Joseph R. Dalovisio

Therapeutic monitoring of vancomycin in adult patients: A consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists

Vancomycin is a glycopeptide antibiotic that has been in clinical use for nearly 50 years as a penicillin alternative to treat penicillinase-producing strains of Staphylococcus aureus . It is one of the most widely used antibiotics in the United States for the treatment of serious gram-positive

Vancomycin Therapeutic Guidelines: A Summary of Consensus Recommendations from the Infectious Diseases Society of America, the American Society of Health-System Pharmacists, and the Society of Infectious Diseases Pharmacists

Practice guidelines for therapeutic monitoring of vancomycin treatment for Staphylococcus aureus infection in adult patients were reviewed by an expert panel of the Infectious Diseases Society of America, the American Society of Health-System Pharmacists, and the Society of Infectious Diseases Pharmacists. A literature review of existing evidence regarding vancomycin dosing and monitoring of serum concentrations, in addition to patient outcomes combined with expert opinion regarding the drugs pharmacokinetic, pharmacodynamic, and safety record, resulted in new recommendations for targeting and adjustment of vancomycin therapy.

Practice Guidelines for Outpatient Parenteral Antimicrobial Therapy

These guidelines were formulated to assist physicians and other health care professionals with various aspects of the administration of outpatient parenteral antimicrobial therapy (OPAT). Although there are many reassuring retrospective studies on the efficacy and safety of OPAT, few prospective studies have been conducted to compare the risks and outcomes for patients who receive treatment as outpatients rather than as inpatients. Because truly evidence-based studies are lacking, the present guidelines are formulated from the collective experience of the committee members and advisors from related organizations.

Disk diffusion testing of susceptibility of Mycobacterium fortuitum and Mycobacterium chelonei to antibacterial agents.

Although recent studies have suggested that some antibacterial agents have good activity against the rapidly growing mycobacteria Mycobacterium fortuitum and Mycobacterium chelonei, an easily applicable method for susceptibility testing of clinical isolates is not yet available. We evaluated a disk diffusion method with Mueller-Hinton agar and 48-h readings with 59 strains of M. fortuitum and 11 strains of M. chelonei and compared the results to agar dilution susceptibilities for nine antimicrobial agents. All isolates were susceptible to 16 micrograms of amikacin or kanamycin per ml with minimum zone diameters of 14 and 18 mm, respectively. Amikacin inhibited 100% of isolates of M. fortuitum at 2 micrograms/ml, whereas 10 of 11 (91%) of M. chelonei strains had minimum inhibitory concentrations of 4.0 micrograms/ml or greater. Doxycycline and minocycline had almost identical activities, inhibiting 44% of strains at 4.0 micrograms/ml, and both allowed easy differentiation between susceptible and resistant strains by disk diffusion. Although most isolates of M. chelonei grew better on 7H10 agar, this media gave two- to eight-fold higher minimum inhibitory concentrations than were obtained with Mueller-Hinton agar. Disk diffusion susceptibility testing appears to be a simple and reliable means of predicting susceptibility results for M. fortuitum and most isolates of M. chelonei by the agar dilution method.

Dalbavancin: a Novel Once-Weekly Lipoglycopeptide Antibiotic

The increasing prevalence of drug-resistant gram-positive cocci, such as methicillin-resistant Staphylococcus aureus, has underscored the need for new agents for the treatment of this type of infection. Dalbavancin, a new lipoglycopeptide, has the desirable characteristics of increased in vitro activity, compared with vancomycin, for most gram-positive pathogenic bacteria, as well as an extremely long half-life, permitting once-weekly intravenous dosing. Clinical studies comparing linezolid with 2 doses of dalbavancin have shown comparable efficacy for the treatment of skin and soft-tissue infection. Dalbavancin has also proven to be effective for therapy of catheter-related bloodstream infections. It has an excellent safety profile in studies to date. Dalbavancin will likely have a significant role in outpatient intravenous therapy for patients with potentially serious drug-resistant gram-positive coccal infections.

Evaluation of the efficacy and safety of outpatient parenteral antimicrobial therapy for infections with methicillin-sensitive Staphylococcus aureus.

