin, a pharmacist at the University of Utah Burn Trauma Center, Salt Lake City. "Burn patients are hypermetabolic. One dose does not fit everyone."

Dr. Lin and her associates evaluated the effectiveness of a protocol for graduated enoxaparin dosing with concurrent monitoring to achieve a peak anti-Xa level of 0.2-0.4 U/mL in 84 patients with acute burn injuries who received venous thromboembolism (VTE) prophylaxis with an initial dosage of 30 mg subcutaneously twice daily. They adjusted the dosages until patients obtained therapeutic levels or until they were discharged. About 1 month later, the patients were interviewed by telephone to determine if any VTE events had occurred.

The median age of patients was 39 years, their median body mass index was 27 kg/m2, and their injuries covered a median of 15% of body surface area.

Of the 84 patients, 64 showed initial anti-Xa levels below target (0.2 U/mL), and their enoxaparin dosage was then increased. In 15 patients, the target anti-Xa level was never reached before discharge. Of 69 patients who had appropriate anti-Xa levels, 1 had a deep vein thrombosis during the hospital stay, 1 developed pulmonary embolism 1 month after discharge, 2 died of non-VTE causes, and 5 were unable to be reached by telephone.

There were no episodes of abnormal hemorrhage, thrombocytopenia, or heparin allergy documented.

Dr. Lin reported that the median final enoxaparin dosage required to achieve therapeutic anti-Xa levels was 40 mg every 12 hours, ranging from 20 to 70 mg. Linear regression analysis revealed that the final enoxaparin dosage correlated with total body surface area and weight.

"Enoxaparin dose adjustment was associated with a low incidence of VTE events, and there was no hemorrhagic bleeding–related complication," Dr. Lin said. "In patients with acute burn injury, routine monitoring of anti-Xa levels is recommended."

Dr. Lin said that she had no relevant financial disclosures to make.

SAN DIEGO – Administering enoxaparin to patients with acute burn injuries at a dosage of less than 30 mg every 12 hours often leads to subtherapeutic anti-Xa levels that are associated with an increase in risk of venous thromboembolism, according to results from a single-center study.

The finding suggests that enoxaparin dosing should be individualized for this patient population, Hsin Lin, Pharm.D., said in an interview during a poster session at the annual congress of the Society of Critical Care Medicine. "Most of the published enoxaparin dosing regimens we see are not for burn patients," said Dr. Lin, a pharmacist at the University of Utah Burn Trauma Center, Salt Lake City. "Burn patients are hypermetabolic. One dose does not fit everyone."

Dr. Lin and her associates evaluated the effectiveness of a protocol for graduated enoxaparin dosing with concurrent monitoring to achieve a peak anti-Xa level of 0.2-0.4 U/mL in 84 patients with acute burn injuries who received venous thromboembolism (VTE) prophylaxis with an initial dosage of 30 mg subcutaneously twice daily. They adjusted the dosages until patients obtained therapeutic levels or until they were discharged. About 1 month later, the patients were interviewed by telephone to determine if any VTE events had occurred.

The median age of patients was 39 years, their median body mass index was 27 kg/m2, and their injuries covered a median of 15% of body surface area.

Of the 84 patients, 64 showed initial anti-Xa levels below target (0.2 U/mL), and their enoxaparin dosage was then increased. In 15 patients, the target anti-Xa level was never reached before discharge. Of 69 patients who had appropriate anti-Xa levels, 1 had a deep vein thrombosis during the hospital stay, 1 developed pulmonary embolism 1 month after discharge, 2 died of non-VTE causes, and 5 were unable to be reached by telephone.

There were no episodes of abnormal hemorrhage, thrombocytopenia, or heparin allergy documented.

Dr. Lin reported that the median final enoxaparin dosage required to achieve therapeutic anti-Xa levels was 40 mg every 12 hours, ranging from 20 to 70 mg. Linear regression analysis revealed that the final enoxaparin dosage correlated with total body surface area and weight.

"Enoxaparin dose adjustment was associated with a low incidence of VTE events, and there was no hemorrhagic bleeding–related complication," Dr. Lin said. "In patients with acute burn injury, routine monitoring of anti-Xa levels is recommended."

Dr. Lin said that she had no relevant financial disclosures to make.

SAN DIEGO – The development of hospital-acquired pressure ulcers may be unavoidable in patients who present with respiratory and hemodynamic medical problems that impede optimal oxygenation to tissues, results from a study of more than 800 patients showed.

The findings challenge the position of the Centers for Medicaid and Medicare Services that pressure ulcers in this setting are a so-called "never event," Margaret Mullen-Fortino, R.N., said at the annual congress of the Society of Critical Care Medicine.

"They are categorized as a never event because it’s believed that these are reasonably preventable through the application of evidence-based guidelines," said Ms. Mullen-Fortino, operations director of the surgical/trauma ICU at the Hospital of the University of Pennsylvania, Philadelphia. "The evidence-based guidelines include the acronym SKIN, with the S standing for surface selection such as low-air-pressure mattresses. The K stands for keep turning patients, the I stands for incontinence management, and the N stands for nutrition – making sure that patients are adequately nourished with enough protein."

However, she continued, "There is a large population of practitioners who believe that pressure ulcers are not a never event, that there are comorbidities that increase the chances of patients developing pressure ulcers. Much like a patient experiences a myocardial infarction because blood does not get to the heart muscle, we believe that pressure ulcers develop because adequate blood supply does not get to the skin, which is the largest organ in the body. Our hypothesis is that there is an association between the severity of illness and the development of pressure ulcers."

To test this hypothesis, Ms. Mullen-Fortino and her associates conducted a prospective cohort study of 824 patients who were admitted to the 20-bed surgical/trauma ICU at the Hospital of the University of Pennsylvania and to the 20-bed medical ICU at the Christ Hospital, Cincinnati, between Dec. 15, 2009, and Dec. 12, 2010. Variables assessed included age, length of stay, APACHE score, Braden score, readmission, and use of mechanical ventilation and vasopressors.

Ms. Mullen-Fortino reported that of the 824 patients studied, 221 (26.8%) developed pressure ulcers. Of these patients, 144 (65.1%) were ventilated and 67 (30.3%) required vasopressor support.

Among the entire study population, the median APACHE score was 74, with a range of 26-153. The median length of stay was 2 days, with a range of 1-91 days; the median Braden score was 14, with a range of 7-20; and the median patient age was 63 years.

All of the variables studied had a statistically significant association with the development of pressure ulcers with the exception of the use of vasopressors, "which was a surprise," Ms. Mullen-Fortino said.

She and her associates then performed logistic regression analysis that was limited to ICU length of stay, APACHE score, use of mechanical ventilation, and use of vasopressors. The Braden score was excluded "because that’s a predictive model for skin integrity, not really for severity of illness," she explained. In this analysis, only use of mechanical ventilation and vasopressors were significantly associated with the development of pressure ulcers (odds ratios of 4.55 and 2.17, respectively).

Next, the researchers intend to prospectively examine the cohort using the Sequential Organ Failure Assessment, which quantifies the severity of the patient’s illness based on the degree of organ dysfunction serially over time, "as opposed to the APACHE score, which provides you severity of illness on admission," Ms. Mullen-Fortino said. "We’re hoping to see if the progression of the severity of illness correlates with the development of pressure ulcers. The compilation of this evidence will hopefully serve to inform future policy."

In 2007, she said, more than 250,000 hospitalized patients were reported to have stage 3 and 4 pressure ulcers. The cost of treatment is about $43,000 per pressure ulcer, and the condition demands "a tremendous amount of nursing resources and time," she said.

Ms. Mullen-Fortino said that she had no relevant financial conflicts to disclose.

SAN DIEGO – The development of hospital-acquired pressure ulcers may be unavoidable in patients who present with respiratory and hemodynamic medical problems that impede optimal oxygenation to tissues, results from a study of more than 800 patients showed.

The findings challenge the position of the Centers for Medicaid and Medicare Services that pressure ulcers in this setting are a so-called "never event," Margaret Mullen-Fortino, R.N., said at the annual congress of the Society of Critical Care Medicine.

"They are categorized as a never event because it’s believed that these are reasonably preventable through the application of evidence-based guidelines," said Ms. Mullen-Fortino, operations director of the surgical/trauma ICU at the Hospital of the University of Pennsylvania, Philadelphia. "The evidence-based guidelines include the acronym SKIN, with the S standing for surface selection such as low-air-pressure mattresses. The K stands for keep turning patients, the I stands for incontinence management, and the N stands for nutrition – making sure that patients are adequately nourished with enough protein."

However, she continued, "There is a large population of practitioners who believe that pressure ulcers are not a never event, that there are comorbidities that increase the chances of patients developing pressure ulcers. Much like a patient experiences a myocardial infarction because blood does not get to the heart muscle, we believe that pressure ulcers develop because adequate blood supply does not get to the skin, which is the largest organ in the body. Our hypothesis is that there is an association between the severity of illness and the development of pressure ulcers."

To test this hypothesis, Ms. Mullen-Fortino and her associates conducted a prospective cohort study of 824 patients who were admitted to the 20-bed surgical/trauma ICU at the Hospital of the University of Pennsylvania and to the 20-bed medical ICU at the Christ Hospital, Cincinnati, between Dec. 15, 2009, and Dec. 12, 2010. Variables assessed included age, length of stay, APACHE score, Braden score, readmission, and use of mechanical ventilation and vasopressors.

Ms. Mullen-Fortino reported that of the 824 patients studied, 221 (26.8%) developed pressure ulcers. Of these patients, 144 (65.1%) were ventilated and 67 (30.3%) required vasopressor support.

Among the entire study population, the median APACHE score was 74, with a range of 26-153. The median length of stay was 2 days, with a range of 1-91 days; the median Braden score was 14, with a range of 7-20; and the median patient age was 63 years.

All of the variables studied had a statistically significant association with the development of pressure ulcers with the exception of the use of vasopressors, "which was a surprise," Ms. Mullen-Fortino said.

She and her associates then performed logistic regression analysis that was limited to ICU length of stay, APACHE score, use of mechanical ventilation, and use of vasopressors. The Braden score was excluded "because that’s a predictive model for skin integrity, not really for severity of illness," she explained. In this analysis, only use of mechanical ventilation and vasopressors were significantly associated with the development of pressure ulcers (odds ratios of 4.55 and 2.17, respectively).

