Sherry Boschert

SAN FRANCISCO — Internists prescribed the most broad-spectrum antibiotics and pediatricians chose the most narrow-spectrum antibiotics for respiratory tract infections in a national managed care population, Katie J. Suda, Pharm.D., reported in a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

“Looking at a managed care population, a majority of them aren't going to have ten different diseases. In general, you don't need broad-spectrum therapy right off the bat,” said Dr. Suda of the University of Tennessee, Memphis.

She and her associates performed what may be the first national analysis of outpatient antimicrobial prescribing for respiratory tract infections by specialty. They studied databases from nine managed care organizations for 48,182 antibiotic prescriptions by 7,613 physicians for 26,875 patients with respiratory tract infections from 2001 through 2003, excluding cases in which the drug was dispensed for more than 27 days. Treatment averaged 10 days for patients in the study.

Among the physicians, 21% were pediatricians, 39% were family physicians, 4% were internists, 3% were general medical physicians, 5% were emergency medicine physicians, and 5% each were specialists in infectious diseases, gastroenterology, or other specialties. Four percent of physicians were dermatologists, 3% were ob.gyns., 3% were surgeons, and other physicians composed 3% of the total.

The bulk of treatments consisted of penicillins (29%) or macrolides (27%), with fluoroquinolones accounting for 15%, she reported at the meeting, which was sponsored by the American Society for Microbiology. Cephalosporins made up 14% of prescriptions, tetracyclines were 6%, and 9% were other drugs.

For upper respiratory tract infections, internists and emergency physicians favored macrolides, in about 40% and 51% of prescriptions, respectively. They ordered beta-lactamase inhibitors second most commonly, in about 30% of prescriptions.

Family physicians and specialists wrote predominantly for beta-lactamase inhibitors, in about 40% of prescriptions for upper respiratory tract infections. Pediatricians most often prescribed penicillins (in about 42% of prescriptions), followed by macrolides (about 22%) and beta-lactamase inhibitors (16%).

Internists led other physicians in prescribing fluoroquinolones, composing 20% of their prescriptions for upper respiratory tract infections. Fluoroquinolones made up approximately 1% of prescriptions by pediatricians for this indication, 10% by emergency physicians, 11% by family physicians, and about 13% by specialists.

For lower respiratory tract infections, pediatricians favored macrolides (about 58% of prescriptions) and beta-lactamase inhibitors (39%). They ordered fluoroquinolones only about 2% of the time.

Fluoroquinolone use was much higher among other physicians for lower respiratory tract infection, composing about 43% of prescriptions by internists, 40% by family physicians, and 30% by emergency physicians. These physicians used more broad-spectrum agents for lower than for upper respiratory tract infections, Dr. Suda noted.

Comorbidities were more common with lower than with upper respiratory tract infection. Nearly 10% of lower respiratory tract infections were accompanied by pulmonary problems, 7% had cardiovascular problems, 5% had endocrine morbidities, 5% had oncologic problems, and around 4% had gastrointestinal comorbidities.

Diagnoses of upper respiratory tract infections were accompanied by pulmonary problems in 5% of cases, cardiovascular comorbidities in 4%, gastrointestinal problems in 3%, endocrine problems in 2%, and oncological comorbidities in less than 2%.

Two-thirds of all prescriptions went to females. Patients averaged 34 years in age, ranging from 3 months to 101 years.

SAN FRANCISCO — Internists prescribed the most broad-spectrum antibiotics and pediatricians chose the most narrow-spectrum antibiotics for respiratory tract infections in a national managed care population, Katie J. Suda, Pharm.D., reported in a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

“Looking at a managed care population, a majority of them aren't going to have ten different diseases. In general, you don't need broad-spectrum therapy right off the bat,” said Dr. Suda of the University of Tennessee, Memphis.

She and her associates performed what may be the first national analysis of outpatient antimicrobial prescribing for respiratory tract infections by specialty. They studied databases from nine managed care organizations for 48,182 antibiotic prescriptions by 7,613 physicians for 26,875 patients with respiratory tract infections from 2001 through 2003, excluding cases in which the drug was dispensed for more than 27 days. Treatment averaged 10 days for patients in the study.

Among the physicians, 21% were pediatricians, 39% were family physicians, 4% were internists, 3% were general medical physicians, 5% were emergency medicine physicians, and 5% each were specialists in infectious diseases, gastroenterology, or other specialties. Four percent of physicians were dermatologists, 3% were ob.gyns., 3% were surgeons, and other physicians composed 3% of the total.

The bulk of treatments consisted of penicillins (29%) or macrolides (27%), with fluoroquinolones accounting for 15%, she reported at the meeting, which was sponsored by the American Society for Microbiology. Cephalosporins made up 14% of prescriptions, tetracyclines were 6%, and 9% were other drugs.

For upper respiratory tract infections, internists and emergency physicians favored macrolides, in about 40% and 51% of prescriptions, respectively. They ordered beta-lactamase inhibitors second most commonly, in about 30% of prescriptions.

Family physicians and specialists wrote predominantly for beta-lactamase inhibitors, in about 40% of prescriptions for upper respiratory tract infections. Pediatricians most often prescribed penicillins (in about 42% of prescriptions), followed by macrolides (about 22%) and beta-lactamase inhibitors (16%).

Internists led other physicians in prescribing fluoroquinolones, composing 20% of their prescriptions for upper respiratory tract infections. Fluoroquinolones made up approximately 1% of prescriptions by pediatricians for this indication, 10% by emergency physicians, 11% by family physicians, and about 13% by specialists.

For lower respiratory tract infections, pediatricians favored macrolides (about 58% of prescriptions) and beta-lactamase inhibitors (39%). They ordered fluoroquinolones only about 2% of the time.

Fluoroquinolone use was much higher among other physicians for lower respiratory tract infection, composing about 43% of prescriptions by internists, 40% by family physicians, and 30% by emergency physicians. These physicians used more broad-spectrum agents for lower than for upper respiratory tract infections, Dr. Suda noted.

Comorbidities were more common with lower than with upper respiratory tract infection. Nearly 10% of lower respiratory tract infections were accompanied by pulmonary problems, 7% had cardiovascular problems, 5% had endocrine morbidities, 5% had oncologic problems, and around 4% had gastrointestinal comorbidities.

Diagnoses of upper respiratory tract infections were accompanied by pulmonary problems in 5% of cases, cardiovascular comorbidities in 4%, gastrointestinal problems in 3%, endocrine problems in 2%, and oncological comorbidities in less than 2%.

Two-thirds of all prescriptions went to females. Patients averaged 34 years in age, ranging from 3 months to 101 years.

SAN FRANCISCO — Internists prescribed the most broad-spectrum antibiotics and pediatricians chose the most narrow-spectrum antibiotics for respiratory tract infections in a national managed care population, Katie J. Suda, Pharm.D., reported in a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

“Looking at a managed care population, a majority of them aren't going to have ten different diseases. In general, you don't need broad-spectrum therapy right off the bat,” said Dr. Suda of the University of Tennessee, Memphis.

She and her associates performed what may be the first national analysis of outpatient antimicrobial prescribing for respiratory tract infections by specialty. They studied databases from nine managed care organizations for 48,182 antibiotic prescriptions by 7,613 physicians for 26,875 patients with respiratory tract infections from 2001 through 2003, excluding cases in which the drug was dispensed for more than 27 days. Treatment averaged 10 days for patients in the study.

Among the physicians, 21% were pediatricians, 39% were family physicians, 4% were internists, 3% were general medical physicians, 5% were emergency medicine physicians, and 5% each were specialists in infectious diseases, gastroenterology, or other specialties. Four percent of physicians were dermatologists, 3% were ob.gyns., 3% were surgeons, and other physicians composed 3% of the total.

The bulk of treatments consisted of penicillins (29%) or macrolides (27%), with fluoroquinolones accounting for 15%, she reported at the meeting, which was sponsored by the American Society for Microbiology. Cephalosporins made up 14% of prescriptions, tetracyclines were 6%, and 9% were other drugs.

For upper respiratory tract infections, internists and emergency physicians favored macrolides, in about 40% and 51% of prescriptions, respectively. They ordered beta-lactamase inhibitors second most commonly, in about 30% of prescriptions.

Family physicians and specialists wrote predominantly for beta-lactamase inhibitors, in about 40% of prescriptions for upper respiratory tract infections. Pediatricians most often prescribed penicillins (in about 42% of prescriptions), followed by macrolides (about 22%) and beta-lactamase inhibitors (16%).

Internists led other physicians in prescribing fluoroquinolones, composing 20% of their prescriptions for upper respiratory tract infections. Fluoroquinolones made up approximately 1% of prescriptions by pediatricians for this indication, 10% by emergency physicians, 11% by family physicians, and about 13% by specialists.

For lower respiratory tract infections, pediatricians favored macrolides (about 58% of prescriptions) and beta-lactamase inhibitors (39%). They ordered fluoroquinolones only about 2% of the time.

Fluoroquinolone use was much higher among other physicians for lower respiratory tract infection, composing about 43% of prescriptions by internists, 40% by family physicians, and 30% by emergency physicians. These physicians used more broad-spectrum agents for lower than for upper respiratory tract infections, Dr. Suda noted.

