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Empirical Therapy (empirical + therapy)

Distribution by Scientific Domains

Medical Sciences	100%

Selected Abstracts

Clinical trial: a randomized trial of early endoscopy, Helicobacter pylori testing and empirical therapy for the management of dyspepsia in primary care

ALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 1 2009
A. E. DUGGAN
Summary Background, Early endoscopy, Helicobacter pylori eradication and empirical acid suppression are commonly used dyspepsia management strategies in primary care but have not been directly compared in a single trial. Aim, To compare endoscopy, H. pylori test and refer, H. pylori test and treat and empirical acid suppression for dyspepsia in primary care. Methods, Patients presenting to their general practitioner with dyspepsia were randomized to endoscopy, H. pylori,test and treat', H. pylori test and endoscope positives, or empirical therapy with symptoms, patient satisfaction, healthcare costs and cost effectiveness at 12 months being the outcomes. Results, At 2 months, the proportion of patients reporting no or minimal dyspeptic symptoms ranged from 74% for those having early endoscopy to 55% for those on empirical therapy (P = 0.009), but at 1 year, there was little difference among the four strategies. Early endoscopy was associated with fewer subsequent consultations for dyspepsia (P = 0.003). ,Test and treat' resulted in fewer endoscopies overall and was most cost-effective over a range of cost assumptions. Empirical therapy resulted in the lowest initial costs, but the highest rate of subsequent endoscopy. Gastro-oesophageal cancers were found in four patients randomized to the H. pylori testing strategies. Conclusions, While early endoscopy offered some advantages ,Test and treat' was the most cost-effective strategy. In older patients, early endoscopy may be an appropriate strategy in view of the greater risk of malignant disease. [source]

Empirical therapy for diabetic foot infections: are there clinical clues to guide antibiotic selection?

CLINICAL MICROBIOLOGY AND INFECTION, Issue 4 2007
B. A. Lipsky
Abstract Initial antibiotic therapy for diabetic foot infections is usually empirical. Several principles may help to avoid selecting either an unnecessarily broad or inappropriately narrow regimen. First, clinically severe infections require broad-spectrum therapy, while less severe infections may not. Second, aerobic Gram-positive cocci, particularly Staphylococcus aureus (including methicillin-resistant S. aureus (MRSA) for patients at high-risk) should always be covered. Third, therapy should also be targeted at aerobic Gram-negative pathogens if the infection is chronic or has failed to respond to previous antibiotic therapy. Fourth, anti-anaerobe agents should be considered for necrotic or gangrenous infections on an ischaemic limb. Parenteral therapy is needed for severe infections, but oral therapy is adequate for most mild or moderate infections. [source]

Biological weapons preparedness: the role of physicians

INTERNAL MEDICINE JOURNAL, Issue 5-6 2003
C. L. Cherry
Abstract The real risk posed by biological weapons was demonstrated with the distribution of anthrax spores via the USA postal service in 2001. This review outlines the central roles of physicians in optimizing biopreparedness in Australia, including maintaining awareness of the risk, promptly recognizing an event, notifying appropriate authorities upon suspicion of an event, and instituting appropriate management. Management aspects covered include appropriate diagnostic tests, infection control procedures, and empirical therapy of agents considered possible biological weapons. The critical role of physicians as public health advocates working to prevent the use of biological weapons is also outlined. (Intern Med J 2003; 33: 242,253) [source]

Resistant Pathogens in Urinary Tract Infections

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2002
Lindsay E. Nicolle MD
Antimicrobial susceptibility of bacteria causing urinary tract infection (UTI) has evolved over several decades as antimicrobial exposure has repeatedly been followed by emergence of resistance. Older populations in the community, long-term care facilities, or acute care facilities have an increased prevalence of resistant bacteria isolated from UTI. Resistant isolates are more frequent in long-term care populations than the community. Resistant isolates include common uropathogens, such as Escherichia coli or Proteus mirabilis, and organisms with higher levels of intrinsic resistance, such as Pseudomonas aeruginosa or Providencia stuartii. Isolation of resistant organisms is consistently associated with prior antimicrobial exposure and higher functional impairment. The increased likelihood of resistant bacteria makes it essential that a urine specimen for culture and susceptibility testing be obtained before instituting antimicrobial therapy. Therapy for the individual patient must be balanced with the possibility that antimicrobial use will promote further resistance. Antimicrobial therapy should be avoided unless there is a clear clinical indication. In particular, asymptomatic bacteriuria should not be treated with antimicrobials. Where symptoms are mild or equivocal, urine culture results should be obtained before initiating therapy. This permits selection of specific therapy for the infecting organism and avoids empiric, usually broad-spectrum, therapy. Where empirical therapy is necessary, prior infecting organisms should be isolated, and recent antimicrobial therapy, as well as regional or facility susceptibility patterns, should be considered in antimicrobial choice. Where empirical therapy is used, it should be reassessed 48 to 72 hours after initiation, once pretherapy cultures are available. [source]