Next, the researchers intend to prospectively examine the cohort using the Sequential Organ Failure Assessment, which quantifies the severity of the patient’s illness based on the degree of organ dysfunction serially over time, "as opposed to the APACHE score, which provides you severity of illness on admission," Ms. Mullen-Fortino said. "We’re hoping to see if the progression of the severity of illness correlates with the development of pressure ulcers. The compilation of this evidence will hopefully serve to inform future policy."

In 2007, she said, more than 250,000 hospitalized patients were reported to have stage 3 and 4 pressure ulcers. The cost of treatment is about $43,000 per pressure ulcer, and the condition demands "a tremendous amount of nursing resources and time," she said.

Ms. Mullen-Fortino said that she had no relevant financial conflicts to disclose.

SAN DIEGO – The development of hospital-acquired pressure ulcers may be unavoidable in patients who present with respiratory and hemodynamic medical problems that impede optimal oxygenation to tissues, results from a study of more than 800 patients showed.

The findings challenge the position of the Centers for Medicaid and Medicare Services that pressure ulcers in this setting are a so-called "never event," Margaret Mullen-Fortino, R.N., said at the annual congress of the Society of Critical Care Medicine.

"They are categorized as a never event because it’s believed that these are reasonably preventable through the application of evidence-based guidelines," said Ms. Mullen-Fortino, operations director of the surgical/trauma ICU at the Hospital of the University of Pennsylvania, Philadelphia. "The evidence-based guidelines include the acronym SKIN, with the S standing for surface selection such as low-air-pressure mattresses. The K stands for keep turning patients, the I stands for incontinence management, and the N stands for nutrition – making sure that patients are adequately nourished with enough protein."

However, she continued, "There is a large population of practitioners who believe that pressure ulcers are not a never event, that there are comorbidities that increase the chances of patients developing pressure ulcers. Much like a patient experiences a myocardial infarction because blood does not get to the heart muscle, we believe that pressure ulcers develop because adequate blood supply does not get to the skin, which is the largest organ in the body. Our hypothesis is that there is an association between the severity of illness and the development of pressure ulcers."

To test this hypothesis, Ms. Mullen-Fortino and her associates conducted a prospective cohort study of 824 patients who were admitted to the 20-bed surgical/trauma ICU at the Hospital of the University of Pennsylvania and to the 20-bed medical ICU at the Christ Hospital, Cincinnati, between Dec. 15, 2009, and Dec. 12, 2010. Variables assessed included age, length of stay, APACHE score, Braden score, readmission, and use of mechanical ventilation and vasopressors.

Ms. Mullen-Fortino reported that of the 824 patients studied, 221 (26.8%) developed pressure ulcers. Of these patients, 144 (65.1%) were ventilated and 67 (30.3%) required vasopressor support.

Among the entire study population, the median APACHE score was 74, with a range of 26-153. The median length of stay was 2 days, with a range of 1-91 days; the median Braden score was 14, with a range of 7-20; and the median patient age was 63 years.

All of the variables studied had a statistically significant association with the development of pressure ulcers with the exception of the use of vasopressors, "which was a surprise," Ms. Mullen-Fortino said.

She and her associates then performed logistic regression analysis that was limited to ICU length of stay, APACHE score, use of mechanical ventilation, and use of vasopressors. The Braden score was excluded "because that’s a predictive model for skin integrity, not really for severity of illness," she explained. In this analysis, only use of mechanical ventilation and vasopressors were significantly associated with the development of pressure ulcers (odds ratios of 4.55 and 2.17, respectively).

Next, the researchers intend to prospectively examine the cohort using the Sequential Organ Failure Assessment, which quantifies the severity of the patient’s illness based on the degree of organ dysfunction serially over time, "as opposed to the APACHE score, which provides you severity of illness on admission," Ms. Mullen-Fortino said. "We’re hoping to see if the progression of the severity of illness correlates with the development of pressure ulcers. The compilation of this evidence will hopefully serve to inform future policy."

In 2007, she said, more than 250,000 hospitalized patients were reported to have stage 3 and 4 pressure ulcers. The cost of treatment is about $43,000 per pressure ulcer, and the condition demands "a tremendous amount of nursing resources and time," she said.

Ms. Mullen-Fortino said that she had no relevant financial conflicts to disclose.

SAN DIEGO – The development of hospital-acquired pressure ulcers may be unavoidable in patients who present with respiratory and hemodynamic medical problems that impede optimal oxygenation to tissues, results from a study of more than 800 patients showed.

The findings challenge the position of the Centers for Medicaid and Medicare Services that pressure ulcers in this setting are a so-called "never event," Margaret Mullen-Fortino, R.N., said at the annual congress of the Society of Critical Care Medicine.

"They are categorized as a never event because it’s believed that these are reasonably preventable through the application of evidence-based guidelines," said Ms. Mullen-Fortino, operations director of the surgical/trauma ICU at the Hospital of the University of Pennsylvania, Philadelphia. "The evidence-based guidelines include the acronym SKIN, with the S standing for surface selection such as low-air-pressure mattresses. The K stands for keep turning patients, the I stands for incontinence management, and the N stands for nutrition – making sure that patients are adequately nourished with enough protein."

However, she continued, "There is a large population of practitioners who believe that pressure ulcers are not a never event, that there are comorbidities that increase the chances of patients developing pressure ulcers. Much like a patient experiences a myocardial infarction because blood does not get to the heart muscle, we believe that pressure ulcers develop because adequate blood supply does not get to the skin, which is the largest organ in the body. Our hypothesis is that there is an association between the severity of illness and the development of pressure ulcers."

To test this hypothesis, Ms. Mullen-Fortino and her associates conducted a prospective cohort study of 824 patients who were admitted to the 20-bed surgical/trauma ICU at the Hospital of the University of Pennsylvania and to the 20-bed medical ICU at the Christ Hospital, Cincinnati, between Dec. 15, 2009, and Dec. 12, 2010. Variables assessed included age, length of stay, APACHE score, Braden score, readmission, and use of mechanical ventilation and vasopressors.

Ms. Mullen-Fortino reported that of the 824 patients studied, 221 (26.8%) developed pressure ulcers. Of these patients, 144 (65.1%) were ventilated and 67 (30.3%) required vasopressor support.

Among the entire study population, the median APACHE score was 74, with a range of 26-153. The median length of stay was 2 days, with a range of 1-91 days; the median Braden score was 14, with a range of 7-20; and the median patient age was 63 years.

All of the variables studied had a statistically significant association with the development of pressure ulcers with the exception of the use of vasopressors, "which was a surprise," Ms. Mullen-Fortino said.

She and her associates then performed logistic regression analysis that was limited to ICU length of stay, APACHE score, use of mechanical ventilation, and use of vasopressors. The Braden score was excluded "because that’s a predictive model for skin integrity, not really for severity of illness," she explained. In this analysis, only use of mechanical ventilation and vasopressors were significantly associated with the development of pressure ulcers (odds ratios of 4.55 and 2.17, respectively).

Next, the researchers intend to prospectively examine the cohort using the Sequential Organ Failure Assessment, which quantifies the severity of the patient’s illness based on the degree of organ dysfunction serially over time, "as opposed to the APACHE score, which provides you severity of illness on admission," Ms. Mullen-Fortino said. "We’re hoping to see if the progression of the severity of illness correlates with the development of pressure ulcers. The compilation of this evidence will hopefully serve to inform future policy."

In 2007, she said, more than 250,000 hospitalized patients were reported to have stage 3 and 4 pressure ulcers. The cost of treatment is about $43,000 per pressure ulcer, and the condition demands "a tremendous amount of nursing resources and time," she said.

Ms. Mullen-Fortino said that she had no relevant financial conflicts to disclose.

SAN DIEGO – The development of hospital-acquired pressure ulcers may be unavoidable in patients who present with respiratory and hemodynamic medical problems that impede optimal oxygenation to tissues, results from a study of more than 800 patients showed.

The findings challenge the position of the Centers for Medicaid and Medicare Services that pressure ulcers in this setting are a so-called "never event," Margaret Mullen-Fortino, R.N., said at the annual congress of the Society of Critical Care Medicine.

"They are categorized as a never event because it’s believed that these are reasonably preventable through the application of evidence-based guidelines," said Ms. Mullen-Fortino, operations director of the surgical/trauma ICU at the Hospital of the University of Pennsylvania, Philadelphia. "The evidence-based guidelines include the acronym SKIN, with the S standing for surface selection such as low-air-pressure mattresses. The K stands for keep turning patients, the I stands for incontinence management, and the N stands for nutrition – making sure that patients are adequately nourished with enough protein."

However, she continued, "There is a large population of practitioners who believe that pressure ulcers are not a never event, that there are comorbidities that increase the chances of patients developing pressure ulcers. Much like a patient experiences a myocardial infarction because blood does not get to the heart muscle, we believe that pressure ulcers develop because adequate blood supply does not get to the skin, which is the largest organ in the body. Our hypothesis is that there is an association between the severity of illness and the development of pressure ulcers."

To test this hypothesis, Ms. Mullen-Fortino and her associates conducted a prospective cohort study of 824 patients who were admitted to the 20-bed surgical/trauma ICU at the Hospital of the University of Pennsylvania and to the 20-bed medical ICU at the Christ Hospital, Cincinnati, between Dec. 15, 2009, and Dec. 12, 2010. Variables assessed included age, length of stay, APACHE score, Braden score, readmission, and use of mechanical ventilation and vasopressors.

Ms. Mullen-Fortino reported that of the 824 patients studied, 221 (26.8%) developed pressure ulcers. Of these patients, 144 (65.1%) were ventilated and 67 (30.3%) required vasopressor support.

Among the entire study population, the median APACHE score was 74, with a range of 26-153. The median length of stay was 2 days, with a range of 1-91 days; the median Braden score was 14, with a range of 7-20; and the median patient age was 63 years.

All of the variables studied had a statistically significant association with the development of pressure ulcers with the exception of the use of vasopressors, "which was a surprise," Ms. Mullen-Fortino said.

She and her associates then performed logistic regression analysis that was limited to ICU length of stay, APACHE score, use of mechanical ventilation, and use of vasopressors. The Braden score was excluded "because that’s a predictive model for skin integrity, not really for severity of illness," she explained. In this analysis, only use of mechanical ventilation and vasopressors were significantly associated with the development of pressure ulcers (odds ratios of 4.55 and 2.17, respectively).

Next, the researchers intend to prospectively examine the cohort using the Sequential Organ Failure Assessment, which quantifies the severity of the patient’s illness based on the degree of organ dysfunction serially over time, "as opposed to the APACHE score, which provides you severity of illness on admission," Ms. Mullen-Fortino said. "We’re hoping to see if the progression of the severity of illness correlates with the development of pressure ulcers. The compilation of this evidence will hopefully serve to inform future policy."