Comorbidities were more common with lower than with upper respiratory tract infection. Nearly 10% of lower respiratory tract infections were accompanied by pulmonary problems, 7% had cardiovascular problems, 5% had endocrine morbidities, 5% had oncologic problems, and around 4% had gastrointestinal comorbidities.

Diagnoses of upper respiratory tract infections were accompanied by pulmonary problems in 5% of cases, cardiovascular comorbidities in 4%, gastrointestinal problems in 3%, endocrine problems in 2%, and oncological comorbidities in less than 2%.

Two-thirds of all prescriptions went to females. Patients averaged 34 years in age, ranging from 3 months to 101 years.

MONTEREY, CALIF. — Four strategies that have been proposed to improve treatment of bacterial vaginosis produced mixed results, with only an extended course of metronidazole improving cure rates, and that only in the short term, Dr. Jane R. Schwebke reported.

A double-blind study randomized 568 women with bacterial vaginosis (BV) to one of four treatment arms: daily metronidazole for 7 days; metronidazole for 14 days; metronidazole for 7 days plus 1 g azithromycin on days 1 and 3, or metronidazole for 14 days plus azithromycin on days 1 and 3. The metronidazole was given in 750-mg extended-release form.

At a first follow-up visit 7 days after completion of treatment, BV was cured in 63% of patients who took metronidazole for 14 days, compared with 45% of patients who took metronidazole for 7 days.

By a second follow-up 21 days after completing treatment, however, there was no significant difference in cure rates among any groups.

Azithromycin therapy did not seem to make a difference at either time point, Dr. Schwebke and her associates reported in a poster presentation at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Any benefit from the longer course of metronidazole in the short term was lost in the long term. “We don't know if that's because of relapse of the problem or reinfection,” she said in an interview at the meeting.

Some physicians have advocated using 10–14 days of metronidazole to treat recurrent BV, although they lacked supportive data. Others have suggested that the relatively low cure rates of 50%–80% seen when treating BV with metronidazole or clindamycin may be due to resistant organisms that are susceptible to macrolide antibiotics, such as mycoplasmas and Mobiluncus curtisii, noted Dr. Schwebke, professor of medicine at the University of Alabama, Birmingham, and her associates.

Patients with a Nugent score at baseline of 5–8 (reflecting less complicated flora) were more likely to be cured than women with Nugent scores of 9–10, the intent-to-treat analysis found.

Other factors that have been shown in previous studies to affect cure rates also proved significant in this study. Consistent condom use, sexual abstinence, and refraining from douching improved chances of curing BV with treatment.

MONTEREY, CALIF. — Four strategies that have been proposed to improve treatment of bacterial vaginosis produced mixed results, with only an extended course of metronidazole improving cure rates, and that only in the short term, Dr. Jane R. Schwebke reported.

A double-blind study randomized 568 women with bacterial vaginosis (BV) to one of four treatment arms: daily metronidazole for 7 days; metronidazole for 14 days; metronidazole for 7 days plus 1 g azithromycin on days 1 and 3, or metronidazole for 14 days plus azithromycin on days 1 and 3. The metronidazole was given in 750-mg extended-release form.

At a first follow-up visit 7 days after completion of treatment, BV was cured in 63% of patients who took metronidazole for 14 days, compared with 45% of patients who took metronidazole for 7 days.

By a second follow-up 21 days after completing treatment, however, there was no significant difference in cure rates among any groups.

Azithromycin therapy did not seem to make a difference at either time point, Dr. Schwebke and her associates reported in a poster presentation at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Any benefit from the longer course of metronidazole in the short term was lost in the long term. “We don't know if that's because of relapse of the problem or reinfection,” she said in an interview at the meeting.

Some physicians have advocated using 10–14 days of metronidazole to treat recurrent BV, although they lacked supportive data. Others have suggested that the relatively low cure rates of 50%–80% seen when treating BV with metronidazole or clindamycin may be due to resistant organisms that are susceptible to macrolide antibiotics, such as mycoplasmas and Mobiluncus curtisii, noted Dr. Schwebke, professor of medicine at the University of Alabama, Birmingham, and her associates.

Patients with a Nugent score at baseline of 5–8 (reflecting less complicated flora) were more likely to be cured than women with Nugent scores of 9–10, the intent-to-treat analysis found.

Other factors that have been shown in previous studies to affect cure rates also proved significant in this study. Consistent condom use, sexual abstinence, and refraining from douching improved chances of curing BV with treatment.

MONTEREY, CALIF. — Four strategies that have been proposed to improve treatment of bacterial vaginosis produced mixed results, with only an extended course of metronidazole improving cure rates, and that only in the short term, Dr. Jane R. Schwebke reported.

A double-blind study randomized 568 women with bacterial vaginosis (BV) to one of four treatment arms: daily metronidazole for 7 days; metronidazole for 14 days; metronidazole for 7 days plus 1 g azithromycin on days 1 and 3, or metronidazole for 14 days plus azithromycin on days 1 and 3. The metronidazole was given in 750-mg extended-release form.

At a first follow-up visit 7 days after completion of treatment, BV was cured in 63% of patients who took metronidazole for 14 days, compared with 45% of patients who took metronidazole for 7 days.

By a second follow-up 21 days after completing treatment, however, there was no significant difference in cure rates among any groups.

Azithromycin therapy did not seem to make a difference at either time point, Dr. Schwebke and her associates reported in a poster presentation at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

Any benefit from the longer course of metronidazole in the short term was lost in the long term. “We don't know if that's because of relapse of the problem or reinfection,” she said in an interview at the meeting.

Some physicians have advocated using 10–14 days of metronidazole to treat recurrent BV, although they lacked supportive data. Others have suggested that the relatively low cure rates of 50%–80% seen when treating BV with metronidazole or clindamycin may be due to resistant organisms that are susceptible to macrolide antibiotics, such as mycoplasmas and Mobiluncus curtisii, noted Dr. Schwebke, professor of medicine at the University of Alabama, Birmingham, and her associates.

Patients with a Nugent score at baseline of 5–8 (reflecting less complicated flora) were more likely to be cured than women with Nugent scores of 9–10, the intent-to-treat analysis found.

Other factors that have been shown in previous studies to affect cure rates also proved significant in this study. Consistent condom use, sexual abstinence, and refraining from douching improved chances of curing BV with treatment.

SEATTLE — One-fourth of 182 women with peripartum cardiomyopathy developed major adverse events, half of which were death or heart transplantation, Dr. Sorel Goland reported in a poster presentation at the annual meeting of the Heart Failure Society of America.

Women with peripartum cardiomyopathy who had very low ejection fractions of 25% or who were not white were most likely to develop major adverse events, 50% of which occurred before the diagnosis of peripartum cardiomyopathy was made, said Dr. Goland of the department of cardiology at Cedars-Sinai Medical Center, Los Angeles, and associates.

A delay in diagnosing peripartum cardiomyopathy of a week or longer increased the risk for death or heart transplant fivefold.

“Diagnosis of peripartum cardiomyopathy is often delayed and preceded by major adverse events. Early diagnosis and aggressive therapy, including treatment of heart failure, anticoagulation, and sudden death prevention, should improve the outcome of patients,” the investigators stated.

The clinical profile of peripartum cardiomyopathy and the risk factors for complications have not been well characterized previously because of the low incidence of this disorder. Peripartum cardiomyopathy occurs during pregnancy or the postpartum period because of unknown causes and can be associated with severe complications.

The retrospective review of data on 182 patients found that 25% died, underwent heart transplantation, developed cardiopulmonary arrest, required temporary circulatory support by an intra-aortic balloon pump or a left ventricular assist device, developed pulmonary edema or thromboembolic complications, or had a pacemaker or implantable cardioverter defibrillator implanted. Of the 46 major adverse events, 36 (78%) occurred within 6 months of the diagnosis of peripartum cardiomyopathy.

Of the 182 patients, 24 (13%) died or underwent heart transplantation; 16 of the 24 deaths or transplants happened within 6 months of diagnosis.

Patients with ejection fractions of 25% or less had quadruple the risk for major adverse events in general and for death or heart transplant, compared with patients who had higher ejection fractions. Nonwhite patients were three times more likely to develop major complications and four times more likely to die or need a heart transplant, compared with white patients.

ELSEVIER GLOBAL MEDICAL NEWS

SEATTLE — One-fourth of 182 women with peripartum cardiomyopathy developed major adverse events, half of which were death or heart transplantation, Dr. Sorel Goland reported in a poster presentation at the annual meeting of the Heart Failure Society of America.

Women with peripartum cardiomyopathy who had very low ejection fractions of 25% or who were not white were most likely to develop major adverse events, 50% of which occurred before the diagnosis of peripartum cardiomyopathy was made, said Dr. Goland of the department of cardiology at Cedars-Sinai Medical Center, Los Angeles, and associates.

A delay in diagnosing peripartum cardiomyopathy of a week or longer increased the risk for death or heart transplant fivefold.

“Diagnosis of peripartum cardiomyopathy is often delayed and preceded by major adverse events. Early diagnosis and aggressive therapy, including treatment of heart failure, anticoagulation, and sudden death prevention, should improve the outcome of patients,” the investigators stated.

