Robert Press

A survey of 77 major infectious complications of median sternotomy: a review of 7,949 consecutive operative procedures.

Sternal wound infections developed following 77 (0.97%) of 7,949 operative procedures involving median sternotomy at New York University Medical Center from 1976 to 1984. Risk factors associated with the development of a sternal wound infection included combined revascularization and valve replacement, early reexploration for bleeding, prolonged low cardiac output syndrome, and prolonged ventilatory support (greater than 24 hours). Concomitant infection at other sites with the same organism as cultured from the sternum was present in 42% of the patients. Thirty-seven patients (48%) were treated with radical debridement followed by closed antibiotic irrigation. In 31 other patients (40%), the wounds were debrided and left to heal by open granulation. Both initial treatments had equally high success rates (78.4% and 74.2%, respectively). However, the open granulation method resulted in a hospital stay that was an average of 10 days longer than the closed antibiotic irrigation method. Muscle flaps were used to expedite healing of open granulation in 9 patients. Analysis of the results of different treatment strategies revealed that if debridement was accomplished within 20 days of the initial cardiac procedure, 76% of the patients could be successfully treated with closed antibiotic irrigation. Conversely, if treatment was delayed for longer than 20 days, 81% of the patients were treated with open granulation (p less than 0.001). Also noted was an inverse relationship between the serum blood urea nitrogen (BUN) level and the success rate of initial treatment with closed antibiotic irrigation. Patients with a serum BUN level of less than 40 mg/dl at the time of debridement had a 90% success rate as opposed to a success rate of 38% when the BUN level was 40 mg/dl or greater. The data presented suggest the following conclusions. Early diagnosis is crucial to successful treatment of sternal wound infection. When diagnosis can be established within 20 days, 80% of infections can be eradicated by the simple approach of debridement and closed antibiotic irrigation. When diagnosis is delayed, however, prompt debridement followed by muscle flaps is the procedure of choice. Open granulation alone, while successful, unnecessarily prolongs the hospital course.

Linezolid-associated toxic optic neuropathy: a report of 2 cases.

We describe 2 cases in which the prolonged use of linezolid to treat complicated methicillin-resistant Staphylococcus aureus infections was followed by acutely developed blurred vision and progressive loss of vision and color perception during the ensuing few weeks. Both patients received a diagnosis of toxic optic neuropathy, and linezolid therapy was stopped. The patients experienced an initial rapid partial improvement and a subsequent gradual, almost complete, recovery over many months.

Linezolid-Resistant, Vancomycin-Resistant Enterococcus faecium Infection in Patients without Prior Exposure to Linezolid

We describe 2 patients without prior exposure to linezolid who were infected with closely related strains of linezolid- and vancomycin-resistant Enterococcus faecium (LRVREF) that may have been hospital acquired. Polymerase chain reaction amplification of the domain V region of the 23S ribosomal RNA gene demonstrated the presence of the G2576U mutation previously reported to be associated with linezolid resistance. Nosocomial transmission of LRVREF is an ominous sign and underscores the importance of meticulous infection-control measures.

Preventing Surgical Site Infections: A Randomized, Open-Label Trial of Nasal Mupirocin Ointment and Nasal Povidone-Iodine Solution

BACKGROUNDnTreatment of Staphylococcus aureus colonization before surgery reduces risk of surgical site infection (SSI). The regimen of nasal mupirocin ointment and topical chlorhexidine gluconate is effective, but cost and patient compliance may be a barrier. Nasal povidone-iodine solution may provide an alternative to mupirocin.nnnMETHODSnWe conducted an investigator-initiated, open-label, randomized trial comparing SSI after arthroplasty or spine fusion in patients receiving topical chlorhexidine wipes in combination with either twice daily application of nasal mupirocin ointment during the 5 days before surgery or 2 applications of povidone-iodine solution into each nostril within 2 hours of surgical incision. The primary study end point was deep SSI within the 3 months after surgery.nnnRESULTSnIn the modified intent-to-treat analysis, a deep SSI developed after 14 of 855 surgical procedures in the mupirocin group and 6 of 842 surgical procedures in the povidone-iodine group (P = .1); S. aureus deep SSI developed after 5 surgical procedures in the mupirocin group and 1 surgical procedure in the povidone-iodine group (P = .2). In the per protocol analysis, S. aureus deep SSI developed in 5 of 763 surgical procedures in the mupirocin group and 0 of 776 surgical procedures in the povidone-iodine group (P = .03).nnnCONCLUSIONSnNasal povidone-iodine may be considered as an alternative to mupirocin in a multifaceted approach to reduce SSI.nnnTRIAL REGISTRATIONnClinicalTrials.gov identifier: NCT01313182.