Objectives: As increasing numbers of patients are being treated with outpatient parenteral antimicrobial therapy (OPAT), it becomes ever more important to ascertain the risks and benefits of such treatment for patients. Methods: We conducted a retrospective analysis of 1,515 patients with methicillin-sensitive Staphylococcus aureus infections who were treated with outpatient parenteral antimicrobial monotherapy. All patients were included in the adverse drug reaction analysis; 1,252 were evaluable for purposes of evaluating treatment efficacy. Results: The six antibiotics most frequently used in this study (ceftriaxone, cefazolin, vancomycin, oxacillin, nafcillin, and clindamycin) appeared to be equivalent in achieving the desired efficacy outcome. Conclusions: Vancomycin was associated with a significantly greater number of side effects than was ceftriaxone, cefazolin, or oxacillin, and nafcillin was associated with a significantly greater number of adverse events than ceftriaxone.

Overview of bacterial infections of the skin and soft tissue and clinical experience with ticarcillin plus clavulanate potassium in their treatment

The etiology, diagnosis, and treatment of skin and soft tissue infections are discussed, and the results of clinical experience with ticarcillin plus clavulanate potassium in these diseases at one clinic are reported. In a randomized and controlled clinical trial, the safety and effectiveness of ticarcillin plus clavulanate potassium and cefazolin were compared in the treatment of soft tissue infections in 20 patients. The 12 patients in the group treated with ticarcillin plus clavulanate potassium included 10 men and two women, with a mean age of 61 years; the eight patients in the group treated with cefazolin were five men and three women, with a mean age of 63.8 years. Ticarcillin plus clavulanate potassium was administered for four to 26 days (mean 12.5 days), and cefazolin for four to 20 days (mean 12 days). There were 29 evaluable pathogens in the group receiving ticarcillin plus clavulanate potassium and 22 in the group receiving cefazolin. Of the 29 pathogens in the former group, 22 were eradicated; three reinfections or superinfections occurred but were ultimately eradicated, and four pathogens persisted. Eighteen of the 22 pathogens in the cefazolin-treated group were eliminated and the other four persisted. Clinically, six of the 12 patients in the ticarcillin plus clavulanate potassium-treated group had cures, four showed improvement, and two failed to show a response. In the cefazolin-treated group, five of the eight patients had cures, one showed improvement, and two failed to show a response.

Subacute Thyroiditis with Increased Serum Alkaline Phosphatase

Three patients had subacute thyroiditis and elevated serum alkaline phosphatase, presumably related to the thyroiditis. Concomitant elevation of the serum gamma-glutamyl transferase suggested that the alkaline phosphatase was of hepatic origin. The elevation of the serum alkaline phosphatase could not be definitely related to the degree or duration of elevation of the serum thyroxine. The combination of elevated serum alkaline phosphatase with the systemic symptoms of subacute thyroiditis may obscure the diagnosis, especially if patients have little or no neck pain.

In Vitro Susceptibility of Nocardia asteroides to Amikacin

By drug dilution tests in agar, it has been shown that each of 27 strains of Nocardia asteroides was inhibited by 1 μg or less of amikacin per ml of medium.

Myocardial sarcoidosis complicated by mural thrombosis.

A 30-year-old black woman was diagnosed as having sarcoidosis on the basis of a lymph node biopsy six years before admission. During that time the patient received no treatment, and did well until one month before admission, when she developed night sweats, fever, and easy fatiguability. One week before admission she experienced nausea, vomiting, and abdominal pain, and she was admitted to another hospital. A lymph node biopsy at that hospital showed confluent non-caseating granulomas. She was then transferred to Shands Teaching Hospital for evaluation of cardiac arrhythmias and right pleural effusion. On admission the patient was in no distress. Her temperature was 390C (102-20F); blood pressure, 100/70 mmHg; pulse rate, 90 beats/min, with frequent premature beats; and respiratory rate, 25/min. Dullness to percussion, decreased fremitus, and decreased breath sounds were present at the right lung base as well as bibasilar inspiratory crackles. Cardiac examination was with normal limits except for frequent premature beats. The spleen was palpable, and lymphadenopathy was present. Haematocrit was 45%, haemoglobin, 15 g/ 100 ml; white cell count, 49000/mm3 with 66% polymorphonuclear cells, 11% band forms, 18% lymphocytes, 3% monocytes, and 2% eosinophils. Serum alkaline phosphatase was 510 IU/l (normal