Fever of unknown origin in the elderly

JOURNAL OF INTERNAL MEDICINE, Issue 4 2002
S. Tal
Fever of unknown origin (FUO) means fever that does not resolve itself in the period expected for self-limited infection and whose cause cannot be ascertained despite considerable diagnostic efforts. The differential diagnosis is often different in older patients, and presentation of disease is frequently nonspecific and symptoms are difficult to interpret. Multisystem disease has emerged as the most frequent cause of FUO in the elderly, and temporal arteritis is the most frequent specific diagnosis. Infections, particular tuberculosis, remain an important group. FUO is often associated with treatable conditions in this age group. Early recognition and prompt initiation of appropriate empirical therapy are cornerstones of the strategy. [source]

Clinical trial: a randomized trial of early endoscopy, Helicobacter pylori testing and empirical therapy for the management of dyspepsia in primary care

Multicentre evaluation of prescribing concurrence with anti-infective guidelines: epidemiological assessment of indicators

PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 5 2002
Roel Fijn
Abstract Purpose To assess indicators for anti-infective prescribing not concurrent with regional pharmacotherapeutic treatment guidelines (PTGs) on infectious diseases. Methods A retrospective explorative cohort study based on hospital-wide anti-infective prescription data of a 2-month cross-sectional period (n=1037). Risk rates (absolute risks: AR), risk rate ratios (relative risks: RR) and odds ratios (OR) with 95% confidence intervals (95%CI) were estimated for patient, disease, drug, and prescriber variables considered to be potential indicators. Univariable and multivariable logistic regression analyses were performed. Findings Non-concurrence existed of non-indicated prescribing of (particular) anti-infectives (24.3%) and prescribing of non-first choice anti-infectives (55.2%). Non-concurrent durations of treatment and dosing issues accounted for 17.2% and 16.2% respectively. Non-concurrence was associated with empirical therapy, with certain diagnoses, such as skin and soft tissue, urinary, and osteoarthrological infections, and with prescriptions involving topical dosage forms, cephalosporins, macrolides and lincosamides, and quinolones. There was also an association with certain hospitals and with prescribing by geriatricians, surgeons, pulmonologists, and urologists and, in general, junior clinicians in training. Conclusions Other hospitals could use our epidemiological framework to identify their own indicators for non-concurrent prescribing. Our findings suggest tailor-made enforcement of PTG adherence for certain prescribers while conversely, adaptation of the PTGs will be required for some infectious diseases. Copyright © 2002 John Wiley & Sons, Ltd. [source]

Efficacy and safety of modified sequential three-step empirical therapy for chronic cough

RESPIROLOGY, Issue 5 2010
Weili WEI
ABSTRACT Background and objective: Sequential three-step empirical therapy is useful for the management of chronic cough. The purpose of this study was to evaluate the efficacy and safety of modified sequential three-step empirical therapy. Methods: Consecutive patients (n = 240) with chronic cough were recruited and randomly assigned to receive modified (modified group) or primary (primary group) sequential three-step empirical therapy. The primary end-point was the overall rate of control of chronic cough. Secondary end-points were the rate of control of chronic cough at each step of therapy, the duration of treatment required, changes in cough symptom score, health-related quality of life and possible adverse effects. Results: The study was completed by 106 patients in the modified group and 108 patients in the primary group. The overall rate of control of chronic cough was 88.7% in the modified group and 91.7% in the primary group (,2 = 0.54, P > 0.05). There were no obvious differences in the rate of control of cough at each step of therapy, the duration of treatment required, patterns of cough symptom scores or improvements in the health-related quality of life between the modified and primary groups. However, the incidence of drowsiness was significantly lower in the modified group than in the primary group (11.7% vs 21.7%, ,2 = 4.32, P = 0.04). Conclusions: Modified three-step empirical therapy was as efficacious as primary three-step therapy for chronic cough, but was preferable because it had fewer side-effects. [source]

Have the Organisms that Cause Breast Abscess Changed With Time?,,Implications for Appropriate Antibiotic Usage in Primary and Secondary Care