In 2007, she said, more than 250,000 hospitalized patients were reported to have stage 3 and 4 pressure ulcers. The cost of treatment is about $43,000 per pressure ulcer, and the condition demands "a tremendous amount of nursing resources and time," she said.

Ms. Mullen-Fortino said that she had no relevant financial conflicts to disclose.

SAN DIEGO – The development of hospital-acquired pressure ulcers may be unavoidable in patients who present with respiratory and hemodynamic medical problems that impede optimal oxygenation to tissues, results from a study of more than 800 patients showed.

The findings challenge the position of the Centers for Medicaid and Medicare Services that pressure ulcers in this setting are a so-called "never event," Margaret Mullen-Fortino, R.N., said at the annual congress of the Society of Critical Care Medicine.

"They are categorized as a never event because it’s believed that these are reasonably preventable through the application of evidence-based guidelines," said Ms. Mullen-Fortino, operations director of the surgical/trauma ICU at the Hospital of the University of Pennsylvania, Philadelphia. "The evidence-based guidelines include the acronym SKIN, with the S standing for surface selection such as low-air-pressure mattresses. The K stands for keep turning patients, the I stands for incontinence management, and the N stands for nutrition – making sure that patients are adequately nourished with enough protein."

However, she continued, "There is a large population of practitioners who believe that pressure ulcers are not a never event, that there are comorbidities that increase the chances of patients developing pressure ulcers. Much like a patient experiences a myocardial infarction because blood does not get to the heart muscle, we believe that pressure ulcers develop because adequate blood supply does not get to the skin, which is the largest organ in the body. Our hypothesis is that there is an association between the severity of illness and the development of pressure ulcers."

To test this hypothesis, Ms. Mullen-Fortino and her associates conducted a prospective cohort study of 824 patients who were admitted to the 20-bed surgical/trauma ICU at the Hospital of the University of Pennsylvania and to the 20-bed medical ICU at the Christ Hospital, Cincinnati, between Dec. 15, 2009, and Dec. 12, 2010. Variables assessed included age, length of stay, APACHE score, Braden score, readmission, and use of mechanical ventilation and vasopressors.

Ms. Mullen-Fortino reported that of the 824 patients studied, 221 (26.8%) developed pressure ulcers. Of these patients, 144 (65.1%) were ventilated and 67 (30.3%) required vasopressor support.

Among the entire study population, the median APACHE score was 74, with a range of 26-153. The median length of stay was 2 days, with a range of 1-91 days; the median Braden score was 14, with a range of 7-20; and the median patient age was 63 years.

All of the variables studied had a statistically significant association with the development of pressure ulcers with the exception of the use of vasopressors, "which was a surprise," Ms. Mullen-Fortino said.

She and her associates then performed logistic regression analysis that was limited to ICU length of stay, APACHE score, use of mechanical ventilation, and use of vasopressors. The Braden score was excluded "because that’s a predictive model for skin integrity, not really for severity of illness," she explained. In this analysis, only use of mechanical ventilation and vasopressors were significantly associated with the development of pressure ulcers (odds ratios of 4.55 and 2.17, respectively).

Next, the researchers intend to prospectively examine the cohort using the Sequential Organ Failure Assessment, which quantifies the severity of the patient’s illness based on the degree of organ dysfunction serially over time, "as opposed to the APACHE score, which provides you severity of illness on admission," Ms. Mullen-Fortino said. "We’re hoping to see if the progression of the severity of illness correlates with the development of pressure ulcers. The compilation of this evidence will hopefully serve to inform future policy."

In 2007, she said, more than 250,000 hospitalized patients were reported to have stage 3 and 4 pressure ulcers. The cost of treatment is about $43,000 per pressure ulcer, and the condition demands "a tremendous amount of nursing resources and time," she said.

Ms. Mullen-Fortino said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Antimicrobial resistance continues to be a significant problem, but a few new agents have shown promise against certain pathogens.

"As clinicians, we need to look forward to new drug discovery and development, and keep an eye on the current pipeline," April D. Miller, Pharm. D., said at the annual congress of the Society of Critical Care Medicine. "We also need to think of and study new and unique strategies to preserve the agents that we currently have available."

The problem of antimicrobial resistance "lies in the bugs themselves," said Dr. Miller of the South Carolina College of Pharmacy at the University of South Carolina, Columbia. Among gram-positive organisms, she said, there are rising rates of community- and hospital-acquired methicillin-resistant Staphylococcus aureus and rising minimum inhibitory concentrations to vancomycin. There are also increasing rates of vancomycin-resistant Enterococci, and reports about the possibility of linezolid-resistant Enterococci. In addition, she said, "increases in the rate of Streptococcus pneumoniae resistance can impact ICU clinicians as patients come in from the community with resistant organisms because of inadequately treated infections."

Among gram-negative organisms, increases in Acinetobacter baumannii, Enterobacteriaceae-producing carbapenemases, and Escherichia coli–producing extended-spectrum beta-lactamases have been reported. "Along with the bugs themselves, we also have new mechanisms of resistance," she continued. "The bugs are getting smarter. These include emergence of aminoglycoside 16S ribosomal RNA methylation and New Delhi metallo-beta-lactamase."

In the perfect world, Dr. Miller said, "we could match up all of these bugs with new agents. It doesn’t work that way, unfortunately. We’re all aware of the issue of the lack of available agents on the market or in the pipeline to be developed."

This prompted the Infectious Diseases Society of America to launch an initiative in 2010 calling for the development of 10 new antibiotics by the year 2020. One of those new agents is telavancin, a lipoglycopeptide from Theravance that was approved in September 2009 for complicated skin and skin-structure infections and is currently marketed under the brand name Vibativ. Two other lipoglycopeptides, dalbavancin and oritavancin, are not currently available and continue to be studied.

Newer lipoglycopeptides influence cell membrane potential in addition to inhibiting cell wall synthesis by preventing polymerization and cross-linking of the cell wall, Dr. Miller said. They also feature increased protein binding. "While there are not a lot of data on what this means clinically, they do have the ability to affect their penetration into various body sites," she explained. "These new mechanisms and new binding sites afford us additional and expanded spectrums of activity."

Lipoglycopeptides also have unique pharmacokinetics compared with currently available agents. For example, the half-life of vancomycin is 6-12 hours, while that of telavancin is 7.5 hours. Both oritavancin and dalbavancin have a half-life of about 195 hours. "In clinical studies, the manufacturers are exploring once-weekly or twice-weekly dosing [of oritavancin and dalbavancin], which would be of tremendous benefit for outpatients," Dr. Miller commented. "But for ICU patients we think about the possibility of adverse reactions or dosing issues as renal function changes. That could be a real problem because of the prolonged elimination."

The phase III trial of telavancin for complicated skin and skin-structure infections found that a dose of 10 mg/kg IV daily was as effective as vancomycin 1 g IV every 12 hours (Clin. Infect. Dis. 2008;46:1683-93).

Two phase II trials of telavancin for hospital-acquired pneumonia found that a dose of 10 mg/kg IV daily was not inferior to vancomycin 1,000 mg daily. The unpublished studies involved 1,503 patients and "were good enough for FDA approval, but leave us with some lingering questions about how telavancin compares to vancomycin for hospital-acquired pneumonia," Dr. Miller said.

Among all three telavancin studies combined, a higher proportion of patients in the telavancin group experienced a 1.5-fold increase of serum creatinine from baseline, compared with their counterparts in the vancomycin group (15% vs. 7%, respectively). The proportion of adverse renal events was also higher in the telavancin group (3.1% vs. 1.1%).

Dr. Miller next discussed ceftaroline, a fourth-generation cephalosporin approved in October 2010 for acute skin and skin-structure infections as well as for community-acquired bacterial pneumonia. The drug is expected to be on the market soon under the brand name Teflaro (Forest Laboratories).

"Its spectrum of activity is quite different from that of the other cephalosporins, such that it retains activity against methicillin-susceptible Staphylococcus aureus isolates as well as isolates that are resistant to vancomycin," Dr. Miller said. "It has very good activity against Streptococcus pneumoniae, and like other cephalosporins it has minimal activity against Enterococci. It retains activity against Moraxella catarrhalis and Haemophilus influenzae, which we think about as common pathogens in community-acquired pneumonia. It has some activity against Klebsiella species, but unfortunately it doesn’t have any activity against extended-spectrum beta-lactamase producers or Pseudomonas species. So when we think about empiric coverage, there are definitely some holes with ceftaroline."

The recommended dosing of ceftaroline is 600 mg IV every 12 hours. The half-life is 1.6 hours for single doses and 2.66 hours for multiple doses.

Two phase III studies comparing ceftaroline with ceftriaxone in the treatment of community-acquired pneumonia were presented during the 2009 meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy. The studies demonstrated higher cure rates for patients in the ceftaroline group, compared with those in the ceftriaxone group (83% vs. 77%, respectively, among all study participants, and 86% vs. 69% among patients with S. pneumoniae).

Another strategy for combating antibiotic resistance involves improving ways to use available antibiotics on the market. Dr. Miller said that there are eight National Institutes of Health–funded trials aimed at this approach, including short-course therapy, narrow-spectrum therapies, combination vs. monotherapy, and pharmacodynamic dosing guidance.

Dr. Miller said that she had no relevant financial disclosures to make.

SAN DIEGO – Antimicrobial resistance continues to be a significant problem, but a few new agents have shown promise against certain pathogens.

"As clinicians, we need to look forward to new drug discovery and development, and keep an eye on the current pipeline," April D. Miller, Pharm. D., said at the annual congress of the Society of Critical Care Medicine. "We also need to think of and study new and unique strategies to preserve the agents that we currently have available."

The problem of antimicrobial resistance "lies in the bugs themselves," said Dr. Miller of the South Carolina College of Pharmacy at the University of South Carolina, Columbia. Among gram-positive organisms, she said, there are rising rates of community- and hospital-acquired methicillin-resistant Staphylococcus aureus and rising minimum inhibitory concentrations to vancomycin. There are also increasing rates of vancomycin-resistant Enterococci, and reports about the possibility of linezolid-resistant Enterococci. In addition, she said, "increases in the rate of Streptococcus pneumoniae resistance can impact ICU clinicians as patients come in from the community with resistant organisms because of inadequately treated infections."