The clinical profile of peripartum cardiomyopathy and the risk factors for complications have not been well characterized previously because of the low incidence of this disorder. Peripartum cardiomyopathy occurs during pregnancy or the postpartum period because of unknown causes and can be associated with severe complications.

The retrospective review of data on 182 patients found that 25% died, underwent heart transplantation, developed cardiopulmonary arrest, required temporary circulatory support by an intra-aortic balloon pump or a left ventricular assist device, developed pulmonary edema or thromboembolic complications, or had a pacemaker or implantable cardioverter defibrillator implanted. Of the 46 major adverse events, 36 (78%) occurred within 6 months of the diagnosis of peripartum cardiomyopathy.

Of the 182 patients, 24 (13%) died or underwent heart transplantation; 16 of the 24 deaths or transplants happened within 6 months of diagnosis.

Patients with ejection fractions of 25% or less had quadruple the risk for major adverse events in general and for death or heart transplant, compared with patients who had higher ejection fractions. Nonwhite patients were three times more likely to develop major complications and four times more likely to die or need a heart transplant, compared with white patients.

ELSEVIER GLOBAL MEDICAL NEWS

SEATTLE — One-fourth of 182 women with peripartum cardiomyopathy developed major adverse events, half of which were death or heart transplantation, Dr. Sorel Goland reported in a poster presentation at the annual meeting of the Heart Failure Society of America.

Women with peripartum cardiomyopathy who had very low ejection fractions of 25% or who were not white were most likely to develop major adverse events, 50% of which occurred before the diagnosis of peripartum cardiomyopathy was made, said Dr. Goland of the department of cardiology at Cedars-Sinai Medical Center, Los Angeles, and associates.

A delay in diagnosing peripartum cardiomyopathy of a week or longer increased the risk for death or heart transplant fivefold.

“Diagnosis of peripartum cardiomyopathy is often delayed and preceded by major adverse events. Early diagnosis and aggressive therapy, including treatment of heart failure, anticoagulation, and sudden death prevention, should improve the outcome of patients,” the investigators stated.

The clinical profile of peripartum cardiomyopathy and the risk factors for complications have not been well characterized previously because of the low incidence of this disorder. Peripartum cardiomyopathy occurs during pregnancy or the postpartum period because of unknown causes and can be associated with severe complications.

The retrospective review of data on 182 patients found that 25% died, underwent heart transplantation, developed cardiopulmonary arrest, required temporary circulatory support by an intra-aortic balloon pump or a left ventricular assist device, developed pulmonary edema or thromboembolic complications, or had a pacemaker or implantable cardioverter defibrillator implanted. Of the 46 major adverse events, 36 (78%) occurred within 6 months of the diagnosis of peripartum cardiomyopathy.

Of the 182 patients, 24 (13%) died or underwent heart transplantation; 16 of the 24 deaths or transplants happened within 6 months of diagnosis.

Patients with ejection fractions of 25% or less had quadruple the risk for major adverse events in general and for death or heart transplant, compared with patients who had higher ejection fractions. Nonwhite patients were three times more likely to develop major complications and four times more likely to die or need a heart transplant, compared with white patients.

ELSEVIER GLOBAL MEDICAL NEWS

MONTEREY, CALIF. — Neonates who were exposed to gentamicin in utero when their mothers were treated for pyelonephritis showed no increased risk of failing screening tests for hearing loss in a controlled study of 284 pregnancies, Dr. Tony Wen said.

The ongoing retrospective chart review analyzed cases of pregnant women who received gentamicin and ampicillin for pyelonephritis and delivered at 32 weeks' gestational age or later with the next gentamicin-free pregnancy matched by gestational age. All neonates underwent otoacoustic emissions testing after birth. Failure or incomplete results brought a second round of otoacoustic emissions testing before discharge. A second failure led to referral for more definitive hearing tests.

Among women with pyelonephritis, 92% received gentamicin, which crosses the placenta at term. Overall, 8% of newborns exposed to gentamicin in utero and 10% of controls failed otoacoustic emissions testing—opposite the trend that investigators expected to see because of concerns about gentamicin's potential effects on hearing, he said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In the general population, 5%–8% of newborns fail otoacoustic emissions tests. The study was inspired by animal studies that found hearing loss in rats exposed in utero to gentamicin.

Gentamicin is an aminoglycoside with broad-spectrum coverage that is commonly used to treat women with pyelonephritis and chorioamnionitis, according to Dr. Wen of the University of Texas, Galveston, and his associates.

A subset analysis by trimester found that early-trimester exposure to gentamicin did not increase risk for otoacoustic emissions testing failure.

Neonates who were small for gestational age showed no increased risk for failing otoacoustic emissions testing from gentamicin exposure.

There was a statistically nonsignificant trend for longer courses of gentamicin to increase the risk for otoacoustic emissions test failure. After 4 days or less of gentamicin treatment, 2% of neonates failed the tests, compared with 12% of neonates whose mothers got gentamicin for 5 days or longer.

“If you have a patient who requires prolonged treatment, once you get the sensitivity testing results, you might consider changing antibiotics” if the mother is on gentamicin, Dr. Wen said.

Women treated with gentamicin and ampicillin received gentamicin in a loading dose of 120 mg followed by 80 mg gentamicin every 8 hours. Patients got 6–20 doses of gentamicin in the study.

The case and control groups did not differ in maternal or gestational age, gravidity, Apgar scores, birth weights, or mode of delivery, among other factors.

MONTEREY, CALIF. — Neonates who were exposed to gentamicin in utero when their mothers were treated for pyelonephritis showed no increased risk of failing screening tests for hearing loss in a controlled study of 284 pregnancies, Dr. Tony Wen said.

The ongoing retrospective chart review analyzed cases of pregnant women who received gentamicin and ampicillin for pyelonephritis and delivered at 32 weeks' gestational age or later with the next gentamicin-free pregnancy matched by gestational age. All neonates underwent otoacoustic emissions testing after birth. Failure or incomplete results brought a second round of otoacoustic emissions testing before discharge. A second failure led to referral for more definitive hearing tests.

Among women with pyelonephritis, 92% received gentamicin, which crosses the placenta at term. Overall, 8% of newborns exposed to gentamicin in utero and 10% of controls failed otoacoustic emissions testing—opposite the trend that investigators expected to see because of concerns about gentamicin's potential effects on hearing, he said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In the general population, 5%–8% of newborns fail otoacoustic emissions tests. The study was inspired by animal studies that found hearing loss in rats exposed in utero to gentamicin.

Gentamicin is an aminoglycoside with broad-spectrum coverage that is commonly used to treat women with pyelonephritis and chorioamnionitis, according to Dr. Wen of the University of Texas, Galveston, and his associates.

A subset analysis by trimester found that early-trimester exposure to gentamicin did not increase risk for otoacoustic emissions testing failure.

Neonates who were small for gestational age showed no increased risk for failing otoacoustic emissions testing from gentamicin exposure.

There was a statistically nonsignificant trend for longer courses of gentamicin to increase the risk for otoacoustic emissions test failure. After 4 days or less of gentamicin treatment, 2% of neonates failed the tests, compared with 12% of neonates whose mothers got gentamicin for 5 days or longer.

“If you have a patient who requires prolonged treatment, once you get the sensitivity testing results, you might consider changing antibiotics” if the mother is on gentamicin, Dr. Wen said.

Women treated with gentamicin and ampicillin received gentamicin in a loading dose of 120 mg followed by 80 mg gentamicin every 8 hours. Patients got 6–20 doses of gentamicin in the study.

The case and control groups did not differ in maternal or gestational age, gravidity, Apgar scores, birth weights, or mode of delivery, among other factors.

MONTEREY, CALIF. — Neonates who were exposed to gentamicin in utero when their mothers were treated for pyelonephritis showed no increased risk of failing screening tests for hearing loss in a controlled study of 284 pregnancies, Dr. Tony Wen said.

The ongoing retrospective chart review analyzed cases of pregnant women who received gentamicin and ampicillin for pyelonephritis and delivered at 32 weeks' gestational age or later with the next gentamicin-free pregnancy matched by gestational age. All neonates underwent otoacoustic emissions testing after birth. Failure or incomplete results brought a second round of otoacoustic emissions testing before discharge. A second failure led to referral for more definitive hearing tests.

Among women with pyelonephritis, 92% received gentamicin, which crosses the placenta at term. Overall, 8% of newborns exposed to gentamicin in utero and 10% of controls failed otoacoustic emissions testing—opposite the trend that investigators expected to see because of concerns about gentamicin's potential effects on hearing, he said at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In the general population, 5%–8% of newborns fail otoacoustic emissions tests. The study was inspired by animal studies that found hearing loss in rats exposed in utero to gentamicin.

Gentamicin is an aminoglycoside with broad-spectrum coverage that is commonly used to treat women with pyelonephritis and chorioamnionitis, according to Dr. Wen of the University of Texas, Galveston, and his associates.

A subset analysis by trimester found that early-trimester exposure to gentamicin did not increase risk for otoacoustic emissions testing failure.

Neonates who were small for gestational age showed no increased risk for failing otoacoustic emissions testing from gentamicin exposure.

There was a statistically nonsignificant trend for longer courses of gentamicin to increase the risk for otoacoustic emissions test failure. After 4 days or less of gentamicin treatment, 2% of neonates failed the tests, compared with 12% of neonates whose mothers got gentamicin for 5 days or longer.

