Michael R. Weitekamp

Potential for Bleeding with the New Beta-Lactam Antibiotics

Several new beta-lactam antibiotics impair normal hemostasis. Hypoprothrombinemia has occurred frequently with cephalosporins that possess a methylthiotetrazole substitution (cefamandole, moxalactam, and cefoperazone). The incidence ranges from 4% to 68%, and the risk is greatest in debilitated patients with cancer, intra-abdominal infection, or renal failure. Impaired platelet function caused by perturbation of agonist receptors on the platelet surface has occurred primarily with beta-lactam antibiotics having an alpha-carboxyl substitution (moxalactam, carbenicillin, and ticarcillin). These antibiotics often cause the template bleeding time to be markedly prolonged (greater than 20 minutes). Acylureidopenicillins, which lack the alpha-carboxyl marker, impair platelet function less frequently and only modestly prolong the bleeding time. If serious hemorrhage occurs, hypoprothrombinemia associated with methylthiotetrazole-substituted cephalosporins should be treated with fresh frozen plasma. Likewise, dangerous bleeding due to impaired platelet aggregation requires treatment with platelet concentrates.

Osteomyelitis caused by Veillonella

Veillonella parvula and alcalescens are anaerobic gram-negative cocci that, when isolated from anaerobic cultures of clinical specimens, are usually regarded as commensal organisms. Occasionally they play a pathogenic role and require antibiotic therapy. Limited clinical experience and in vitro susceptibility studies suggest that penicillin G is the drug of choice for these organisms and that cephalosporins, clindamycin, chloramphenicol, and metronidazole may be acceptable therapeutic alternatives. Presented herein is a case report of a Veillonella infection, a discussion of the importance of these organisms when they occur in a clinical infection, and a discussion of the appropriate antibiotic therapy.

Impaired hemostasis caused by beta-lactam antibiotics

Beta-lactam antibiotics can directly impair hemostasis by two separate nonimmune mechanisms. First, the NMTT-substituted cephalosporin drugs may cause hypoprothrombinemia by interfering with the hepatic activation of clotting factors II, VII, IX, and X. Second, the antipseudomonal penicillins may cause the bleeding time to be prolonged by interfering with platelet aggregation to physiologic agonists. In surgical patients who are malnourished, have impaired gastrointestinal function, or have renal failure, the potential for these adverse effects is increased. Serious bleeding requires treatment with fresh frozen plasma when hypoprothrombinemia is caused by NMTT-containing cephalosporins, since the prothrombin time returns to baseline relatively slowly after therapy with vitamin K. Hemorrhage caused by beta-lactam-induced platelet dysfunction must be treated with platelet concentrates, since new platelets sufficient to correct the defect do not enter the circulation for several days after treatment with the offending drug is discontinued. The more desirable approach is to prevent hypoprothrombinemia by giving vitamin K prophylaxis and to avoid beta-lactams that impair platelet function in seriously ill patients at increased risk for bleeding.

An algorithm for the control of nosocomial varicella-zoster virus infection

Inadvertent or uncontrolled introduction of varicella-zoster virus into the hospital environment occurs commonly and must be investigated in a systematic and efficient manner to minimize secondary spread to patients (particularly the immunocompromised) or hospital personnel. On the basis of a review of the literature and our practical experience with 11 such exposures to varicella-zoster virus during a 2-year period, we have developed a working algorithm for such investigations. Index cases most often are children, resident physicians, students, young nurses, and ancillary personnel, or adult patients with herpes zoster. A negative or uncertain past history of this infection is an unreliable predictor of susceptibility among the exposed and should be confirmed by serology tests or delayed hypersensitivity skin testing. An incubation-contagion timetable, coupled with a stratification of risk among the exposed, permits a prioritized response in dealing with an introduction of varicella-zoster virus. The preemployment screening of all hospital workers for susceptibility to varicella-zoster virus should be considered as a practical and cost effective policy.

The Health Policy and Legislative Awareness Initiative at the Pennsylvania State University College of Medicine: theory meets practice.

In a constantly evolving health care landscape shaped by many voices—including those of third party payers and government—physicians must learn to play a more proactive role to become better advocates for their patients and to uphold the basic tenets of their noble profession. As legislation and public health become increasingly intertwined with the practice of medicine, educators must provide future physicians with the tools to meet these new challenges. Accordingly, in 1996 Pennsylvania State University College of Medicine embarked on its Health Policy and Legislative Awareness Initiative, a medical school elective designed to provide theoretical knowledge as well as practical experience in legislative and policy issues for future physicians early in their careers. The Initiative has three key elements: a series of lectures taught by national and local experts covering a basic health policy curriculum, a mini-internship conducted at the office of a Pennsylvania State legislator, and a practical assignment leading to authorship of a resolution to a national medical organization or assisting in drafting a bill intended for introduction to the Pennsylvania State Legislature. Following several years of successful implementation and a moderate growth in enrollment, recent changes in the local and national scene have peaked the interest of most students to learn about the system in which they will practice medicine. Therefore, in addition to describing the Initiative in its current form, the authors discuss future plans for expanded elective opportunities and consider the issue of integrating health policy education into core medical school curricula.