Among gram-negative organisms, increases in Acinetobacter baumannii, Enterobacteriaceae-producing carbapenemases, and Escherichia coli–producing extended-spectrum beta-lactamases have been reported. "Along with the bugs themselves, we also have new mechanisms of resistance," she continued. "The bugs are getting smarter. These include emergence of aminoglycoside 16S ribosomal RNA methylation and New Delhi metallo-beta-lactamase."

In the perfect world, Dr. Miller said, "we could match up all of these bugs with new agents. It doesn’t work that way, unfortunately. We’re all aware of the issue of the lack of available agents on the market or in the pipeline to be developed."

This prompted the Infectious Diseases Society of America to launch an initiative in 2010 calling for the development of 10 new antibiotics by the year 2020. One of those new agents is telavancin, a lipoglycopeptide from Theravance that was approved in September 2009 for complicated skin and skin-structure infections and is currently marketed under the brand name Vibativ. Two other lipoglycopeptides, dalbavancin and oritavancin, are not currently available and continue to be studied.

Newer lipoglycopeptides influence cell membrane potential in addition to inhibiting cell wall synthesis by preventing polymerization and cross-linking of the cell wall, Dr. Miller said. They also feature increased protein binding. "While there are not a lot of data on what this means clinically, they do have the ability to affect their penetration into various body sites," she explained. "These new mechanisms and new binding sites afford us additional and expanded spectrums of activity."

Lipoglycopeptides also have unique pharmacokinetics compared with currently available agents. For example, the half-life of vancomycin is 6-12 hours, while that of telavancin is 7.5 hours. Both oritavancin and dalbavancin have a half-life of about 195 hours. "In clinical studies, the manufacturers are exploring once-weekly or twice-weekly dosing [of oritavancin and dalbavancin], which would be of tremendous benefit for outpatients," Dr. Miller commented. "But for ICU patients we think about the possibility of adverse reactions or dosing issues as renal function changes. That could be a real problem because of the prolonged elimination."

The phase III trial of telavancin for complicated skin and skin-structure infections found that a dose of 10 mg/kg IV daily was as effective as vancomycin 1 g IV every 12 hours (Clin. Infect. Dis. 2008;46:1683-93).

Two phase II trials of telavancin for hospital-acquired pneumonia found that a dose of 10 mg/kg IV daily was not inferior to vancomycin 1,000 mg daily. The unpublished studies involved 1,503 patients and "were good enough for FDA approval, but leave us with some lingering questions about how telavancin compares to vancomycin for hospital-acquired pneumonia," Dr. Miller said.

Among all three telavancin studies combined, a higher proportion of patients in the telavancin group experienced a 1.5-fold increase of serum creatinine from baseline, compared with their counterparts in the vancomycin group (15% vs. 7%, respectively). The proportion of adverse renal events was also higher in the telavancin group (3.1% vs. 1.1%).

Dr. Miller next discussed ceftaroline, a fourth-generation cephalosporin approved in October 2010 for acute skin and skin-structure infections as well as for community-acquired bacterial pneumonia. The drug is expected to be on the market soon under the brand name Teflaro (Forest Laboratories).

"Its spectrum of activity is quite different from that of the other cephalosporins, such that it retains activity against methicillin-susceptible Staphylococcus aureus isolates as well as isolates that are resistant to vancomycin," Dr. Miller said. "It has very good activity against Streptococcus pneumoniae, and like other cephalosporins it has minimal activity against Enterococci. It retains activity against Moraxella catarrhalis and Haemophilus influenzae, which we think about as common pathogens in community-acquired pneumonia. It has some activity against Klebsiella species, but unfortunately it doesn’t have any activity against extended-spectrum beta-lactamase producers or Pseudomonas species. So when we think about empiric coverage, there are definitely some holes with ceftaroline."

The recommended dosing of ceftaroline is 600 mg IV every 12 hours. The half-life is 1.6 hours for single doses and 2.66 hours for multiple doses.

Two phase III studies comparing ceftaroline with ceftriaxone in the treatment of community-acquired pneumonia were presented during the 2009 meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy. The studies demonstrated higher cure rates for patients in the ceftaroline group, compared with those in the ceftriaxone group (83% vs. 77%, respectively, among all study participants, and 86% vs. 69% among patients with S. pneumoniae).

Another strategy for combating antibiotic resistance involves improving ways to use available antibiotics on the market. Dr. Miller said that there are eight National Institutes of Health–funded trials aimed at this approach, including short-course therapy, narrow-spectrum therapies, combination vs. monotherapy, and pharmacodynamic dosing guidance.

Dr. Miller said that she had no relevant financial disclosures to make.

SAN DIEGO – Antimicrobial resistance continues to be a significant problem, but a few new agents have shown promise against certain pathogens.

"As clinicians, we need to look forward to new drug discovery and development, and keep an eye on the current pipeline," April D. Miller, Pharm. D., said at the annual congress of the Society of Critical Care Medicine. "We also need to think of and study new and unique strategies to preserve the agents that we currently have available."

The problem of antimicrobial resistance "lies in the bugs themselves," said Dr. Miller of the South Carolina College of Pharmacy at the University of South Carolina, Columbia. Among gram-positive organisms, she said, there are rising rates of community- and hospital-acquired methicillin-resistant Staphylococcus aureus and rising minimum inhibitory concentrations to vancomycin. There are also increasing rates of vancomycin-resistant Enterococci, and reports about the possibility of linezolid-resistant Enterococci. In addition, she said, "increases in the rate of Streptococcus pneumoniae resistance can impact ICU clinicians as patients come in from the community with resistant organisms because of inadequately treated infections."

Among gram-negative organisms, increases in Acinetobacter baumannii, Enterobacteriaceae-producing carbapenemases, and Escherichia coli–producing extended-spectrum beta-lactamases have been reported. "Along with the bugs themselves, we also have new mechanisms of resistance," she continued. "The bugs are getting smarter. These include emergence of aminoglycoside 16S ribosomal RNA methylation and New Delhi metallo-beta-lactamase."

In the perfect world, Dr. Miller said, "we could match up all of these bugs with new agents. It doesn’t work that way, unfortunately. We’re all aware of the issue of the lack of available agents on the market or in the pipeline to be developed."

This prompted the Infectious Diseases Society of America to launch an initiative in 2010 calling for the development of 10 new antibiotics by the year 2020. One of those new agents is telavancin, a lipoglycopeptide from Theravance that was approved in September 2009 for complicated skin and skin-structure infections and is currently marketed under the brand name Vibativ. Two other lipoglycopeptides, dalbavancin and oritavancin, are not currently available and continue to be studied.

Newer lipoglycopeptides influence cell membrane potential in addition to inhibiting cell wall synthesis by preventing polymerization and cross-linking of the cell wall, Dr. Miller said. They also feature increased protein binding. "While there are not a lot of data on what this means clinically, they do have the ability to affect their penetration into various body sites," she explained. "These new mechanisms and new binding sites afford us additional and expanded spectrums of activity."

Lipoglycopeptides also have unique pharmacokinetics compared with currently available agents. For example, the half-life of vancomycin is 6-12 hours, while that of telavancin is 7.5 hours. Both oritavancin and dalbavancin have a half-life of about 195 hours. "In clinical studies, the manufacturers are exploring once-weekly or twice-weekly dosing [of oritavancin and dalbavancin], which would be of tremendous benefit for outpatients," Dr. Miller commented. "But for ICU patients we think about the possibility of adverse reactions or dosing issues as renal function changes. That could be a real problem because of the prolonged elimination."

The phase III trial of telavancin for complicated skin and skin-structure infections found that a dose of 10 mg/kg IV daily was as effective as vancomycin 1 g IV every 12 hours (Clin. Infect. Dis. 2008;46:1683-93).

Two phase II trials of telavancin for hospital-acquired pneumonia found that a dose of 10 mg/kg IV daily was not inferior to vancomycin 1,000 mg daily. The unpublished studies involved 1,503 patients and "were good enough for FDA approval, but leave us with some lingering questions about how telavancin compares to vancomycin for hospital-acquired pneumonia," Dr. Miller said.

Among all three telavancin studies combined, a higher proportion of patients in the telavancin group experienced a 1.5-fold increase of serum creatinine from baseline, compared with their counterparts in the vancomycin group (15% vs. 7%, respectively). The proportion of adverse renal events was also higher in the telavancin group (3.1% vs. 1.1%).

Dr. Miller next discussed ceftaroline, a fourth-generation cephalosporin approved in October 2010 for acute skin and skin-structure infections as well as for community-acquired bacterial pneumonia. The drug is expected to be on the market soon under the brand name Teflaro (Forest Laboratories).

"Its spectrum of activity is quite different from that of the other cephalosporins, such that it retains activity against methicillin-susceptible Staphylococcus aureus isolates as well as isolates that are resistant to vancomycin," Dr. Miller said. "It has very good activity against Streptococcus pneumoniae, and like other cephalosporins it has minimal activity against Enterococci. It retains activity against Moraxella catarrhalis and Haemophilus influenzae, which we think about as common pathogens in community-acquired pneumonia. It has some activity against Klebsiella species, but unfortunately it doesn’t have any activity against extended-spectrum beta-lactamase producers or Pseudomonas species. So when we think about empiric coverage, there are definitely some holes with ceftaroline."

The recommended dosing of ceftaroline is 600 mg IV every 12 hours. The half-life is 1.6 hours for single doses and 2.66 hours for multiple doses.

Two phase III studies comparing ceftaroline with ceftriaxone in the treatment of community-acquired pneumonia were presented during the 2009 meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy. The studies demonstrated higher cure rates for patients in the ceftaroline group, compared with those in the ceftriaxone group (83% vs. 77%, respectively, among all study participants, and 86% vs. 69% among patients with S. pneumoniae).

Another strategy for combating antibiotic resistance involves improving ways to use available antibiotics on the market. Dr. Miller said that there are eight National Institutes of Health–funded trials aimed at this approach, including short-course therapy, narrow-spectrum therapies, combination vs. monotherapy, and pharmacodynamic dosing guidance.

Dr. Miller said that she had no relevant financial disclosures to make.

SAN DIEGO – Antimicrobial resistance continues to be a significant problem, but a few new agents have shown promise against certain pathogens.

"As clinicians, we need to look forward to new drug discovery and development, and keep an eye on the current pipeline," April D. Miller, Pharm. D., said at the annual congress of the Society of Critical Care Medicine. "We also need to think of and study new and unique strategies to preserve the agents that we currently have available."