“If you have a patient who requires prolonged treatment, once you get the sensitivity testing results, you might consider changing antibiotics” if the mother is on gentamicin, Dr. Wen said.

Women treated with gentamicin and ampicillin received gentamicin in a loading dose of 120 mg followed by 80 mg gentamicin every 8 hours. Patients got 6–20 doses of gentamicin in the study.

The case and control groups did not differ in maternal or gestational age, gravidity, Apgar scores, birth weights, or mode of delivery, among other factors.

SEATTLE — Low-dose aspirin did not reduce the beneficial effects of ACE inhibitors in patients with atrial fibrillation and a history of heart failure, a subset analysis of 2,031 patients found.

The analysis addressed recurring concerns that aspirin use attenuates the effects of ACE inhibitors in heart failure patients and supported the use of both low-dose aspirin and an ACE inhibitor when indications for both treatments exist, Dr. Akshay S. Desai said at the annual meeting of the Heart Failure Society of America.

Dr. Desai and associates studied data from the Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events (ACTIVE-W). The prospective, open-label study randomized patients with atrial fibrillation to combination antiplatelet therapy with clopidogrel and 75–100 mg/day of aspirin or to oral anticoagulation with warfarin. ACTIVE-W was discontinued early because warfarin clearly reduced the risk of MI, vascular events, or death.

Compared with all ACTIVE-W patients, the 2,031 patients with prior heart failure were more likely to be hypertensive or diabetic; have left ventricular dysfunction, a prior MI, or coronary disease; and be on an ACE inhibitor or angiotensin receptor blocker at baseline. Patients with prior heart failure in ACTIVE-W were twice as likely to develop MI, vascular events, or death, as those with no such history.

Notably, however, the relative benefits of antiplatelet or anticoagulant therapy to prevent thromboembolic events did not differ significantly either in ACTIVE-W patients as a whole or in the subset of patients with heart failure, said Dr. Desai of Brigham and Women's Hospital, Boston. The risk of bleeding complications also did not differ between treatment groups.

Looking at the composite end point of death or hospitalization for heart failure, patients with a history of heart failure carried triple the risk, compared with non-heart failure patients, but again there was no significant difference between the antiplatelet and anticoagulant treatment groups.

The investigators stratified patients with heart failure based on whether they did or did not use an ACE inhibitor at baseline, expecting to see a greater relative benefit in the warfarin group if aspirin attenuated the effects of ACE inhibitors. They found no statistically significant differences between the antiplatelet and anticoagulation groups, suggesting no interaction between aspirin and ACE inhibitors.

Some heart failure patients in the warfarin group also were on ACE inhibitors at baseline, which might have limited the power to detect an aspirin-ACE inhibitor interaction, so they repeated the analyses after excluding patients on an ACE inhibitor at baseline who were randomized to warfarin. Again, they found no significant aspirin-ACE inhibitor interaction.

Concerns about such an interaction began with a 1992 hemodynamic study, later confirmed by others, that showed that coadministration of enalapril and aspirin in 18 patients with severe heart failure attenuated some of the hemodynamic effects of ACE inhibitors on vascular resistance. A retrospective analysis of the SOLVD trial suggested that patients on enalapril were more likely to die if they also took aspirin. A similar finding came from a retrospective analysis of the Scandinavian CONSENSUS II study. A large meta-analysis of ACE inhibitor trials, however, found no significant increase in death or hospitalization for heart failure with concurrent use of aspirin, said Dr. Desai, who has no relationships with the companies that make the drugs he discussed.

SEATTLE — Low-dose aspirin did not reduce the beneficial effects of ACE inhibitors in patients with atrial fibrillation and a history of heart failure, a subset analysis of 2,031 patients found.

The analysis addressed recurring concerns that aspirin use attenuates the effects of ACE inhibitors in heart failure patients and supported the use of both low-dose aspirin and an ACE inhibitor when indications for both treatments exist, Dr. Akshay S. Desai said at the annual meeting of the Heart Failure Society of America.

Dr. Desai and associates studied data from the Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events (ACTIVE-W). The prospective, open-label study randomized patients with atrial fibrillation to combination antiplatelet therapy with clopidogrel and 75–100 mg/day of aspirin or to oral anticoagulation with warfarin. ACTIVE-W was discontinued early because warfarin clearly reduced the risk of MI, vascular events, or death.

Compared with all ACTIVE-W patients, the 2,031 patients with prior heart failure were more likely to be hypertensive or diabetic; have left ventricular dysfunction, a prior MI, or coronary disease; and be on an ACE inhibitor or angiotensin receptor blocker at baseline. Patients with prior heart failure in ACTIVE-W were twice as likely to develop MI, vascular events, or death, as those with no such history.

Notably, however, the relative benefits of antiplatelet or anticoagulant therapy to prevent thromboembolic events did not differ significantly either in ACTIVE-W patients as a whole or in the subset of patients with heart failure, said Dr. Desai of Brigham and Women's Hospital, Boston. The risk of bleeding complications also did not differ between treatment groups.

Looking at the composite end point of death or hospitalization for heart failure, patients with a history of heart failure carried triple the risk, compared with non-heart failure patients, but again there was no significant difference between the antiplatelet and anticoagulant treatment groups.

The investigators stratified patients with heart failure based on whether they did or did not use an ACE inhibitor at baseline, expecting to see a greater relative benefit in the warfarin group if aspirin attenuated the effects of ACE inhibitors. They found no statistically significant differences between the antiplatelet and anticoagulation groups, suggesting no interaction between aspirin and ACE inhibitors.

Some heart failure patients in the warfarin group also were on ACE inhibitors at baseline, which might have limited the power to detect an aspirin-ACE inhibitor interaction, so they repeated the analyses after excluding patients on an ACE inhibitor at baseline who were randomized to warfarin. Again, they found no significant aspirin-ACE inhibitor interaction.

Concerns about such an interaction began with a 1992 hemodynamic study, later confirmed by others, that showed that coadministration of enalapril and aspirin in 18 patients with severe heart failure attenuated some of the hemodynamic effects of ACE inhibitors on vascular resistance. A retrospective analysis of the SOLVD trial suggested that patients on enalapril were more likely to die if they also took aspirin. A similar finding came from a retrospective analysis of the Scandinavian CONSENSUS II study. A large meta-analysis of ACE inhibitor trials, however, found no significant increase in death or hospitalization for heart failure with concurrent use of aspirin, said Dr. Desai, who has no relationships with the companies that make the drugs he discussed.

SEATTLE — Low-dose aspirin did not reduce the beneficial effects of ACE inhibitors in patients with atrial fibrillation and a history of heart failure, a subset analysis of 2,031 patients found.

The analysis addressed recurring concerns that aspirin use attenuates the effects of ACE inhibitors in heart failure patients and supported the use of both low-dose aspirin and an ACE inhibitor when indications for both treatments exist, Dr. Akshay S. Desai said at the annual meeting of the Heart Failure Society of America.

Dr. Desai and associates studied data from the Atrial Fibrillation Clopidogrel Trial with Irbesartan for Prevention of Vascular Events (ACTIVE-W). The prospective, open-label study randomized patients with atrial fibrillation to combination antiplatelet therapy with clopidogrel and 75–100 mg/day of aspirin or to oral anticoagulation with warfarin. ACTIVE-W was discontinued early because warfarin clearly reduced the risk of MI, vascular events, or death.

Compared with all ACTIVE-W patients, the 2,031 patients with prior heart failure were more likely to be hypertensive or diabetic; have left ventricular dysfunction, a prior MI, or coronary disease; and be on an ACE inhibitor or angiotensin receptor blocker at baseline. Patients with prior heart failure in ACTIVE-W were twice as likely to develop MI, vascular events, or death, as those with no such history.

Notably, however, the relative benefits of antiplatelet or anticoagulant therapy to prevent thromboembolic events did not differ significantly either in ACTIVE-W patients as a whole or in the subset of patients with heart failure, said Dr. Desai of Brigham and Women's Hospital, Boston. The risk of bleeding complications also did not differ between treatment groups.

Looking at the composite end point of death or hospitalization for heart failure, patients with a history of heart failure carried triple the risk, compared with non-heart failure patients, but again there was no significant difference between the antiplatelet and anticoagulant treatment groups.

The investigators stratified patients with heart failure based on whether they did or did not use an ACE inhibitor at baseline, expecting to see a greater relative benefit in the warfarin group if aspirin attenuated the effects of ACE inhibitors. They found no statistically significant differences between the antiplatelet and anticoagulation groups, suggesting no interaction between aspirin and ACE inhibitors.

Some heart failure patients in the warfarin group also were on ACE inhibitors at baseline, which might have limited the power to detect an aspirin-ACE inhibitor interaction, so they repeated the analyses after excluding patients on an ACE inhibitor at baseline who were randomized to warfarin. Again, they found no significant aspirin-ACE inhibitor interaction.

Concerns about such an interaction began with a 1992 hemodynamic study, later confirmed by others, that showed that coadministration of enalapril and aspirin in 18 patients with severe heart failure attenuated some of the hemodynamic effects of ACE inhibitors on vascular resistance. A retrospective analysis of the SOLVD trial suggested that patients on enalapril were more likely to die if they also took aspirin. A similar finding came from a retrospective analysis of the Scandinavian CONSENSUS II study. A large meta-analysis of ACE inhibitor trials, however, found no significant increase in death or hospitalization for heart failure with concurrent use of aspirin, said Dr. Desai, who has no relationships with the companies that make the drugs he discussed.