Academic health centers and HMOs: a systems perspective on collaboration in training generalists physicians and advancing mutual interests

Academic health centers (AHCs) and health maintenance organizations (HMOs) often hold each other at arms length because of fundamental organizational differences. AHCs view HMOs as too intrusive in the clinical management of patients and too concerned with the financial bottom line. HMOs view AHCs as organizationally fragmented and expensive in providing health care services. AHCs must expand their primary care networks and reassess their mission and public accountability in training a more balanced physician workforce. HMOs are growing rapidly and need well-trained generalist physicians to support that growth. This paper uses an organizational systems model in examining AHCs and HMOs to identify common needs, mutual interests, areas for potential collaboration, and bridging strategies. These include health care systems development, professional education, information management systems, and health services research. As the financing and delivery of health care continue to change and to become more integrated, both organizations have much to gain from collaboration.

Clostridium difficile infection: a common clinical problem for the general internist

SummaryConsidering the current wide use of antimicrobial agents, the general internist is commonly faced with the patient at risk for diarrhea due toC. difficile. The diagnosis should be considered for any patient with diarrhea who has received any type of antibiotic therapy in the preceding 4–6 weeks. Symptoms may range from a minor bout of diarrhea to fulminant and fatal colitis. Diagnosis usually requires demonstration of the toxin in stool; culture of the organism and fiberoptic endoscopy may play an adjunctive role in selected clinical settings. The ultimate goal in the treatment forC. difficile infection is to repopulate the normal colonic flora in the most efficacious manner. Minimally symptomatic patients may respond to discontinuing the offending antimicrobial agent or using nonspecific binding agents. Oral vancomycin continues to be the “gold standard” for specific treatment, while metronidazole therapy is considered the first-line agent for individuals with milder infection. Oral bacitracin shows promise, though large studies are lacking. Patients with multiple relapses ofC. difficile diarrhea can be treated with prolonged courses of vancomycin or a combination of vancomycin and rifampin. Intensive care unit patients who are NPO have few therapeutic options besides intravenous administration of metronidazole and oral administration of vancomycin via clamped nasogastric tube. Preventive efforts are directed at cautious use of antibiotics and the use of vinyl gloves when caring for patients with known infection.

Infections due to antibiotic-resistant gram-positive cocci.

SummaryGram-positive cocci are becoming increasingly resistant to traditionally used antimicrobial agents.Staphylococcus aureus, coagulase-negative staphylococci, the enterococcus, andStreptococcus pneumoniae are the most commonly encountered of such pathogens in clinical practice. Clinicians should be keenly aware of the usual types of infections that are caused by these organisms and the importance of documenting susceptibilities of infecting strains. The basic mechanisms of resistance should be familiar to clinicians so that an inappropriate empiric regimen will not be selected (e.g., addition of a beta-lactamase inhibitor for penicillin-resistant pneumococci). Vancomycin remains the agent of choice, sometimes in combination with gentamicin and/or rifampin, for most cases of infection due to these resistant gram-positive organisms. Last, increased efforts toward prevention, such as strict adherence to infection control measures, selective use of broad-spectrum antibiotics, and increased use of pneumococcal vaccine, may be useful to help stem the rising tide of infections due to resistant gram-positive cocci.

Health knowledge among the millennial generation

The Millennial Generation, also known as Generation Y, is the demographic cohort following Generation X, and is generally regarded to be composed of those individuals born between 1980 and 2000. They are the first to grow up in an environment where health-related information is widely available by internet, TV and other electronic media, yet we know very little about the scope of their health knowledge. This study was undertaken to quantify two domains of clinically relevant health knowledge: factual content and ability to solve health related questions (application) in nine clinically related medical areas. Study subjects correctly answered, on average, 75% of health application questions but only 54% of health content questions. Since students were better able to correctly answer questions dealing with applications compared to those on factual content contemporary US high school students may not use traditional hierarchical learning models in acquisition of their health knowledge.

Commitment in academic medicine—is it moribund? can it be resuscitated?

In recent years, academic medical center leadership has come to realize that their most precious asset is neither the buildings and equipment they own nor the liquid assets they have in the bank—rather, it is those employees who add superior value to the organization. We have all had colleagues who go above and beyond the call of duty, take an additional night of call without complaining, spend extra time with an overwhelmed resident, or willingly see another patient in clinic. We say that these people are committed. Committed to what? To their patients? To their job? To their department? To academic medicine as a noble profession? To the institution that signs their paycheck? To the purpose and core values the organization stands for? Practically, commitment may vary and might be divided among any or all of these. Individuals may connect with their work at multiple levels: their job, profession, department, boss, or organization. Commitment is a business necessity. Committed workers are more productive and more fulfilled. Work environments with a high level of commitment are more enjoyable, more desirable, and more profitable places to work [1]. On the other hand, disengaged