The problem of antimicrobial resistance "lies in the bugs themselves," said Dr. Miller of the South Carolina College of Pharmacy at the University of South Carolina, Columbia. Among gram-positive organisms, she said, there are rising rates of community- and hospital-acquired methicillin-resistant Staphylococcus aureus and rising minimum inhibitory concentrations to vancomycin. There are also increasing rates of vancomycin-resistant Enterococci, and reports about the possibility of linezolid-resistant Enterococci. In addition, she said, "increases in the rate of Streptococcus pneumoniae resistance can impact ICU clinicians as patients come in from the community with resistant organisms because of inadequately treated infections."

Among gram-negative organisms, increases in Acinetobacter baumannii, Enterobacteriaceae-producing carbapenemases, and Escherichia coli–producing extended-spectrum beta-lactamases have been reported. "Along with the bugs themselves, we also have new mechanisms of resistance," she continued. "The bugs are getting smarter. These include emergence of aminoglycoside 16S ribosomal RNA methylation and New Delhi metallo-beta-lactamase."

In the perfect world, Dr. Miller said, "we could match up all of these bugs with new agents. It doesn't work that way, unfortunately. We're all aware of the issue of the lack of available agents on the market or in the pipeline to be developed."

This prompted the Infectious Diseases Society of America to launch an initiative in 2010 calling for the development of 10 new antibiotics by the year 2020. One of those new agents is telavancin, a lipoglycopeptide from Theravance that was approved in September 2009 for complicated skin and skin-structure infections and is currently marketed under the brand name Vibativ. Two other lipoglycopeptides, dalbavancin and oritavancin, are not currently available and continue to be studied.

Newer lipoglycopeptides influence cell membrane potential in addition to inhibiting cell wall synthesis by preventing polymerization and cross-linking of the cell wall, Dr. Miller said. They also feature increased protein binding. "While there are not a lot of data on what this means clinically, they do have the ability to affect their penetration into various body sites," she explained. "These new mechanisms and new binding sites afford us additional and expanded spectrums of activity."

Lipoglycopeptides also have unique pharmacokinetics compared with currently available agents. For example, the half-life of vancomycin is 6-12 hours, while that of telavancin is 7.5 hours. Both oritavancin and dalbavancin have a half-life of about 195 hours. "In clinical studies, the manufacturers are exploring once-weekly or twice-weekly dosing [of oritavancin and dalbavancin], which would be of tremendous benefit for outpatients," Dr. Miller commented. "But for ICU patients we think about the possibility of adverse reactions or dosing issues as renal function changes. That could be a real problem because of the prolonged elimination."

The phase III trial of telavancin for complicated skin and skin-structure infections found that a dose of 10 mg/kg IV daily was as effective as vancomycin 1 g IV every 12 hours (Clin. Infect. Dis. 2008;46:1683-93).

Two phase II trials of telavancin for hospital-acquired pneumonia found that a dose of 10 mg/kg IV daily was not inferior to vancomycin 1,000 mg daily. The unpublished studies involved 1,503 patients and "were good enough for FDA approval, but leave us with some lingering questions about how telavancin compares to vancomycin for hospital-acquired pneumonia," Dr. Miller said.

Among all three telavancin studies combined, a higher proportion of patients in the telavancin group experienced a 1.5-fold increase of serum creatinine from baseline, compared with their counterparts in the vancomycin group (15% vs. 7%, respectively). The proportion of adverse renal events was also higher in the telavancin group (3.1% vs. 1.1%).

Dr. Miller next discussed ceftaroline, a fourth-generation cephalosporin approved in October 2010 for acute skin and skin-structure infections as well as for community-acquired bacterial pneumonia. The drug is expected to be on the market soon under the brand name Teflaro (Forest Laboratories).

"Its spectrum of activity is quite different from that of the other cephalosporins, such that it retains activity against methicillin-susceptible Staphylococcus aureus isolates as well as isolates that are resistant to vancomycin," Dr. Miller said. "It has very good activity against Streptococcus pneumoniae, and like other cephalosporins it has minimal activity against Enterococci. It retains activity against Moraxella catarrhalis and Haemophilus influenzae, which we think about as common pathogens in community-acquired pneumonia. It has some activity against Klebsiella species, but unfortunately it doesn’t have any activity against extended-spectrum beta-lactamase producers or Pseudomonas species. So when we think about empiric coverage, there are definitely some holes with ceftaroline."

The recommended dosing of ceftaroline is 600 mg IV every 12 hours. The half-life is 1.6 hours for single doses and 2.66 hours for multiple doses.

Two phase III studies comparing ceftaroline with ceftriaxone in the treatment of community-acquired pneumonia were presented during the 2009 meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy. The studies demonstrated higher cure rates for patients in the ceftaroline group, compared with those in the ceftriaxone group (83% vs. 77%, respectively, among all study participants, and 86% vs. 69% among patients with S. pneumoniae).

Another strategy for combating antibiotic resistance involves improving ways to use available antibiotics on the market. Dr. Miller said that there are eight National Institutes of Health–funded trials aimed at this approach, including short-course therapy, narrow-spectrum therapies, combination vs. monotherapy, and pharmacodynamic dosing guidance.

Dr. Miller said that she had no relevant financial disclosures to make.

SAN DIEGO – Antimicrobial resistance continues to be a significant problem, but a few new agents have shown promise against certain pathogens.

"As clinicians, we need to look forward to new drug discovery and development, and keep an eye on the current pipeline," April D. Miller, Pharm. D., said at the annual congress of the Society of Critical Care Medicine. "We also need to think of and study new and unique strategies to preserve the agents that we currently have available."

The problem of antimicrobial resistance "lies in the bugs themselves," said Dr. Miller of the South Carolina College of Pharmacy at the University of South Carolina, Columbia. Among gram-positive organisms, she said, there are rising rates of community- and hospital-acquired methicillin-resistant Staphylococcus aureus and rising minimum inhibitory concentrations to vancomycin. There are also increasing rates of vancomycin-resistant Enterococci, and reports about the possibility of linezolid-resistant Enterococci. In addition, she said, "increases in the rate of Streptococcus pneumoniae resistance can impact ICU clinicians as patients come in from the community with resistant organisms because of inadequately treated infections."

Among gram-negative organisms, increases in Acinetobacter baumannii, Enterobacteriaceae-producing carbapenemases, and Escherichia coli–producing extended-spectrum beta-lactamases have been reported. "Along with the bugs themselves, we also have new mechanisms of resistance," she continued. "The bugs are getting smarter. These include emergence of aminoglycoside 16S ribosomal RNA methylation and New Delhi metallo-beta-lactamase."

In the perfect world, Dr. Miller said, "we could match up all of these bugs with new agents. It doesn't work that way, unfortunately. We're all aware of the issue of the lack of available agents on the market or in the pipeline to be developed."

This prompted the Infectious Diseases Society of America to launch an initiative in 2010 calling for the development of 10 new antibiotics by the year 2020. One of those new agents is telavancin, a lipoglycopeptide from Theravance that was approved in September 2009 for complicated skin and skin-structure infections and is currently marketed under the brand name Vibativ. Two other lipoglycopeptides, dalbavancin and oritavancin, are not currently available and continue to be studied.

Newer lipoglycopeptides influence cell membrane potential in addition to inhibiting cell wall synthesis by preventing polymerization and cross-linking of the cell wall, Dr. Miller said. They also feature increased protein binding. "While there are not a lot of data on what this means clinically, they do have the ability to affect their penetration into various body sites," she explained. "These new mechanisms and new binding sites afford us additional and expanded spectrums of activity."

Lipoglycopeptides also have unique pharmacokinetics compared with currently available agents. For example, the half-life of vancomycin is 6-12 hours, while that of telavancin is 7.5 hours. Both oritavancin and dalbavancin have a half-life of about 195 hours. "In clinical studies, the manufacturers are exploring once-weekly or twice-weekly dosing [of oritavancin and dalbavancin], which would be of tremendous benefit for outpatients," Dr. Miller commented. "But for ICU patients we think about the possibility of adverse reactions or dosing issues as renal function changes. That could be a real problem because of the prolonged elimination."

The phase III trial of telavancin for complicated skin and skin-structure infections found that a dose of 10 mg/kg IV daily was as effective as vancomycin 1 g IV every 12 hours (Clin. Infect. Dis. 2008;46:1683-93).

Two phase II trials of telavancin for hospital-acquired pneumonia found that a dose of 10 mg/kg IV daily was not inferior to vancomycin 1,000 mg daily. The unpublished studies involved 1,503 patients and "were good enough for FDA approval, but leave us with some lingering questions about how telavancin compares to vancomycin for hospital-acquired pneumonia," Dr. Miller said.

Among all three telavancin studies combined, a higher proportion of patients in the telavancin group experienced a 1.5-fold increase of serum creatinine from baseline, compared with their counterparts in the vancomycin group (15% vs. 7%, respectively). The proportion of adverse renal events was also higher in the telavancin group (3.1% vs. 1.1%).

Dr. Miller next discussed ceftaroline, a fourth-generation cephalosporin approved in October 2010 for acute skin and skin-structure infections as well as for community-acquired bacterial pneumonia. The drug is expected to be on the market soon under the brand name Teflaro (Forest Laboratories).

"Its spectrum of activity is quite different from that of the other cephalosporins, such that it retains activity against methicillin-susceptible Staphylococcus aureus isolates as well as isolates that are resistant to vancomycin," Dr. Miller said. "It has very good activity against Streptococcus pneumoniae, and like other cephalosporins it has minimal activity against Enterococci. It retains activity against Moraxella catarrhalis and Haemophilus influenzae, which we think about as common pathogens in community-acquired pneumonia. It has some activity against Klebsiella species, but unfortunately it doesn’t have any activity against extended-spectrum beta-lactamase producers or Pseudomonas species. So when we think about empiric coverage, there are definitely some holes with ceftaroline."

The recommended dosing of ceftaroline is 600 mg IV every 12 hours. The half-life is 1.6 hours for single doses and 2.66 hours for multiple doses.

Two phase III studies comparing ceftaroline with ceftriaxone in the treatment of community-acquired pneumonia were presented during the 2009 meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy. The studies demonstrated higher cure rates for patients in the ceftaroline group, compared with those in the ceftriaxone group (83% vs. 77%, respectively, among all study participants, and 86% vs. 69% among patients with S. pneumoniae).

Another strategy for combating antibiotic resistance involves improving ways to use available antibiotics on the market. Dr. Miller said that there are eight National Institutes of Health–funded trials aimed at this approach, including short-course therapy, narrow-spectrum therapies, combination vs. monotherapy, and pharmacodynamic dosing guidance.

Dr. Miller said that she had no relevant financial disclosures to make.