SAN FRANCISCO — Patients with end-stage heart failure who received cardiac injections of autologous endothelial progenitor cells showed significant improvements in function and ejection fraction 3 months later, Dr. Kitipan V. Arom reported.

The stem cell therapy treated 32 patients with ischemic cardiomyopathy and 21 with nonischemic dilated cardiomyopathy. Forty-three patients received the cell injections alone, eight underwent coronary artery bypass grafting with the cell injections, and two had a redo CABG with the cell injections, he said at the annual meeting of the International Society for Minimally Invasive Cardiothoracic Surgery.

One patient died 3 days after treatment, most likely from pulmonary emboli. The rest of the patients improved their New York Heart Association functional class from an average of class III to less than class II, said Dr. Arom of Bangkok Heart Hospital, Thailand, and associates.

The NYHA class improved in patients with ischemic cardiomyopathy from an average of 2.7 before cell injections to 1.4 at the 3-month follow-up. In the dilated cardiomyopathy group, the average improved from class III before treatment to II at the 3-month follow-up. Preoperative left ventricular ejection fractions averaged 26% in the ischemic cardiomyopathy group and 23% in the dilated cardiomyopathy group. Cell injection therapy improved ejection fractions significantly by an absolute 10% and 11%, respectively, he said.

Perfusion defects were seen in 19 patients before treatment and 11 patients at follow-up. Patients were able to walk farther in the 6-minute walk test after treatment, and scores on quality-of-life measures improved. Improvements in regional wall motion after therapy could be seen on cardiac MRI and four-chamber echocardiography.

The results are short term, and no one yet has data on outcomes longer than 2 years after stem cell transplants, Dr. Arom noted. So far, however, results are encouraging. “Hopefully, some time in the future, cell therapy can replace heart transplantation for end-stage heart failure,” he said.

Stem cells can come from many sources; this study used peripheral blood, which has the capacity to self-renew and differentiate into one or more cell types, Dr. Arom said. A week before surgery, patients donated 250 cc of blood that was sent for cell separation and growing. The stem cells produced were returned in 15-cc vials, each containing 1.5 million cells. All patients underwent cardiac MRI, echocardiography, and coronary angiography to help plan the injections.

In the dilated cardiomyopathy group, surgeons made 30 injections into multiple areas of the left ventricular wall using 0.5 cc per injection. Patients with ischemic cardiomyopathy received injections directly into the scar area and surrounding tissue.

The treatment was the last hope for these patients, who were much sicker than the average patient undergoing CABG is, he said. They had run the course of medical and surgical therapies. They suffered from mitral or tricuspid regurgitation, renal insufficiency, or other problems, and had been turned down for redo CABGs, valve replacements, or other surgeries.

The use of autologous progenitor cells avoids rejection concerns, and so far, there has been no evidence with these cells of the arrhythmogenic side effects seen with bone marrow cell transplant, he said.

SAN FRANCISCO — Patients with end-stage heart failure who received cardiac injections of autologous endothelial progenitor cells showed significant improvements in function and ejection fraction 3 months later, Dr. Kitipan V. Arom reported.

The stem cell therapy treated 32 patients with ischemic cardiomyopathy and 21 with nonischemic dilated cardiomyopathy. Forty-three patients received the cell injections alone, eight underwent coronary artery bypass grafting with the cell injections, and two had a redo CABG with the cell injections, he said at the annual meeting of the International Society for Minimally Invasive Cardiothoracic Surgery.

One patient died 3 days after treatment, most likely from pulmonary emboli. The rest of the patients improved their New York Heart Association functional class from an average of class III to less than class II, said Dr. Arom of Bangkok Heart Hospital, Thailand, and associates.

The NYHA class improved in patients with ischemic cardiomyopathy from an average of 2.7 before cell injections to 1.4 at the 3-month follow-up. In the dilated cardiomyopathy group, the average improved from class III before treatment to II at the 3-month follow-up. Preoperative left ventricular ejection fractions averaged 26% in the ischemic cardiomyopathy group and 23% in the dilated cardiomyopathy group. Cell injection therapy improved ejection fractions significantly by an absolute 10% and 11%, respectively, he said.

Perfusion defects were seen in 19 patients before treatment and 11 patients at follow-up. Patients were able to walk farther in the 6-minute walk test after treatment, and scores on quality-of-life measures improved. Improvements in regional wall motion after therapy could be seen on cardiac MRI and four-chamber echocardiography.

The results are short term, and no one yet has data on outcomes longer than 2 years after stem cell transplants, Dr. Arom noted. So far, however, results are encouraging. “Hopefully, some time in the future, cell therapy can replace heart transplantation for end-stage heart failure,” he said.

Stem cells can come from many sources; this study used peripheral blood, which has the capacity to self-renew and differentiate into one or more cell types, Dr. Arom said. A week before surgery, patients donated 250 cc of blood that was sent for cell separation and growing. The stem cells produced were returned in 15-cc vials, each containing 1.5 million cells. All patients underwent cardiac MRI, echocardiography, and coronary angiography to help plan the injections.

In the dilated cardiomyopathy group, surgeons made 30 injections into multiple areas of the left ventricular wall using 0.5 cc per injection. Patients with ischemic cardiomyopathy received injections directly into the scar area and surrounding tissue.

The treatment was the last hope for these patients, who were much sicker than the average patient undergoing CABG is, he said. They had run the course of medical and surgical therapies. They suffered from mitral or tricuspid regurgitation, renal insufficiency, or other problems, and had been turned down for redo CABGs, valve replacements, or other surgeries.

The use of autologous progenitor cells avoids rejection concerns, and so far, there has been no evidence with these cells of the arrhythmogenic side effects seen with bone marrow cell transplant, he said.

SAN FRANCISCO — Patients with end-stage heart failure who received cardiac injections of autologous endothelial progenitor cells showed significant improvements in function and ejection fraction 3 months later, Dr. Kitipan V. Arom reported.

The stem cell therapy treated 32 patients with ischemic cardiomyopathy and 21 with nonischemic dilated cardiomyopathy. Forty-three patients received the cell injections alone, eight underwent coronary artery bypass grafting with the cell injections, and two had a redo CABG with the cell injections, he said at the annual meeting of the International Society for Minimally Invasive Cardiothoracic Surgery.

One patient died 3 days after treatment, most likely from pulmonary emboli. The rest of the patients improved their New York Heart Association functional class from an average of class III to less than class II, said Dr. Arom of Bangkok Heart Hospital, Thailand, and associates.

The NYHA class improved in patients with ischemic cardiomyopathy from an average of 2.7 before cell injections to 1.4 at the 3-month follow-up. In the dilated cardiomyopathy group, the average improved from class III before treatment to II at the 3-month follow-up. Preoperative left ventricular ejection fractions averaged 26% in the ischemic cardiomyopathy group and 23% in the dilated cardiomyopathy group. Cell injection therapy improved ejection fractions significantly by an absolute 10% and 11%, respectively, he said.

Perfusion defects were seen in 19 patients before treatment and 11 patients at follow-up. Patients were able to walk farther in the 6-minute walk test after treatment, and scores on quality-of-life measures improved. Improvements in regional wall motion after therapy could be seen on cardiac MRI and four-chamber echocardiography.

The results are short term, and no one yet has data on outcomes longer than 2 years after stem cell transplants, Dr. Arom noted. So far, however, results are encouraging. “Hopefully, some time in the future, cell therapy can replace heart transplantation for end-stage heart failure,” he said.

Stem cells can come from many sources; this study used peripheral blood, which has the capacity to self-renew and differentiate into one or more cell types, Dr. Arom said. A week before surgery, patients donated 250 cc of blood that was sent for cell separation and growing. The stem cells produced were returned in 15-cc vials, each containing 1.5 million cells. All patients underwent cardiac MRI, echocardiography, and coronary angiography to help plan the injections.

In the dilated cardiomyopathy group, surgeons made 30 injections into multiple areas of the left ventricular wall using 0.5 cc per injection. Patients with ischemic cardiomyopathy received injections directly into the scar area and surrounding tissue.

The treatment was the last hope for these patients, who were much sicker than the average patient undergoing CABG is, he said. They had run the course of medical and surgical therapies. They suffered from mitral or tricuspid regurgitation, renal insufficiency, or other problems, and had been turned down for redo CABGs, valve replacements, or other surgeries.

The use of autologous progenitor cells avoids rejection concerns, and so far, there has been no evidence with these cells of the arrhythmogenic side effects seen with bone marrow cell transplant, he said.

SAN FRANCISCO — Dedicating an ECG technician to the emergency department triage team shortened the wait for ECGs in patients with ST-elevation MI, but it didn't decrease times to reperfusion, Kathy Parish, R.N., reported.

She and her associates in the emergency department at William Beaumont Hospital, Royal Oak, Mich., compared arrival-to-ECG times and arrival-to-reperfusion times in the first 6 months of 2005 with data from the second 6 months of 2005 after institution of a rapid-ECG protocol.

