Sanjay Saint

The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: a meta-analysis

PURPOSEnIndwelling urinary catheters are implicated in most cases of nosocomial urinary tract infection. Silver-coating of catheters may reduce the risk of these infections; however, trials have provided mixed results. We performed a meta-analysis to estimate the effectiveness of silver-coated urinary catheters.nnnSUBJECTS AND METHODSnPublished or unpublished articles were sought using MEDLINE, reference review, and correspondence with original authors, catheter manufacturers, and experts. Trials using silver-coated urinary catheters in the treatment group and uncoated urinary catheters in the control group were included. Bacteriuria, as evaluated by urine culture, was the outcome variable used to indicate urinary tract infection. Summary odds ratios (OR) and 95% confidence intervals (CI) were calculated using Mantel-Haenszel methods with a fixed-effects model.nnnRESULTSnOf 117 reports retrieved, eight trials with a total of 2,355 patients satisfied inclusion criteria. The summary OR for urinary tract infection was 0.59 (95% CI, 0.42 to 0.84) indicating a significant benefit in the patients receiving silver-coated catheters. A test of heterogeneity, however, indicated that the odds ratios varied significantly among studies. Silver alloy catheters (OR = 0.24; 95% CI, 0.11 to 0.52) were significantly more protective against bacteriuria than silver oxide catheters (OR = 0.79; 95% CI, 0.56 to 1.10).nnnCONCLUSIONSnThis meta-analysis clarifies discrepant results among trials of silver-coated urinary catheters by revealing that silver alloy catheters are significantly more effective in preventing urinary tract infections than are silver oxide catheters. Though silver alloy urinary catheters cost about

The effectiveness of a clinical practice guideline for the management of presumed uncomplicated urinary tract infection in women

6 more than standard urinary catheters, they may be worth the extra cost since catheter-related infection is a common cause of nosocomial infection and bacteremia.

Risk reduction in the intensive care unit

PURPOSEnAcute uncomplicated urinary tract infection is a common and costly disorder in women. To reduce potentially unnecessary expense and inconvenience, a large staff-model health maintenance organization instituted a telephone-based clinical practice guideline for managing presumed cystitis in which women 18 to 55 years of age who met specific criteria were managed without a clinic visit or laboratory testing. We sought to evaluate the effects of the guideline.nnnSUBJECTS AND METHODSnWe performed a population-based, before-and-after study with concurrent control groups at 24 primary care clinics to assess the effect of guideline implementation on resource utilization and on the occurrence of potential adverse outcomes. We measured the proportion of patients with presumed uncomplicated cystitis who had a return office visit for cystitis or sexually transmitted disease or who developed pyelonephritis within 60 days of the initial diagnosis. Relative risks (RR) and 95% confidence intervals (CI) were estimated, adjusting for the effects of clustering within clinics.nnnRESULTSnA total of 3,889 eligible patients with presumed acute uncomplicated cystitis were evaluated. As compared with baseline, guideline implementation significantly decreased the proportion of patients with presumed cystitis who received urinalysis (RR = 0.75; CI, 0.70 to 0.80), urine culture (RR = 0.73; CI, 0.68 to 0.79), and an initial office visit (RR = 0.67; CI, 0.62 to 0.73), while increasing the proportion who received a guideline-recommended antibiotic 2.9-fold (CI, 2.4 to 3.7-fold). In the prospective comparison of the 22 intervention and two control clinics, the guideline decreased the proportion of patients who had urinalyses performed (RR = 0.80; CI, 0.65 to 0.98) and increased the proportion of patients who were prescribed a guideline-recommended antibiotic (RR = 1.53; CI, 1.01 to 2.33). Adverse outcomes did not increase significantly in either comparison.nnnCONCLUSIONnGuideline use decreased laboratory utilization and overall costs while maintaining or improving the quality of care for patients who were presumptively treated for acute uncomplicated cystitis.

A square peg in a round hole

Many potentially preventable complications occur in patients who receive intensive care. We have reviewed the epidemiology of three important complications (venous thromboembolism, stress-related upper gastrointestinal bleeding, and vascular catheter-related infection) and evaluated common preventive treatments to provide evidence-based recommendations for prevention. We used English language articles located by MEDLINE or cross-citation, giving preference to articles published in the last 10 years, meta-analyses, and clinical trials that were randomized, double-blinded, and used intention-to-treat analysis. We recommend prophylaxis against venous thromboembolism in most patients, whereas those without respiratory failure or coagulopathy may not require prophylaxis against stress-related upper gastrointestinal hemorrhage. Chlorhexidine gluconate is the preferred antiseptic for disinfecting the skin prior to and during intravascular catheterization. Central venous catheters impregnated with antibacterial or antiseptic agents should be considered in patients at high risk for vascular catheter-related infection. Finally, central venous, pulmonary arterial, and systemic arterial catheters should be changed only when clinically indicated.

USING CLINICAL REASONING TO IMPROVE SKILLS IN ORAL CASE PRESENTATION

Stage A 51-year-old woman had had blurring of vision, polyuria, and anorexia for approximately six weeks. She had lost 9 kg (20 lb) in weight over the previous three months without the use of diet or exercise. Other symptoms included vaginal discharge and gum irritation. Her physician made a diagnosis of diabetes mellitus (on the basis of a random glucose measurement of 317 mg per deciliter [17.6 mmol per liter]) and candidal vaginitis. Other laboratory studies done at that time revealed a hematocrit of 41 percent, with a mean corpuscular volume of 74 fl. Response This sounds like a case .xa0.xa0.