SAN DIEGO – Antimicrobial resistance continues to be a significant problem, but a few new agents have shown promise against certain pathogens.

"As clinicians, we need to look forward to new drug discovery and development, and keep an eye on the current pipeline," April D. Miller, Pharm. D., said at the annual congress of the Society of Critical Care Medicine. "We also need to think of and study new and unique strategies to preserve the agents that we currently have available."

The problem of antimicrobial resistance "lies in the bugs themselves," said Dr. Miller of the South Carolina College of Pharmacy at the University of South Carolina, Columbia. Among gram-positive organisms, she said, there are rising rates of community- and hospital-acquired methicillin-resistant Staphylococcus aureus and rising minimum inhibitory concentrations to vancomycin. There are also increasing rates of vancomycin-resistant Enterococci, and reports about the possibility of linezolid-resistant Enterococci. In addition, she said, "increases in the rate of Streptococcus pneumoniae resistance can impact ICU clinicians as patients come in from the community with resistant organisms because of inadequately treated infections."

Among gram-negative organisms, increases in Acinetobacter baumannii, Enterobacteriaceae-producing carbapenemases, and Escherichia coli–producing extended-spectrum beta-lactamases have been reported. "Along with the bugs themselves, we also have new mechanisms of resistance," she continued. "The bugs are getting smarter. These include emergence of aminoglycoside 16S ribosomal RNA methylation and New Delhi metallo-beta-lactamase."

In the perfect world, Dr. Miller said, "we could match up all of these bugs with new agents. It doesn't work that way, unfortunately. We're all aware of the issue of the lack of available agents on the market or in the pipeline to be developed."

This prompted the Infectious Diseases Society of America to launch an initiative in 2010 calling for the development of 10 new antibiotics by the year 2020. One of those new agents is telavancin, a lipoglycopeptide from Theravance that was approved in September 2009 for complicated skin and skin-structure infections and is currently marketed under the brand name Vibativ. Two other lipoglycopeptides, dalbavancin and oritavancin, are not currently available and continue to be studied.

Newer lipoglycopeptides influence cell membrane potential in addition to inhibiting cell wall synthesis by preventing polymerization and cross-linking of the cell wall, Dr. Miller said. They also feature increased protein binding. "While there are not a lot of data on what this means clinically, they do have the ability to affect their penetration into various body sites," she explained. "These new mechanisms and new binding sites afford us additional and expanded spectrums of activity."

Lipoglycopeptides also have unique pharmacokinetics compared with currently available agents. For example, the half-life of vancomycin is 6-12 hours, while that of telavancin is 7.5 hours. Both oritavancin and dalbavancin have a half-life of about 195 hours. "In clinical studies, the manufacturers are exploring once-weekly or twice-weekly dosing [of oritavancin and dalbavancin], which would be of tremendous benefit for outpatients," Dr. Miller commented. "But for ICU patients we think about the possibility of adverse reactions or dosing issues as renal function changes. That could be a real problem because of the prolonged elimination."

The phase III trial of telavancin for complicated skin and skin-structure infections found that a dose of 10 mg/kg IV daily was as effective as vancomycin 1 g IV every 12 hours (Clin. Infect. Dis. 2008;46:1683-93).

Two phase II trials of telavancin for hospital-acquired pneumonia found that a dose of 10 mg/kg IV daily was not inferior to vancomycin 1,000 mg daily. The unpublished studies involved 1,503 patients and "were good enough for FDA approval, but leave us with some lingering questions about how telavancin compares to vancomycin for hospital-acquired pneumonia," Dr. Miller said.

Among all three telavancin studies combined, a higher proportion of patients in the telavancin group experienced a 1.5-fold increase of serum creatinine from baseline, compared with their counterparts in the vancomycin group (15% vs. 7%, respectively). The proportion of adverse renal events was also higher in the telavancin group (3.1% vs. 1.1%).

Dr. Miller next discussed ceftaroline, a fourth-generation cephalosporin approved in October 2010 for acute skin and skin-structure infections as well as for community-acquired bacterial pneumonia. The drug is expected to be on the market soon under the brand name Teflaro (Forest Laboratories).

"Its spectrum of activity is quite different from that of the other cephalosporins, such that it retains activity against methicillin-susceptible Staphylococcus aureus isolates as well as isolates that are resistant to vancomycin," Dr. Miller said. "It has very good activity against Streptococcus pneumoniae, and like other cephalosporins it has minimal activity against Enterococci. It retains activity against Moraxella catarrhalis and Haemophilus influenzae, which we think about as common pathogens in community-acquired pneumonia. It has some activity against Klebsiella species, but unfortunately it doesn’t have any activity against extended-spectrum beta-lactamase producers or Pseudomonas species. So when we think about empiric coverage, there are definitely some holes with ceftaroline."

The recommended dosing of ceftaroline is 600 mg IV every 12 hours. The half-life is 1.6 hours for single doses and 2.66 hours for multiple doses.

Two phase III studies comparing ceftaroline with ceftriaxone in the treatment of community-acquired pneumonia were presented during the 2009 meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy. The studies demonstrated higher cure rates for patients in the ceftaroline group, compared with those in the ceftriaxone group (83% vs. 77%, respectively, among all study participants, and 86% vs. 69% among patients with S. pneumoniae).

Another strategy for combating antibiotic resistance involves improving ways to use available antibiotics on the market. Dr. Miller said that there are eight National Institutes of Health–funded trials aimed at this approach, including short-course therapy, narrow-spectrum therapies, combination vs. monotherapy, and pharmacodynamic dosing guidance.

Dr. Miller said that she had no relevant financial disclosures to make.

SAN DIEGO – Antimicrobial resistance continues to be a significant problem, but a few new agents have shown promise against certain pathogens.

"As clinicians, we need to look forward to new drug discovery and development, and keep an eye on the current pipeline," April D. Miller, Pharm. D., said at the annual congress of the Society of Critical Care Medicine. "We also need to think of and study new and unique strategies to preserve the agents that we currently have available."

The problem of antimicrobial resistance "lies in the bugs themselves," said Dr. Miller of the South Carolina College of Pharmacy at the University of South Carolina, Columbia. Among gram-positive organisms, she said, there are rising rates of community- and hospital-acquired methicillin-resistant Staphylococcus aureus and rising minimum inhibitory concentrations to vancomycin. There are also increasing rates of vancomycin-resistant Enterococci, and reports about the possibility of linezolid-resistant Enterococci. In addition, she said, "increases in the rate of Streptococcus pneumoniae resistance can impact ICU clinicians as patients come in from the community with resistant organisms because of inadequately treated infections."

Among gram-negative organisms, increases in Acinetobacter baumannii, Enterobacteriaceae-producing carbapenemases, and Escherichia coli–producing extended-spectrum beta-lactamases have been reported. "Along with the bugs themselves, we also have new mechanisms of resistance," she continued. "The bugs are getting smarter. These include emergence of aminoglycoside 16S ribosomal RNA methylation and New Delhi metallo-beta-lactamase."

In the perfect world, Dr. Miller said, "we could match up all of these bugs with new agents. It doesn’t work that way, unfortunately. We’re all aware of the issue of the lack of available agents on the market or in the pipeline to be developed."

This prompted the Infectious Diseases Society of America to launch an initiative in 2010 calling for the development of 10 new antibiotics by the year 2020. One of those new agents is telavancin, a lipoglycopeptide from Theravance that was approved in September 2009 for complicated skin and skin-structure infections and is currently marketed under the brand name Vibativ. Two other lipoglycopeptides, dalbavancin and oritavancin, are not currently available and continue to be studied.

Newer lipoglycopeptides influence cell membrane potential in addition to inhibiting cell wall synthesis by preventing polymerization and cross-linking of the cell wall, Dr. Miller said. They also feature increased protein binding. "While there are not a lot of data on what this means clinically, they do have the ability to affect their penetration into various body sites," she explained. "These new mechanisms and new binding sites afford us additional and expanded spectrums of activity."

Lipoglycopeptides also have unique pharmacokinetics compared with currently available agents. For example, the half-life of vancomycin is 6-12 hours, while that of telavancin is 7.5 hours. Both oritavancin and dalbavancin have a half-life of about 195 hours. "In clinical studies, the manufacturers are exploring once-weekly or twice-weekly dosing [of oritavancin and dalbavancin], which would be of tremendous benefit for outpatients," Dr. Miller commented. "But for ICU patients we think about the possibility of adverse reactions or dosing issues as renal function changes. That could be a real problem because of the prolonged elimination."

The phase III trial of telavancin for complicated skin and skin-structure infections found that a dose of 10 mg/kg IV daily was as effective as vancomycin 1 g IV every 12 hours (Clin. Infect. Dis. 2008;46:1683-93).

Two phase II trials of telavancin for hospital-acquired pneumonia found that a dose of 10 mg/kg IV daily was not inferior to vancomycin 1,000 mg daily. The unpublished studies involved 1,503 patients and "were good enough for FDA approval, but leave us with some lingering questions about how telavancin compares to vancomycin for hospital-acquired pneumonia," Dr. Miller said.

Among all three telavancin studies combined, a higher proportion of patients in the telavancin group experienced a 1.5-fold increase of serum creatinine from baseline, compared with their counterparts in the vancomycin group (15% vs. 7%, respectively). The proportion of adverse renal events was also higher in the telavancin group (3.1% vs. 1.1%).

Dr. Miller next discussed ceftaroline, a fourth-generation cephalosporin approved in October 2010 for acute skin and skin-structure infections as well as for community-acquired bacterial pneumonia. The drug is expected to be on the market soon under the brand name Teflaro (Forest Laboratories).

"Its spectrum of activity is quite different from that of the other cephalosporins, such that it retains activity against methicillin-susceptible Staphylococcus aureus isolates as well as isolates that are resistant to vancomycin," Dr. Miller said. "It has very good activity against Streptococcus pneumoniae, and like other cephalosporins it has minimal activity against Enterococci. It retains activity against Moraxella catarrhalis and Haemophilus influenzae, which we think about as common pathogens in community-acquired pneumonia. It has some activity against Klebsiella species, but unfortunately it doesn’t have any activity against extended-spectrum beta-lactamase producers or Pseudomonas species. So when we think about empiric coverage, there are definitely some holes with ceftaroline."

The recommended dosing of ceftaroline is 600 mg IV every 12 hours. The half-life is 1.6 hours for single doses and 2.66 hours for multiple doses.

Two phase III studies comparing ceftaroline with ceftriaxone in the treatment of community-acquired pneumonia were presented during the 2009 meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy. The studies demonstrated higher cure rates for patients in the ceftaroline group, compared with those in the ceftriaxone group (83% vs. 77%, respectively, among all study participants, and 86% vs. 69% among patients with S. pneumoniae).