In the first half of the year, education, training, and posters in the emergency department emphasized guidelines for rapid ECG of potential STEMI patients, but the triage team did not include a dedicated ECG technician. In the second half of the year, patients assessed by the triage nurse as having potential STEMI bypassed routine processing and underwent ECG by a technician assigned to the triage team for that purpose, she said in a poster presentation at the annual meeting of the Society for Academic Emergency Medicine.

Patients qualified for rapid ECG during either period if they were at least 30 years old with chest pain or at least 50 years old with syncope, weakness, rapid heartbeat or palpitations, difficulty breathing, or shortness of breath.

Data for 144 patients ultimately diagnosed with STEMI showed that the rapid-ECG protocol significantly decreased arrival-to-ECG times from 26 minutes in the control period to 10 minutes. The proportion of patients who waited longer than 30 minutes for an ECG also significantly decreased, from 19% to 2%.

The proportion of patients who underwent an ECG within 10 minutes did not change significantly: 64% in the control period and 50% with the rapid-ECG protocol. A slight increase in arrival-to-reperfusion times—from 100 minutes in the control period to 105 minutes in the trial period—was not significant.

SAN FRANCISCO — Dedicating an ECG technician to the emergency department triage team shortened the wait for ECGs in patients with ST-elevation MI, but it didn't decrease times to reperfusion, Kathy Parish, R.N., reported.

She and her associates in the emergency department at William Beaumont Hospital, Royal Oak, Mich., compared arrival-to-ECG times and arrival-to-reperfusion times in the first 6 months of 2005 with data from the second 6 months of 2005 after institution of a rapid-ECG protocol.

In the first half of the year, education, training, and posters in the emergency department emphasized guidelines for rapid ECG of potential STEMI patients, but the triage team did not include a dedicated ECG technician. In the second half of the year, patients assessed by the triage nurse as having potential STEMI bypassed routine processing and underwent ECG by a technician assigned to the triage team for that purpose, she said in a poster presentation at the annual meeting of the Society for Academic Emergency Medicine.

Patients qualified for rapid ECG during either period if they were at least 30 years old with chest pain or at least 50 years old with syncope, weakness, rapid heartbeat or palpitations, difficulty breathing, or shortness of breath.

Data for 144 patients ultimately diagnosed with STEMI showed that the rapid-ECG protocol significantly decreased arrival-to-ECG times from 26 minutes in the control period to 10 minutes. The proportion of patients who waited longer than 30 minutes for an ECG also significantly decreased, from 19% to 2%.

The proportion of patients who underwent an ECG within 10 minutes did not change significantly: 64% in the control period and 50% with the rapid-ECG protocol. A slight increase in arrival-to-reperfusion times—from 100 minutes in the control period to 105 minutes in the trial period—was not significant.

SAN FRANCISCO — Dedicating an ECG technician to the emergency department triage team shortened the wait for ECGs in patients with ST-elevation MI, but it didn't decrease times to reperfusion, Kathy Parish, R.N., reported.

She and her associates in the emergency department at William Beaumont Hospital, Royal Oak, Mich., compared arrival-to-ECG times and arrival-to-reperfusion times in the first 6 months of 2005 with data from the second 6 months of 2005 after institution of a rapid-ECG protocol.

In the first half of the year, education, training, and posters in the emergency department emphasized guidelines for rapid ECG of potential STEMI patients, but the triage team did not include a dedicated ECG technician. In the second half of the year, patients assessed by the triage nurse as having potential STEMI bypassed routine processing and underwent ECG by a technician assigned to the triage team for that purpose, she said in a poster presentation at the annual meeting of the Society for Academic Emergency Medicine.

Patients qualified for rapid ECG during either period if they were at least 30 years old with chest pain or at least 50 years old with syncope, weakness, rapid heartbeat or palpitations, difficulty breathing, or shortness of breath.

Data for 144 patients ultimately diagnosed with STEMI showed that the rapid-ECG protocol significantly decreased arrival-to-ECG times from 26 minutes in the control period to 10 minutes. The proportion of patients who waited longer than 30 minutes for an ECG also significantly decreased, from 19% to 2%.

The proportion of patients who underwent an ECG within 10 minutes did not change significantly: 64% in the control period and 50% with the rapid-ECG protocol. A slight increase in arrival-to-reperfusion times—from 100 minutes in the control period to 105 minutes in the trial period—was not significant.

SAN FRANCISCO — Internists prescribed the most broad-spectrum antibiotics and pediatricians the most narrow-spectrum antibiotics for respiratory tract infections in a national managed care population, Katie J. Suda, Pharm.D., reported in a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

“Looking at a managed care population, a majority of them aren't going to have ten different diseases. In general, you don't need broad-spectrum therapy right off the bat,” said Dr. Suda of the University of Tennessee, Memphis.

She and her associates performed what may be the first national analysis of outpatient antimicrobial prescribing for respiratory tract infections by specialty. They studied databases from nine managed care organizations for 48,182 antibiotic prescriptions by 7,613 physicians for 26,875 patients with respiratory tract infections from 2001 through 2003, excluding cases in which the drug was dispensed for more than 27 days. Treatment averaged 10 days for patients in the study.

Among the physicians, 21% were pediatricians, 39% were family physicians, 4% were internists, 3% were general medical physicians, 5% were emergency medicine physicians, and 5% each were specialists in infectious diseases, gastroenterology, or other specialties. Four percent of physicians were dermatologists, 3% were ob.gyns., 3% were surgeons, and other physicians composed 3% of the total.

The bulk of treatments consisted of penicillins (29%) or macrolides (27%), with fluoroquinolones accounting for 15%, she reported at the meeting, which was sponsored by the American Society for Microbiology. Cephalosporins made up 14% of prescriptions, tetracyclines were 6%, and 9% were other drugs.

For upper respiratory tract infections, pediatricians most often prescribed penicillins (in about 42% of prescriptions), followed by macrolides (about 22%) and beta-lactamase inhibitors (16%).

Emergency physicians and internists favored macrolides for upper respiratory tract infections, in about 51% and 40% of prescriptions, respectively. They ordered beta-lactamase inhibitors second most commonly, in about 30% of prescriptions.

Family physicians and specialists wrote predominantly for beta-lactamase inhibitors, in about 40% of prescriptions for upper respiratory tract infections.

Internists led other physicians in prescribing fluoroquinolones, composing 20% of their prescriptions for upper respiratory tract infections. Fluoroquinolones made up approximately 1% of prescriptions by pediatricians for this indication, 10% by emergency physicians, 11% by family physicians, and about 13% by specialists.

For lower respiratory tract infections, pediatricians favored macrolides (about 58% of prescriptions) and beta-lactamase inhibitors (39%). They ordered fluoroquinolones only about 2% of the time.

Fluoroquinolone use was much higher among other physicians for lower respiratory tract infection, composing around 43% of prescriptions by internists, 40% by family physicians, and 30% by emergency physicians. These physicians used more broad-spectrum agents for lower than for upper respiratory tract infections, Dr. Suda noted.

Comorbidities were more common with lower than with upper respiratory tract infection. Nearly 10% of lower respiratory tract infections were accompanied by pulmonary problems, 7% had cardiovascular problems, 5% had endocrine morbidities, 5% had oncologic problems, and around 4% had gastrointestinal comorbidities.

Diagnoses of upper respiratory tract infections were accompanied by pulmonary problems in 5% of cases, cardiovascular comorbidities in 4%, gastrointestinal problems in 3%, endocrine problems in 2%, and oncological comorbidities in less than 2%.

Patients averaged 34 years in age, ranging from 3 months to 101 years old.

SAN FRANCISCO — Internists prescribed the most broad-spectrum antibiotics and pediatricians the most narrow-spectrum antibiotics for respiratory tract infections in a national managed care population, Katie J. Suda, Pharm.D., reported in a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

“Looking at a managed care population, a majority of them aren't going to have ten different diseases. In general, you don't need broad-spectrum therapy right off the bat,” said Dr. Suda of the University of Tennessee, Memphis.

She and her associates performed what may be the first national analysis of outpatient antimicrobial prescribing for respiratory tract infections by specialty. They studied databases from nine managed care organizations for 48,182 antibiotic prescriptions by 7,613 physicians for 26,875 patients with respiratory tract infections from 2001 through 2003, excluding cases in which the drug was dispensed for more than 27 days. Treatment averaged 10 days for patients in the study.

Among the physicians, 21% were pediatricians, 39% were family physicians, 4% were internists, 3% were general medical physicians, 5% were emergency medicine physicians, and 5% each were specialists in infectious diseases, gastroenterology, or other specialties. Four percent of physicians were dermatologists, 3% were ob.gyns., 3% were surgeons, and other physicians composed 3% of the total.

The bulk of treatments consisted of penicillins (29%) or macrolides (27%), with fluoroquinolones accounting for 15%, she reported at the meeting, which was sponsored by the American Society for Microbiology. Cephalosporins made up 14% of prescriptions, tetracyclines were 6%, and 9% were other drugs.

For upper respiratory tract infections, pediatricians most often prescribed penicillins (in about 42% of prescriptions), followed by macrolides (about 22%) and beta-lactamase inhibitors (16%).