Fidaxomicin versus Conventional Antimicrobial Therapy in 59 Recipients of Solid Organ and Hematopoietic Stem Cell Transplantation with Clostridium difficile-Associated Diarrhea

ABSTRACT The feasibility of fidaxomicin versus vancomycin and metronidazole (conventional therapy) was assessed in 59 transplant recipients with 61 episodes of Clostridium difficile-associated diarrhea (CDAD). Overall clinical cure was achieved in 86% of episodes, and in 7% of episodes, infection recurred. Fidaxomicin was well tolerated. Clinical cures were not significantly different compared with conventional therapy (67% versus 89%, respectively; P = 0.06). Univariate analysis of predictors for lack of clinical cure included continued use of broad-spectrum systemic antibiotics (P = 0.026) and prior diagnosis of CDAD (95% confidence interval, 1.113 to 19.569; odds ratio, 4.667; P = 0.041). New-onset vancomycin-resistant Enterococcus (VRE) colonization was not noted after fidaxomicin therapy alone. However, this occurred in 10 of 28 patients (36%) following conventional therapy, and 2 of 3 patients with subsequent bacteremia died.

Cephalosporin therapy in intraabdominal infections: A multicenter randomized, comparative study of cefotetan, moxalactam, and cefoxitin

Three broad-spectrum cephalosporins (cefotetan, moxalactam, and cefoxitin) proved effective in this randomized, prospective trial for treatment of 303 surgical patients with moderately severe regional peritonitis.

Fidaxomicin Therapy in Critically Ill Patients with Clostridium difficile Infection

ABSTRACT Fidaxomicin use to treat proven Clostridium difficile infection (CDI) was compared between 20 patients receiving care in critical care units (CCUs) and 30 patients treated on general medical floors. At baseline, the CCU patients had more initial CDI episodes, more severe and complicated disease, and more concurrent broad-spectrum antibiotic coverage. On multivariate analysis, the response to fidaxomicin therapy among the critically ill patients was comparable to that among patients in the general medical wards.

Inositol production by the brain in normal and alloxan-diabetic dogs

Abstract It was found that there was no net uptake of inositol by CSF from plasma, indicating that the high concentration of inositol in the CSF relative to that in plasma of normal and diabetic dogs originates from inositol synthesized by brain. The inositol concentration and rate of efflux from the CSF were used to measure inositol turnover in CSF, and from this was calculated a minimum rate of inositol production by dog brainin vivo. There was no significant difference in the rate of inositol production by the brain (88 μmoles/kg brain/h) between the normal and alloxan-diabetic dog.

Comparative study of cefotetan and cefoxitin in the treatment of intra-abdominal infections

One hundred eighty-eight patients were enrolled in a multicenter, randomized clinical trial to compare the safety and effectiveness of 1 to 2 gm cefotetan every 12 hours with those of 1 to 2 gm cefoxitin every 6 hours in patients with intra-abdominal infections. Most of the infections were community acquired, were associated with gastrointestinal tract perforation, and were caused by both anaerobic and aerobic bacteria. The median duration of therapy was 6 days for each group. The clinical response rate for the 95 evaluable patients in the cefotetan group was 98%, and that for the 43 evaluable patients in the cefoxitin group was 95%. Bacteriologically, 97% of the 58 evaluable patients in the cefotetan group and 89% of the 27 evaluable patients in the cefoxitin group had a satisfactory or presumed satisfactory response; two patients in the cefotetan group and three in the cefoxitin group were considered bacteriologic failures. Cefotetan was as effective as cefoxitin in eradicating Bacteroides fragilis and other species of Bacteroides, Clostridium sp., and gram-negative bacilli. The incidence of treatment-related adverse reactions for cefotetan (27%) was not statistically different from that for cefoxitin (17%). No clinically significant differences were detected between the treatment groups in changes in the results of clinical laboratory tests performed before and after treatment; a decrease in hematocrit among the cefotetan group was statistically greater (p = 0.04) than that for the cefoxitin group, and a decrease in serum creatinine level for the cefoxitin group was greater than that for the cefotetan group (p = 0.02). Cefotetan may represent an effective, safe, and cost-saving alternative to cefoxitin for the prompt treatment of community-acquired intra-abdominal infections.

The use of fluoroquinolones as antiinfective transition-therapy agents in community-acquired pneumonia.

The newer quinolone antibiotics, including levofloxacin, moxifloxacin, and gatifloxacin, offer coverage of the likely pathogens in community‐acquired pneumonia (CAP) and have been shown to be safe and effective treatments for CAP. Two of these agents, levofloxacin and gatifloxacin, have pharmacokinetic and antibacterial properties that are similar in both oral and intravenous formulations. As such, they may be excellent candidates for transition therapy involving early switch from intravenous to oral therapy followed by early hospital discharge for patients with CAP.