Another strategy for combating antibiotic resistance involves improving ways to use available antibiotics on the market. Dr. Miller said that there are eight National Institutes of Health–funded trials aimed at this approach, including short-course therapy, narrow-spectrum therapies, combination vs. monotherapy, and pharmacodynamic dosing guidance.

Dr. Miller said that she had no relevant financial disclosures to make.

SAN DIEGO – Antimicrobial resistance continues to be a significant problem, but a few new agents have shown promise against certain pathogens.

"As clinicians, we need to look forward to new drug discovery and development, and keep an eye on the current pipeline," April D. Miller, Pharm. D., said at the annual congress of the Society of Critical Care Medicine. "We also need to think of and study new and unique strategies to preserve the agents that we currently have available."

The problem of antimicrobial resistance "lies in the bugs themselves," said Dr. Miller of the South Carolina College of Pharmacy at the University of South Carolina, Columbia. Among gram-positive organisms, she said, there are rising rates of community- and hospital-acquired methicillin-resistant Staphylococcus aureus and rising minimum inhibitory concentrations to vancomycin. There are also increasing rates of vancomycin-resistant Enterococci, and reports about the possibility of linezolid-resistant Enterococci. In addition, she said, "increases in the rate of Streptococcus pneumoniae resistance can impact ICU clinicians as patients come in from the community with resistant organisms because of inadequately treated infections."

Among gram-negative organisms, increases in Acinetobacter baumannii, Enterobacteriaceae-producing carbapenemases, and Escherichia coli–producing extended-spectrum beta-lactamases have been reported. "Along with the bugs themselves, we also have new mechanisms of resistance," she continued. "The bugs are getting smarter. These include emergence of aminoglycoside 16S ribosomal RNA methylation and New Delhi metallo-beta-lactamase."

In the perfect world, Dr. Miller said, "we could match up all of these bugs with new agents. It doesn’t work that way, unfortunately. We’re all aware of the issue of the lack of available agents on the market or in the pipeline to be developed."

This prompted the Infectious Diseases Society of America to launch an initiative in 2010 calling for the development of 10 new antibiotics by the year 2020. One of those new agents is telavancin, a lipoglycopeptide from Theravance that was approved in September 2009 for complicated skin and skin-structure infections and is currently marketed under the brand name Vibativ. Two other lipoglycopeptides, dalbavancin and oritavancin, are not currently available and continue to be studied.

Newer lipoglycopeptides influence cell membrane potential in addition to inhibiting cell wall synthesis by preventing polymerization and cross-linking of the cell wall, Dr. Miller said. They also feature increased protein binding. "While there are not a lot of data on what this means clinically, they do have the ability to affect their penetration into various body sites," she explained. "These new mechanisms and new binding sites afford us additional and expanded spectrums of activity."

Lipoglycopeptides also have unique pharmacokinetics compared with currently available agents. For example, the half-life of vancomycin is 6-12 hours, while that of telavancin is 7.5 hours. Both oritavancin and dalbavancin have a half-life of about 195 hours. "In clinical studies, the manufacturers are exploring once-weekly or twice-weekly dosing [of oritavancin and dalbavancin], which would be of tremendous benefit for outpatients," Dr. Miller commented. "But for ICU patients we think about the possibility of adverse reactions or dosing issues as renal function changes. That could be a real problem because of the prolonged elimination."

The phase III trial of telavancin for complicated skin and skin-structure infections found that a dose of 10 mg/kg IV daily was as effective as vancomycin 1 g IV every 12 hours (Clin. Infect. Dis. 2008;46:1683-93).

Two phase II trials of telavancin for hospital-acquired pneumonia found that a dose of 10 mg/kg IV daily was not inferior to vancomycin 1,000 mg daily. The unpublished studies involved 1,503 patients and "were good enough for FDA approval, but leave us with some lingering questions about how telavancin compares to vancomycin for hospital-acquired pneumonia," Dr. Miller said.

Among all three telavancin studies combined, a higher proportion of patients in the telavancin group experienced a 1.5-fold increase of serum creatinine from baseline, compared with their counterparts in the vancomycin group (15% vs. 7%, respectively). The proportion of adverse renal events was also higher in the telavancin group (3.1% vs. 1.1%).

Dr. Miller next discussed ceftaroline, a fourth-generation cephalosporin approved in October 2010 for acute skin and skin-structure infections as well as for community-acquired bacterial pneumonia. The drug is expected to be on the market soon under the brand name Teflaro (Forest Laboratories).

"Its spectrum of activity is quite different from that of the other cephalosporins, such that it retains activity against methicillin-susceptible Staphylococcus aureus isolates as well as isolates that are resistant to vancomycin," Dr. Miller said. "It has very good activity against Streptococcus pneumoniae, and like other cephalosporins it has minimal activity against Enterococci. It retains activity against Moraxella catarrhalis and Haemophilus influenzae, which we think about as common pathogens in community-acquired pneumonia. It has some activity against Klebsiella species, but unfortunately it doesn’t have any activity against extended-spectrum beta-lactamase producers or Pseudomonas species. So when we think about empiric coverage, there are definitely some holes with ceftaroline."

The recommended dosing of ceftaroline is 600 mg IV every 12 hours. The half-life is 1.6 hours for single doses and 2.66 hours for multiple doses.

Two phase III studies comparing ceftaroline with ceftriaxone in the treatment of community-acquired pneumonia were presented during the 2009 meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy. The studies demonstrated higher cure rates for patients in the ceftaroline group, compared with those in the ceftriaxone group (83% vs. 77%, respectively, among all study participants, and 86% vs. 69% among patients with S. pneumoniae).

Another strategy for combating antibiotic resistance involves improving ways to use available antibiotics on the market. Dr. Miller said that there are eight National Institutes of Health–funded trials aimed at this approach, including short-course therapy, narrow-spectrum therapies, combination vs. monotherapy, and pharmacodynamic dosing guidance.

Dr. Miller said that she had no relevant financial disclosures to make.

SAN DIEGO – Antimicrobial resistance continues to be a significant problem, but a few new agents have shown promise against certain pathogens.

"As clinicians, we need to look forward to new drug discovery and development, and keep an eye on the current pipeline," April D. Miller, Pharm. D., said at the annual congress of the Society of Critical Care Medicine. "We also need to think of and study new and unique strategies to preserve the agents that we currently have available."

The problem of antimicrobial resistance "lies in the bugs themselves," said Dr. Miller of the South Carolina College of Pharmacy at the University of South Carolina, Columbia. Among gram-positive organisms, she said, there are rising rates of community- and hospital-acquired methicillin-resistant Staphylococcus aureus and rising minimum inhibitory concentrations to vancomycin. There are also increasing rates of vancomycin-resistant Enterococci, and reports about the possibility of linezolid-resistant Enterococci. In addition, she said, "increases in the rate of Streptococcus pneumoniae resistance can impact ICU clinicians as patients come in from the community with resistant organisms because of inadequately treated infections."

Among gram-negative organisms, increases in Acinetobacter baumannii, Enterobacteriaceae-producing carbapenemases, and Escherichia coli–producing extended-spectrum beta-lactamases have been reported. "Along with the bugs themselves, we also have new mechanisms of resistance," she continued. "The bugs are getting smarter. These include emergence of aminoglycoside 16S ribosomal RNA methylation and New Delhi metallo-beta-lactamase."

In the perfect world, Dr. Miller said, "we could match up all of these bugs with new agents. It doesn’t work that way, unfortunately. We’re all aware of the issue of the lack of available agents on the market or in the pipeline to be developed."

This prompted the Infectious Diseases Society of America to launch an initiative in 2010 calling for the development of 10 new antibiotics by the year 2020. One of those new agents is telavancin, a lipoglycopeptide from Theravance that was approved in September 2009 for complicated skin and skin-structure infections and is currently marketed under the brand name Vibativ. Two other lipoglycopeptides, dalbavancin and oritavancin, are not currently available and continue to be studied.

Newer lipoglycopeptides influence cell membrane potential in addition to inhibiting cell wall synthesis by preventing polymerization and cross-linking of the cell wall, Dr. Miller said. They also feature increased protein binding. "While there are not a lot of data on what this means clinically, they do have the ability to affect their penetration into various body sites," she explained. "These new mechanisms and new binding sites afford us additional and expanded spectrums of activity."

Lipoglycopeptides also have unique pharmacokinetics compared with currently available agents. For example, the half-life of vancomycin is 6-12 hours, while that of telavancin is 7.5 hours. Both oritavancin and dalbavancin have a half-life of about 195 hours. "In clinical studies, the manufacturers are exploring once-weekly or twice-weekly dosing [of oritavancin and dalbavancin], which would be of tremendous benefit for outpatients," Dr. Miller commented. "But for ICU patients we think about the possibility of adverse reactions or dosing issues as renal function changes. That could be a real problem because of the prolonged elimination."

The phase III trial of telavancin for complicated skin and skin-structure infections found that a dose of 10 mg/kg IV daily was as effective as vancomycin 1 g IV every 12 hours (Clin. Infect. Dis. 2008;46:1683-93).

Two phase II trials of telavancin for hospital-acquired pneumonia found that a dose of 10 mg/kg IV daily was not inferior to vancomycin 1,000 mg daily. The unpublished studies involved 1,503 patients and "were good enough for FDA approval, but leave us with some lingering questions about how telavancin compares to vancomycin for hospital-acquired pneumonia," Dr. Miller said.

Among all three telavancin studies combined, a higher proportion of patients in the telavancin group experienced a 1.5-fold increase of serum creatinine from baseline, compared with their counterparts in the vancomycin group (15% vs. 7%, respectively). The proportion of adverse renal events was also higher in the telavancin group (3.1% vs. 1.1%).

Dr. Miller next discussed ceftaroline, a fourth-generation cephalosporin approved in October 2010 for acute skin and skin-structure infections as well as for community-acquired bacterial pneumonia. The drug is expected to be on the market soon under the brand name Teflaro (Forest Laboratories).

"Its spectrum of activity is quite different from that of the other cephalosporins, such that it retains activity against methicillin-susceptible Staphylococcus aureus isolates as well as isolates that are resistant to vancomycin," Dr. Miller said. "It has very good activity against Streptococcus pneumoniae, and like other cephalosporins it has minimal activity against Enterococci. It retains activity against Moraxella catarrhalis and Haemophilus influenzae, which we think about as common pathogens in community-acquired pneumonia. It has some activity against Klebsiella species, but unfortunately it doesn’t have any activity against extended-spectrum beta-lactamase producers or Pseudomonas species. So when we think about empiric coverage, there are definitely some holes with ceftaroline."