Emergency physicians and internists favored macrolides for upper respiratory tract infections, in about 51% and 40% of prescriptions, respectively. They ordered beta-lactamase inhibitors second most commonly, in about 30% of prescriptions.

Family physicians and specialists wrote predominantly for beta-lactamase inhibitors, in about 40% of prescriptions for upper respiratory tract infections.

Internists led other physicians in prescribing fluoroquinolones, composing 20% of their prescriptions for upper respiratory tract infections. Fluoroquinolones made up approximately 1% of prescriptions by pediatricians for this indication, 10% by emergency physicians, 11% by family physicians, and about 13% by specialists.

For lower respiratory tract infections, pediatricians favored macrolides (about 58% of prescriptions) and beta-lactamase inhibitors (39%). They ordered fluoroquinolones only about 2% of the time.

Fluoroquinolone use was much higher among other physicians for lower respiratory tract infection, composing around 43% of prescriptions by internists, 40% by family physicians, and 30% by emergency physicians. These physicians used more broad-spectrum agents for lower than for upper respiratory tract infections, Dr. Suda noted.

Comorbidities were more common with lower than with upper respiratory tract infection. Nearly 10% of lower respiratory tract infections were accompanied by pulmonary problems, 7% had cardiovascular problems, 5% had endocrine morbidities, 5% had oncologic problems, and around 4% had gastrointestinal comorbidities.

Diagnoses of upper respiratory tract infections were accompanied by pulmonary problems in 5% of cases, cardiovascular comorbidities in 4%, gastrointestinal problems in 3%, endocrine problems in 2%, and oncological comorbidities in less than 2%.

Patients averaged 34 years in age, ranging from 3 months to 101 years old.

SAN FRANCISCO — Internists prescribed the most broad-spectrum antibiotics and pediatricians the most narrow-spectrum antibiotics for respiratory tract infections in a national managed care population, Katie J. Suda, Pharm.D., reported in a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

“Looking at a managed care population, a majority of them aren't going to have ten different diseases. In general, you don't need broad-spectrum therapy right off the bat,” said Dr. Suda of the University of Tennessee, Memphis.

She and her associates performed what may be the first national analysis of outpatient antimicrobial prescribing for respiratory tract infections by specialty. They studied databases from nine managed care organizations for 48,182 antibiotic prescriptions by 7,613 physicians for 26,875 patients with respiratory tract infections from 2001 through 2003, excluding cases in which the drug was dispensed for more than 27 days. Treatment averaged 10 days for patients in the study.

Among the physicians, 21% were pediatricians, 39% were family physicians, 4% were internists, 3% were general medical physicians, 5% were emergency medicine physicians, and 5% each were specialists in infectious diseases, gastroenterology, or other specialties. Four percent of physicians were dermatologists, 3% were ob.gyns., 3% were surgeons, and other physicians composed 3% of the total.

The bulk of treatments consisted of penicillins (29%) or macrolides (27%), with fluoroquinolones accounting for 15%, she reported at the meeting, which was sponsored by the American Society for Microbiology. Cephalosporins made up 14% of prescriptions, tetracyclines were 6%, and 9% were other drugs.

For upper respiratory tract infections, pediatricians most often prescribed penicillins (in about 42% of prescriptions), followed by macrolides (about 22%) and beta-lactamase inhibitors (16%).

Emergency physicians and internists favored macrolides for upper respiratory tract infections, in about 51% and 40% of prescriptions, respectively. They ordered beta-lactamase inhibitors second most commonly, in about 30% of prescriptions.

Family physicians and specialists wrote predominantly for beta-lactamase inhibitors, in about 40% of prescriptions for upper respiratory tract infections.

Internists led other physicians in prescribing fluoroquinolones, composing 20% of their prescriptions for upper respiratory tract infections. Fluoroquinolones made up approximately 1% of prescriptions by pediatricians for this indication, 10% by emergency physicians, 11% by family physicians, and about 13% by specialists.

For lower respiratory tract infections, pediatricians favored macrolides (about 58% of prescriptions) and beta-lactamase inhibitors (39%). They ordered fluoroquinolones only about 2% of the time.

Fluoroquinolone use was much higher among other physicians for lower respiratory tract infection, composing around 43% of prescriptions by internists, 40% by family physicians, and 30% by emergency physicians. These physicians used more broad-spectrum agents for lower than for upper respiratory tract infections, Dr. Suda noted.

Comorbidities were more common with lower than with upper respiratory tract infection. Nearly 10% of lower respiratory tract infections were accompanied by pulmonary problems, 7% had cardiovascular problems, 5% had endocrine morbidities, 5% had oncologic problems, and around 4% had gastrointestinal comorbidities.

Diagnoses of upper respiratory tract infections were accompanied by pulmonary problems in 5% of cases, cardiovascular comorbidities in 4%, gastrointestinal problems in 3%, endocrine problems in 2%, and oncological comorbidities in less than 2%.

Patients averaged 34 years in age, ranging from 3 months to 101 years old.

LAKE TAHOE, CALIF. — The frequency of colonoscopies to screen for cancer in patients with Crohn's disease colitis or ulcerative colitis should be based on how long they've had colitis, Dr. Joshua R. Korzenik said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

Without that pressing motivation, a screening colonoscopy typically would be appropriate every 3–4 years during the first decade of a patient's Crohn's or ulcerative colitis. Because these patients can develop cancer not only from polyps but from flat, normal-appearing mucosa, multiple biopsies are needed. A minimum of 33 biopsies should be taken, spaced about every 4–10 cm throughout the colon. “That has about a 90% likelihood of picking up dysplasia,” said Dr. Korzenik, codirector of the Crohn's and Colitis Center at Massachusetts General Hospital, Boston.

In patients who've had Crohn's or ulcerative colitis for 10–20 years, screening colonoscopy should be performed every other year. For patients with a disease duration longer than 20 years, annual screening colonoscopy is preferred.

If the colonoscopy detects high-grade dysplasia, the patient should undergo a colectomy, Dr. Korzenik advised. Some physicians recommend colectomy for patients with low-grade dysplasia as well, “but that's still an area of dispute,” he added.

LAKE TAHOE, CALIF. — The frequency of colonoscopies to screen for cancer in patients with Crohn's disease colitis or ulcerative colitis should be based on how long they've had colitis, Dr. Joshua R. Korzenik said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

Without that pressing motivation, a screening colonoscopy typically would be appropriate every 3–4 years during the first decade of a patient's Crohn's or ulcerative colitis. Because these patients can develop cancer not only from polyps but from flat, normal-appearing mucosa, multiple biopsies are needed. A minimum of 33 biopsies should be taken, spaced about every 4–10 cm throughout the colon. “That has about a 90% likelihood of picking up dysplasia,” said Dr. Korzenik, codirector of the Crohn's and Colitis Center at Massachusetts General Hospital, Boston.

In patients who've had Crohn's or ulcerative colitis for 10–20 years, screening colonoscopy should be performed every other year. For patients with a disease duration longer than 20 years, annual screening colonoscopy is preferred.

If the colonoscopy detects high-grade dysplasia, the patient should undergo a colectomy, Dr. Korzenik advised. Some physicians recommend colectomy for patients with low-grade dysplasia as well, “but that's still an area of dispute,” he added.

LAKE TAHOE, CALIF. — The frequency of colonoscopies to screen for cancer in patients with Crohn's disease colitis or ulcerative colitis should be based on how long they've had colitis, Dr. Joshua R. Korzenik said at a meeting on gastroenterology and hepatology sponsored by the University of California, Davis.

Without that pressing motivation, a screening colonoscopy typically would be appropriate every 3–4 years during the first decade of a patient's Crohn's or ulcerative colitis. Because these patients can develop cancer not only from polyps but from flat, normal-appearing mucosa, multiple biopsies are needed. A minimum of 33 biopsies should be taken, spaced about every 4–10 cm throughout the colon. “That has about a 90% likelihood of picking up dysplasia,” said Dr. Korzenik, codirector of the Crohn's and Colitis Center at Massachusetts General Hospital, Boston.

In patients who've had Crohn's or ulcerative colitis for 10–20 years, screening colonoscopy should be performed every other year. For patients with a disease duration longer than 20 years, annual screening colonoscopy is preferred.

If the colonoscopy detects high-grade dysplasia, the patient should undergo a colectomy, Dr. Korzenik advised. Some physicians recommend colectomy for patients with low-grade dysplasia as well, “but that's still an area of dispute,” he added.

MONTEREY, CALIF. — Clinically useful tests are on the horizon to detect changes in DNA that can alter health outcomes for patients with infectious diseases, Dr. Michael F. Murray said.

Speaking at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology, he described helpful applications of recent technology that should be available within the next 5 years or so, and some genetic testing that's being marketed now but is not clinically useful. Dr. Murray has no relationships with the companies that make the products he discussed.

An example of the type of technology that will change how clinicians diagnose, treat, and prevent infectious diseases is the AmpliChip CYP450 assay, which employs polymerase chain reaction (PCR) tests followed by microarray analysis to detect 31 genetic polymorphisms in cytochrome P450 (particularly in two genes—CYP2D6 and CYP2C19).