THE BREAST JOURNAL, Issue 4 2010
Natalie Dabbas MBBS
Abstract:, Many patients with breast abscess are managed in primary care. Knowledge of current trends in the bacteriology is valuable in informing antibiotic choices. This study reviews bacterial cultures of a large series of breast abscesses to determine whether there has been a change in the causative organisms during the era of increasing methicillin-resistant Staphylococcus aureus (MRSA). Analysis was undertaken of all breast abscesses treated in a single unit over 2003 , 2006, including abscess type, bacterial culture, antibiotic sensitivity and resistance patterns. One hundred and ninety cultures were obtained (32.8% lactational abscess, 67.2% nonlactational). 83% yielded organisms. Staphylococcus aureus was the commonest organism isolated (51.3%). Of these, 8.6% were MRSA. Other common organisms included mixed anaerobes (13.7%), and anaerobic cocci (6.3%). Lactational abscesses were significantly more likely to be caused by S. aureus (p < 0.05). Methicillin-resistant Staphylococcus aureus rates were not statistically different between lactational and nonlactational abscess groups. Appropriate antibiotic choices are of great importance in the community management of breast abscess. Ideally, microbial cultures should be obtained to institute targeted therapy but we recommend the continued use of flucloxacillin with or without metronidazole (or amoxicillin-clavulanate as a single preparation) as initial empirical therapy. [source]

Diagnosis of common dermatophyte infections by a novel multiplex real-time polymerase chain reaction detection/identification scheme

BRITISH JOURNAL OF DERMATOLOGY, Issue 4 2007
M. Arabatzis
Summary Background, In the absence of a functional dermatophyte-specific polymerase chain reaction (PCR), current diagnosis of dermatophytoses, which constitute the commonest communicable diseases worldwide, relies on microscopy and culture. This combination of techniques is time-consuming and notoriously low in sensitivity. Objectives, Recent dermatophyte gene sequence records were used to design a real-time PCR assay for detection and identification of dermatophytes in clinical specimens in less than 24 h. Patients and methods, Two assays based on amplification of ribosomal internal transcribed spacer regions and on the use of probes specific to relevant species and species-complexes were designed, optimised and clinically evaluated. One assay was for detecting the Trichophyton mentagrophytes species complex plus T. tonsurans and T. violaceum. The second assayed for the T. rubrum species complex, Microsporum canis and M. audouinii. Results, The analytical sensitivity of both assays was 0·1 pg DNA per reaction, corresponding to 2·5,3·3 genomes per sample. The protocol was clinically evaluated over 6 months by testing 92 skin, nail and hair specimens from 67 patients with suspected dermatophytosis. Real-time PCR detected and correctly identified the causal agent in specimens from which T. rubrum, T. interdigitale, M. audouinii or T. violaceum grew in culture, and also identified a dermatophyte species in an additional seven specimens that were negative in microscopy and culture. Conclusions, This highly sensitive assay also proved to have high positive and negative predictive values (95·7% and 100%), facilitating the accurate, rapid diagnosis conducive to targeted rather than empirical therapy for dermatophytoses. [source]

Risk factors for infections with multidrug-resistant Pseudomonas aeruginosa in patients with cancer

CANCER, Issue 1 2005
Norio Ohmagari M.D.
Abstract BACKGROUND Pseudomonas aeruginosa is responsible for a wide range of infections. In immunocompromised patients with cancer, the emergence of multidrug resistant P. aeruginosa may have grave consequences. METHODS Patients with cancer who were infected with multidrug-resistant P. aeruginosa with polyclonal DNA restriction patterns were used as the case group. Two control groups were used: one group of cancer patients who were infected with multidrug-susceptible P. aeruginosa and another group of cancer patients who had the same underlying disease and the same intensive care unit exposure as patients in the case group but who were not infected or colonized by P. aeruginosa. RESULTS Risk factors that were associated significantly with multidrug-resistant P. aeruginosa infection were the use of carbapenem for , 7 days, a history of P. aeruginosa infection during the preceding year, and a history of chronic obstructive pulmonary disease (P < 0.01). CONCLUSIONS Carbapenems may need to be used more judiciously as first-line empirical therapy for cancer patients with prior pseudomonal infection or chronic obstructive pulmonary disease who require hospitalization, and alternative, antipseudomonal antibiotic regimens may need to be considered, especially in this patient population. Cancer 2005. © 2005 American Cancer Society. [source]

Heart block and empirical therapy after transcatheter closure of perimembranous ventricular septal defect

CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 3 2005
FRCP, William C.L. Yip MD
Abstract Two patients with perimembranous ventricular septal defects (VSDs) and inlet extension have undergone uncomplicated transcatheter device closure using the Amplatzer membranous VSD device. Both patients developed complete heart block 2,4 days from the closure. Both patients responded well to high-dose intravenous therapy with steroids and high-dose oral anti-inflammatory aspirin. Both patients remain in normal sinus rhythm 8 weeks and 10 months, respectively, from the episode. © 2005 Wiley-Liss, Inc. [source]

Antimicrobial resistance in Europe and its potential impact on empirical therapy

CLINICAL MICROBIOLOGY AND INFECTION, Issue 2008
G. M. Rossolini
Abstract The problem of microbial drug resistance is a major public health concern, due to its global dimension and alarming magnitude, although the epidemiology of resistance can exhibit remarkable geographical variability and rapid temporal evolution. The major resistance issues overall are those related to methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Enterobacteriaceae producing extended-spectrum ,-lactamases, and multidrug-resistant Pseudomonas aeruginosa and Acinetobacter baumannii. Europe is not free from any of these issues, although their impact may be significantly different in different countries. MRSA rates are high in several European countries, but seem to have levelled off in some settings. Diffusion of VRE is still irregular. The most alarming resistance trends are those observed for Enterobacteriaceae and the Gram-negative non-fermenters, with a generalized increase in rates of resistance to the most important anti-Gram-negative agents (,-lactams and fluoroquinolones) and the circulation of strains showing multidrug resistance phenotypes. [source]

Prevalence of AmpC over-expression in bloodstream isolates of Pseudomonas aeruginosa

CLINICAL MICROBIOLOGY AND INFECTION, Issue 4 2007
V. H. Tam
Abstract This study examined the contribution of AmpC over-expression to ,-lactam resistance in clinical isolates of Pseudomonas aeruginosa obtained from a hospital in Houston, TX, USA. Seventy-six non-repeat bloodstream isolates obtained during 2003 were screened for ceftazidime resistance in the presence and absence of clavulanic acid 4 mg/L. AmpC was identified by isoelectric focusing (with and without cloxacillin inhibition); stable derepression was ascertained phenotypically by a spectrophotometric assay (with and without preceding induction by imipenem) using nitrocefin as the substrate, and was confirmed subsequently by quantitative RT-PCR of the ampC gene. The clonal relatedness of the AmpC-over-expressing isolates was assessed by pulsed-field gel electrophoresis. In addition, the ampC and ampR gene sequences were determined by PCR and sequencing. For comparison, two standard wild-type strains (PAO1 and ATCC 27853) and three multidrug-susceptible isolates were used as controls. AmpC over-expression was confirmed in 14 ceftazidime-resistant isolates (overall prevalence rate, 18.4%), belonging to seven distinct clones. The most prevalent point mutations in ampC were G27D, V205L and G391A. Point mutations in ampR were also detected in eight ceftazidime-resistant isolates. AmpC over-expression appears to be a significant mechanism of ,-lactam resistance in P. aeruginosa. Understanding the prevalence and mechanisms of ,-lactam resistance in P. aeruginosa may guide the choice of empirical therapy for nosocomial infections in hospitals. [source]

Antimicrobial resistance in Escherichia coli in urine samples from children and adults: a 12 year analysis

ACTA PAEDIATRICA, Issue 4 2004
K Abelson Storby
Aim: To investigate the distribution and antimicrobial resistance in urinary tract pathogens, primarily Escherichia coli, in two age groups, children 2 y and adults 18-50 y, over a period of 12 y. Methods: From the database of the microbiological laboratory all urinary tract culture data were extracted and structured according to date, patient age, bacteriological findings, antimicrobial susceptibility results and sample type. Statistical longitudinal analysis of bacteriological findings and antimicrobial resistance trends in the two age groups were performed. Results: Statistical significance was obtained for the following results. Escherichia coli was the most common pathogen in both age groups and irrespective of sample type. In E. coli resistance to ampicillin and trimethoprim was higher in children than in adults and increased over time in both age groups. Resistance to fluoroquinolones was higher in adults than in children and increased over time in both groups. Resistance to pivmecillinam, cefadroxil and nitrofurantoin was below 2% in 2001 in both age groups. Conclusion: The steadily increasing and now high E. coli resistance levels in children to ampicillin and trimethoprim render empirical therapy with these drugs doubtful. The stable and low levels of resistance to pivmecillinam, cefadroxil and nitrofurantoin (>2% in 2001) make these drugs reasonable alternatives in uncomplicated lower urinary tract infections. [source]