The recommended dosing of ceftaroline is 600 mg IV every 12 hours. The half-life is 1.6 hours for single doses and 2.66 hours for multiple doses.

Two phase III studies comparing ceftaroline with ceftriaxone in the treatment of community-acquired pneumonia were presented during the 2009 meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy. The studies demonstrated higher cure rates for patients in the ceftaroline group, compared with those in the ceftriaxone group (83% vs. 77%, respectively, among all study participants, and 86% vs. 69% among patients with S. pneumoniae).

Another strategy for combating antibiotic resistance involves improving ways to use available antibiotics on the market. Dr. Miller said that there are eight National Institutes of Health–funded trials aimed at this approach, including short-course therapy, narrow-spectrum therapies, combination vs. monotherapy, and pharmacodynamic dosing guidance.

Dr. Miller said that she had no relevant financial disclosures to make.

Major Finding: In the first 3 months, the rate of bone loss among patients with early RA who were treated with intra-articular corticosteroid injections plus methotrexate vs. methotrexate alone was −0.45% vs. −2.69%, respectively, in digit 2; −0.34% vs. −3.32% in digit 3; −0.39% vs. −2.57% in digit 4, and −0.59% vs. −2.70% in digit 5.

Data Source: A study of 40 patients who were treated for 12 months.

Disclosures: The researchers stated that they had no relevant financial disclosures to make.

Patients with early rheumatoid arthritis who were on methotrexate and received intra-articular corticosteroid injections into inflamed metacarpophalangeal joints for 3 months lost less periarticular density than did those who received methotrexate alone, results from a small study demonstrated.

The finding “supports the concept that, in conditions where inflammation dominates such as early RA, treating inflammation is more important than the negative effect of corticosteroids on bone,” reported researchers led by Dr. Glenn Haugeberg.

Dr. Haugeberg, professor of neuroscience at the Norwegian University of Science and Technology, Trondheim, and a member of the department of rheumatology at Sørlandet Hospital in Kristiansand (Norway), and his associates at two clinical centers in the United Kingdom treated 19 early RA patients with methotrexate alone and 21 with methotrexate plus intra-articular corticosteroid injections for 3 months. Over the next 9 months, all 40 patients received methotrexate plus intra-articular corticosteroid injections.

To assess the effect of treatment on bone loss, the researchers used MRI of the metacarpophalangeal joints of the dominant hand (that is, MCP joints 2-5) at baseline and 3 and 12 months, as well as DXA images of both hands at baseline and 3, 6, and 12 months (Ann. Rheum. Dis. 2011;70:184-7). They used linear regression analysis to determine the association between reduction in bone mineral density and demographic and disease variables, adjusting for treatment group.

The mean age of patients was 54 years, and 55% were women. In the first 3 months, patients who received methotrexate plus intra-articular corticosteroid injections experienced significantly less bone loss in MCP joints 2–5 than did their counterparts in the methotrexate-only group. The rate of bone loss was −0.45% vs. −2.69%, respectively, in digit 2; −0.34% vs. −3.32% in digit 3; −0.39% vs. −2.57% in digit 4, and −0.59% vs. −2.70% in digit 5.

Bone loss in the hand overall was less pronounced over the same time period (−1.53% in patients who received methotrexate plus injections, compared with −2.42% in those in the methotrexate-only group).

In months 3-12, when all patients received intra-articular corticosteroid injections, only minor, nonsignificant differences in the rate of bone loss were observed between the two groups.

“Data from the current study suggest that bone loss may be arrested by intra-articular corticosteroid injections more effectively in periarticular regions than in the whole hand,” the researchers wrote. “This may support the view that periarticular osteoporosis results from local production of proinflammatory cytokines which activate osteoclasts to break down bone locally and is not predominantly the result of circulating proinflammatory cytokines.”

They acknowledged certain limitations of the study, including the small sample size and the fact that “the precision of DXA for periarticular regions is poor compared with whole hand measurement. Furthermore, the method is not feasible for clinical use; it has therefore been recommended that assessment of the whole hand be used as a marker for periarticlar bone loss.”

Major Finding: In the first 3 months, the rate of bone loss among patients with early RA who were treated with intra-articular corticosteroid injections plus methotrexate vs. methotrexate alone was −0.45% vs. −2.69%, respectively, in digit 2; −0.34% vs. −3.32% in digit 3; −0.39% vs. −2.57% in digit 4, and −0.59% vs. −2.70% in digit 5.

Data Source: A study of 40 patients who were treated for 12 months.

Disclosures: The researchers stated that they had no relevant financial disclosures to make.

Patients with early rheumatoid arthritis who were on methotrexate and received intra-articular corticosteroid injections into inflamed metacarpophalangeal joints for 3 months lost less periarticular density than did those who received methotrexate alone, results from a small study demonstrated.

The finding “supports the concept that, in conditions where inflammation dominates such as early RA, treating inflammation is more important than the negative effect of corticosteroids on bone,” reported researchers led by Dr. Glenn Haugeberg.

Dr. Haugeberg, professor of neuroscience at the Norwegian University of Science and Technology, Trondheim, and a member of the department of rheumatology at Sørlandet Hospital in Kristiansand (Norway), and his associates at two clinical centers in the United Kingdom treated 19 early RA patients with methotrexate alone and 21 with methotrexate plus intra-articular corticosteroid injections for 3 months. Over the next 9 months, all 40 patients received methotrexate plus intra-articular corticosteroid injections.

To assess the effect of treatment on bone loss, the researchers used MRI of the metacarpophalangeal joints of the dominant hand (that is, MCP joints 2-5) at baseline and 3 and 12 months, as well as DXA images of both hands at baseline and 3, 6, and 12 months (Ann. Rheum. Dis. 2011;70:184-7). They used linear regression analysis to determine the association between reduction in bone mineral density and demographic and disease variables, adjusting for treatment group.

The mean age of patients was 54 years, and 55% were women. In the first 3 months, patients who received methotrexate plus intra-articular corticosteroid injections experienced significantly less bone loss in MCP joints 2–5 than did their counterparts in the methotrexate-only group. The rate of bone loss was −0.45% vs. −2.69%, respectively, in digit 2; −0.34% vs. −3.32% in digit 3; −0.39% vs. −2.57% in digit 4, and −0.59% vs. −2.70% in digit 5.

Bone loss in the hand overall was less pronounced over the same time period (−1.53% in patients who received methotrexate plus injections, compared with −2.42% in those in the methotrexate-only group).

In months 3-12, when all patients received intra-articular corticosteroid injections, only minor, nonsignificant differences in the rate of bone loss were observed between the two groups.

“Data from the current study suggest that bone loss may be arrested by intra-articular corticosteroid injections more effectively in periarticular regions than in the whole hand,” the researchers wrote. “This may support the view that periarticular osteoporosis results from local production of proinflammatory cytokines which activate osteoclasts to break down bone locally and is not predominantly the result of circulating proinflammatory cytokines.”

They acknowledged certain limitations of the study, including the small sample size and the fact that “the precision of DXA for periarticular regions is poor compared with whole hand measurement. Furthermore, the method is not feasible for clinical use; it has therefore been recommended that assessment of the whole hand be used as a marker for periarticlar bone loss.”

Major Finding: In the first 3 months, the rate of bone loss among patients with early RA who were treated with intra-articular corticosteroid injections plus methotrexate vs. methotrexate alone was −0.45% vs. −2.69%, respectively, in digit 2; −0.34% vs. −3.32% in digit 3; −0.39% vs. −2.57% in digit 4, and −0.59% vs. −2.70% in digit 5.

Data Source: A study of 40 patients who were treated for 12 months.

Disclosures: The researchers stated that they had no relevant financial disclosures to make.

Patients with early rheumatoid arthritis who were on methotrexate and received intra-articular corticosteroid injections into inflamed metacarpophalangeal joints for 3 months lost less periarticular density than did those who received methotrexate alone, results from a small study demonstrated.

The finding “supports the concept that, in conditions where inflammation dominates such as early RA, treating inflammation is more important than the negative effect of corticosteroids on bone,” reported researchers led by Dr. Glenn Haugeberg.

Dr. Haugeberg, professor of neuroscience at the Norwegian University of Science and Technology, Trondheim, and a member of the department of rheumatology at Sørlandet Hospital in Kristiansand (Norway), and his associates at two clinical centers in the United Kingdom treated 19 early RA patients with methotrexate alone and 21 with methotrexate plus intra-articular corticosteroid injections for 3 months. Over the next 9 months, all 40 patients received methotrexate plus intra-articular corticosteroid injections.

To assess the effect of treatment on bone loss, the researchers used MRI of the metacarpophalangeal joints of the dominant hand (that is, MCP joints 2-5) at baseline and 3 and 12 months, as well as DXA images of both hands at baseline and 3, 6, and 12 months (Ann. Rheum. Dis. 2011;70:184-7). They used linear regression analysis to determine the association between reduction in bone mineral density and demographic and disease variables, adjusting for treatment group.

The mean age of patients was 54 years, and 55% were women. In the first 3 months, patients who received methotrexate plus intra-articular corticosteroid injections experienced significantly less bone loss in MCP joints 2–5 than did their counterparts in the methotrexate-only group. The rate of bone loss was −0.45% vs. −2.69%, respectively, in digit 2; −0.34% vs. −3.32% in digit 3; −0.39% vs. −2.57% in digit 4, and −0.59% vs. −2.70% in digit 5.

Bone loss in the hand overall was less pronounced over the same time period (−1.53% in patients who received methotrexate plus injections, compared with −2.42% in those in the methotrexate-only group).

In months 3-12, when all patients received intra-articular corticosteroid injections, only minor, nonsignificant differences in the rate of bone loss were observed between the two groups.

“Data from the current study suggest that bone loss may be arrested by intra-articular corticosteroid injections more effectively in periarticular regions than in the whole hand,” the researchers wrote. “This may support the view that periarticular osteoporosis results from local production of proinflammatory cytokines which activate osteoclasts to break down bone locally and is not predominantly the result of circulating proinflammatory cytokines.”

They acknowledged certain limitations of the study, including the small sample size and the fact that “the precision of DXA for periarticular regions is poor compared with whole hand measurement. Furthermore, the method is not feasible for clinical use; it has therefore been recommended that assessment of the whole hand be used as a marker for periarticlar bone loss.”