CYP450 is involved in the metabolism of many drugs. The AmpliChip gives clinicians a report that predicts a patient's phenotype as a poor, intermediate, extensive, or ultrarapid metabolizer for CYP2D6 and a poor or extensive metabolizer for CYP2C19. This type of technology can be put to other uses as well, explained Dr. Murray, clinical chief of the division of genetics at Brigham and Women's Hospital, Boston. “This is one of many competing platforms to use technology to rapidly understand the patient's genetics and then to make a clinical decision based on it.”

The technology is capable of delivering the report to a clinician within 8 hours of taking the blood sample, though no one currently has the system set up to deliver results that quickly, he added. Clinicians could then use that information to make clinical decisions without having to know a lot about genetics.

He described a case in which genomic medicine might have made a difference in management of pneumonia. A young woman treated in the emergency department with ceftriaxone for right upper lobe pneumonia was considered to be a low risk and sent home on an oral fluoroquinolone antibiotic. After a day without fever, she worsened over the next few days before calling 911, febrile and confused. She was intubated in the field, developed acute respiratory distress syndrome, and died in the ICU 10 days later.

Theoretically, if a DNA analysis had been done on the patient the first time she came to the emergency department with pneumonia, it might have shown quickly that she had Streptococcus pneumoniae serotype 3 bacteremia, which is associated with a poor prognosis. PCR tests of the organism could have detected genotypic susceptibility to ceftriaxone and resistance to all quinolones.

DNA tests could also establish the patient's “host susceptibility profile,” Dr. Murray said. There are a lot of candidate genes for this profile, such as surfactant B. A polymorphism in surfactant B is associated with an increased need for mechanical ventilation in adults who present with community-acquired pneumonia.

If these tests had been done, the patient might not have been sent home from the emergency department. She could have been admitted, treated with IV antibiotics and aggressive respiratory therapy, and discharged 6 days later on an oral cephalosporin.

These applications of existing genetic technology aren't up and running yet, but “it's reasonable to think that at least in 10 years, probably more like 5, maybe less,” these tools will be available clinically, Dr. Murray said.

One currently available genetic test—the Otodx aminoglycoside hypersensitivity test—offers clinicians a means of detecting a common mutation associated with aminoglycoside-induced hearing loss. Results take 2 weeks, and the test costs about $250.

The marketing company suggests that all patients being considered for aminoglycoside therapy get tested, but a 2-week wait is not clinically helpful, Dr. Murray said. Plus, the genetic epidemiology is not well understood in these cases. It's not clear whether the mutation occurs more frequently in some populations, particularly Asians, or if it's underrecognized in some populations.

“Until we know that, it's hard to recommend this test in everybody that you're going to give aminoglycosides,” Dr. Murray explained.

MONTEREY, CALIF. — Clinically useful tests are on the horizon to detect changes in DNA that can alter health outcomes for patients with infectious diseases, Dr. Michael F. Murray said.

Speaking at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology, he described helpful applications of recent technology that should be available within the next 5 years or so, and some genetic testing that's being marketed now but is not clinically useful. Dr. Murray has no relationships with the companies that make the products he discussed.

An example of the type of technology that will change how clinicians diagnose, treat, and prevent infectious diseases is the AmpliChip CYP450 assay, which employs polymerase chain reaction (PCR) tests followed by microarray analysis to detect 31 genetic polymorphisms in cytochrome P450 (particularly in two genes—CYP2D6 and CYP2C19).

CYP450 is involved in the metabolism of many drugs. The AmpliChip gives clinicians a report that predicts a patient's phenotype as a poor, intermediate, extensive, or ultrarapid metabolizer for CYP2D6 and a poor or extensive metabolizer for CYP2C19. This type of technology can be put to other uses as well, explained Dr. Murray, clinical chief of the division of genetics at Brigham and Women's Hospital, Boston. “This is one of many competing platforms to use technology to rapidly understand the patient's genetics and then to make a clinical decision based on it.”

The technology is capable of delivering the report to a clinician within 8 hours of taking the blood sample, though no one currently has the system set up to deliver results that quickly, he added. Clinicians could then use that information to make clinical decisions without having to know a lot about genetics.

He described a case in which genomic medicine might have made a difference in management of pneumonia. A young woman treated in the emergency department with ceftriaxone for right upper lobe pneumonia was considered to be a low risk and sent home on an oral fluoroquinolone antibiotic. After a day without fever, she worsened over the next few days before calling 911, febrile and confused. She was intubated in the field, developed acute respiratory distress syndrome, and died in the ICU 10 days later.

Theoretically, if a DNA analysis had been done on the patient the first time she came to the emergency department with pneumonia, it might have shown quickly that she had Streptococcus pneumoniae serotype 3 bacteremia, which is associated with a poor prognosis. PCR tests of the organism could have detected genotypic susceptibility to ceftriaxone and resistance to all quinolones.

DNA tests could also establish the patient's “host susceptibility profile,” Dr. Murray said. There are a lot of candidate genes for this profile, such as surfactant B. A polymorphism in surfactant B is associated with an increased need for mechanical ventilation in adults who present with community-acquired pneumonia.

If these tests had been done, the patient might not have been sent home from the emergency department. She could have been admitted, treated with IV antibiotics and aggressive respiratory therapy, and discharged 6 days later on an oral cephalosporin.

These applications of existing genetic technology aren't up and running yet, but “it's reasonable to think that at least in 10 years, probably more like 5, maybe less,” these tools will be available clinically, Dr. Murray said.

One currently available genetic test—the Otodx aminoglycoside hypersensitivity test—offers clinicians a means of detecting a common mutation associated with aminoglycoside-induced hearing loss. Results take 2 weeks, and the test costs about $250.

The marketing company suggests that all patients being considered for aminoglycoside therapy get tested, but a 2-week wait is not clinically helpful, Dr. Murray said. Plus, the genetic epidemiology is not well understood in these cases. It's not clear whether the mutation occurs more frequently in some populations, particularly Asians, or if it's underrecognized in some populations.

“Until we know that, it's hard to recommend this test in everybody that you're going to give aminoglycosides,” Dr. Murray explained.

MONTEREY, CALIF. — Clinically useful tests are on the horizon to detect changes in DNA that can alter health outcomes for patients with infectious diseases, Dr. Michael F. Murray said.

Speaking at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology, he described helpful applications of recent technology that should be available within the next 5 years or so, and some genetic testing that's being marketed now but is not clinically useful. Dr. Murray has no relationships with the companies that make the products he discussed.

An example of the type of technology that will change how clinicians diagnose, treat, and prevent infectious diseases is the AmpliChip CYP450 assay, which employs polymerase chain reaction (PCR) tests followed by microarray analysis to detect 31 genetic polymorphisms in cytochrome P450 (particularly in two genes—CYP2D6 and CYP2C19).

CYP450 is involved in the metabolism of many drugs. The AmpliChip gives clinicians a report that predicts a patient's phenotype as a poor, intermediate, extensive, or ultrarapid metabolizer for CYP2D6 and a poor or extensive metabolizer for CYP2C19. This type of technology can be put to other uses as well, explained Dr. Murray, clinical chief of the division of genetics at Brigham and Women's Hospital, Boston. “This is one of many competing platforms to use technology to rapidly understand the patient's genetics and then to make a clinical decision based on it.”

The technology is capable of delivering the report to a clinician within 8 hours of taking the blood sample, though no one currently has the system set up to deliver results that quickly, he added. Clinicians could then use that information to make clinical decisions without having to know a lot about genetics.

He described a case in which genomic medicine might have made a difference in management of pneumonia. A young woman treated in the emergency department with ceftriaxone for right upper lobe pneumonia was considered to be a low risk and sent home on an oral fluoroquinolone antibiotic. After a day without fever, she worsened over the next few days before calling 911, febrile and confused. She was intubated in the field, developed acute respiratory distress syndrome, and died in the ICU 10 days later.

Theoretically, if a DNA analysis had been done on the patient the first time she came to the emergency department with pneumonia, it might have shown quickly that she had Streptococcus pneumoniae serotype 3 bacteremia, which is associated with a poor prognosis. PCR tests of the organism could have detected genotypic susceptibility to ceftriaxone and resistance to all quinolones.

DNA tests could also establish the patient's “host susceptibility profile,” Dr. Murray said. There are a lot of candidate genes for this profile, such as surfactant B. A polymorphism in surfactant B is associated with an increased need for mechanical ventilation in adults who present with community-acquired pneumonia.

If these tests had been done, the patient might not have been sent home from the emergency department. She could have been admitted, treated with IV antibiotics and aggressive respiratory therapy, and discharged 6 days later on an oral cephalosporin.

These applications of existing genetic technology aren't up and running yet, but “it's reasonable to think that at least in 10 years, probably more like 5, maybe less,” these tools will be available clinically, Dr. Murray said.

One currently available genetic test—the Otodx aminoglycoside hypersensitivity test—offers clinicians a means of detecting a common mutation associated with aminoglycoside-induced hearing loss. Results take 2 weeks, and the test costs about $250.

The marketing company suggests that all patients being considered for aminoglycoside therapy get tested, but a 2-week wait is not clinically helpful, Dr. Murray said. Plus, the genetic epidemiology is not well understood in these cases. It's not clear whether the mutation occurs more frequently in some populations, particularly Asians, or if it's underrecognized in some populations.

“Until we know that, it's hard to recommend this test in everybody that you're going to give aminoglycosides,” Dr. Murray explained.