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Case Studies in Simulation
Published in Andrew P. Grieve, Hybrid Frequentist/Bayesian Power and Bayesian Power in Planning Clinical Trials, 2022
The context in this case study is an active-controlled Phase II study which was planned to compare the efficacy and safety of a novel combination antibiotic (Test) with a standard combination (Control) in hospitalised adult patients suffering from complicated urinary tract infections (cUTI). The primary efficacy endpoint was the eradication of uropathogens from ≥105 colony-forming units (CFU)/mL to < 104 CFU/mL and no pathogens in the blood in the microbiologically evaluable (ME) population. The ME population consisted of subjects with positive urine culture with bacteria susceptible to either antibiotic at enrolment (105 CFU/mL or >104 CFU/mL if bacteraemia present).
Toxic Shock Syndrome and Other Related Severe Infections
Published in Botros Rizk, A. Mostafa Borahay, Abdel Maguid Ramzy, Clinical Diagnosis and Management of Gynecologic Emergencies, 2020
Invasive infections caused by S. pyogenes (GAS), clostridial species, and S. aureus in obstetrics and gynecology are serious and potentially fatal in both pregnant and nonpregnant women. Increasing your index of suspicion will allow you to consider the diagnosis and order the appropriate laboratory tests that can lead you to early diagnosis and intervention. Combination antibiotic therapy with penicillin is recommended to treat the described bacteria; however, if S. aureus is suspected, then vancomycin should be empirically started until a susceptibility panel is available. In addition, clindamycin should be added to the above regimen to not only treat the underlying infection, but also limit toxin production and the resultant inflammatory response. Carbapenems, such as meropenem, also provide excellent coverage and can be substituted for penicillin.
Surgery of the Hip
Published in Timothy W R Briggs, Jonathan Miles, William Aston, Heledd Havard, Daud TS Chou, Operative Orthopaedics, 2020
Daud TS Chou, Jonathan Miles, John Skinner
The patient should be followed up clinically and have regular checks of inflammatory markers. Postoperative antibiotics can be given once the microbiological sensitivities have been received. These cases often require combination antibiotic therapy and should be managed together with a microbiologist. Once the inflammatory markers are normal, the second stage can be undertaken, with reconstruction depending on the extent of femoral and acetabular bone loss. Particular care must be taken with the soft tissues as multiple procedures will often have taken their toll on the surrounding musculature. Many surgeons prefer the use of a cemented stem in this situation as extra antibiotics can be added to decrease the chance of recurrence. Some surgeons may opt to perform a single-stage revision in selected patients, which involves a thorough debridement, removal of implants and re-implantation of definitive prosthesis at the same time. Whichever approach is taken it is important to manage these complex patients within a multidisciplinary team structure consisting of orthopaedic surgeons, plastic surgeons and microbiologists.
Appropriateness of diagnosis and antibiotic use in sepsis patients admitted to a tertiary hospital in Indonesia
Published in Postgraduate Medicine, 2021
Franciscus Ginting, Adhi Kristianto Sugianli, Morris Barimbing, Nina Ginting, Mardianto Mardianto, R. Lia Kusumawati, Ida Parwati, Menno D. de Jong, Constance Schultsz, Frank van Leth
All but four patients started on empirical antibiotic treatment during admission (Table 2), although in around one-third of the patients (147/521), the empirical antibiotic treatment provided consisted of antibiotics from a single class (Table 3). Empirical treatment according to the Indonesian sepsis guidelines was provided for 101/150 (67.3%) patients in the ICU, 256/385 (66.5%) patients on non-ICU wards, 154/240 (64.2%) patients with a hospital-acquired sepsis, and 203/295 (68.9%) patients with a community-acquired sepsis. The preferred combination was a cephalosporin with a fluoroquinolone (n = 125, 35% of combination antibiotic treatment), followed by the combination of cephalosporin, fluoroquinolone, and metronidazole (n = 29, 8.1% of combination antibiotic treatment). Cephalosporins were by far the most preferred antibiotics in any of the settings (70–80%), followed by the quinolones (30–50%). Meropenem was used in almost half the number of patients with sepsis in the ICU.
Elucidating the survival and response of carbapenem resistant Klebsiella pneumoniae after exposure to imipenem at sub-lethal concentrations
Published in Pathogens and Global Health, 2018
Ye Mun Low, Chun Wie Chong, Ivan Kok Seng Yap, Lay Ching Chai, Stuart C. Clarke, Sasheela Ponnampalavanar, Kartini Abdul Jabar, Mohd Yasim Md Yusof, Cindy Shuan Ju Teh
Bacteria are able to protect themselves by undergoing various morphological and physiological changes or adaptations. For instance, bacteria can adapt to fluctuating levels of nutrients, antibiotics or environmental stressors by reorganizing their gene expression or changing the metabolism hubs such as tricarboxylic acid (TCA) cycle and electron transport chain [10,11]. The physiological and morphological plasticity are among the main factors contributing to the development of resistance to antibiotic; however, it is unreassuring as broad-spectrum antibiotics are often given as empiric treatment whilst awaiting laboratory culture results. Furthermore, combination antibiotic therapy is sometimes administered as empiric treatment for patients who are severely ill or in septic shock due to infections such as bacteremia, neutropenic sepsis, pneumonia or surgical site infection [12]. Kumar et al. [13] showed that combination therapy significantly reduced intensive care and hospital mortality while early combination of antibiotic therapy can decrease mortality rates in septic shock patients. Notwithstanding the benefit, careful attention must be given to the usage of antibiotic to prevent the development of antibiotic resistance.
Clinical outcomes associated with carbapenem resistant Klebsiella pneumoniae (CRKP) in abdominal solid organ transplant (SOT) recipients
Published in Infectious Diseases, 2018
Tiffany E. Bias, Gregory E. Malat, Dong H. Lee, Akshay Sharma, Alden M. Doyle
Time to acquisition of CRKP infection (defined as months from transplant to time of initial infection) was a median of 7 months (IQR 3–50), with five liver transplant recipients becoming infected within 30 d post transplantation. Majority of liver transplant recipients were infected in the early post-transplant period of 3 months in comparison to kidney transplant recipients. The primary sources of CRKP infections were most commonly urine (43%), pneumonia (37%), followed by primary bacteremia (10%) and intra-abdominal infection (10%). Secondary bloodstream infections occurred in four additional patients. Susceptibility patterns of CRKP infections indicated increased sensitivity to colistin (93%), but diminished susceptibility to other available agents, namely gentamicin (47%), amikacin (37%) and tigecycline (27%). With regards to treatment, 13 patients (43%) received an antibiotic regimen containing colistin, 12 (40%) an aminoglycoside and 8 (27%) tigecycline. Notably, nine patients (30%) received combination antibiotic therapy with at least two different classes of drugs in comparison to single antibiotic regimens (70%). For combination therapy regimens, patients were treated with an aminoglycoside plus tigecycline or colistin in six cases, colistin plus tigecycline, a carbapenem or an aminoglycoside in three cases and an aminoglycoside plus sulfamethoxazole/trimethoprim in 1 case.