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CDI: Making the Case for Better Prevention Efforts

Clostridium difficile infection (CDI) is a common and sometimes fatal healthcare–associated infection. It manifests as diarrhea that often recurs and can progress to toxic megacolon, sepsis, and death. “The incidence, mor­tality, and healthcare costs resulting from CDIs in hospitalized patients have reached historic highs,” says L. Clifford McDonald, MD, FACP, FSHEA. “CDI often occurs in patients in healthcare settings where antibiotics are prescribed and symp­tomatic patients are concentrated.” From 2000 to 2009, the number of hospitalized patients with any CDI discharge diagnoses more than doubled; the number with a primary CDI diagnosis more than tripled. “While the incidence of other healthcare-associated infections has declined, the incidence of CDI has increased,” Dr. McDonald says. Evidence-based guidelines are available for preventing CDI in hospitals, but the degree to which adherence to these guidelines can effectively help prevent these infections is unknown. Analyzing the Impact of CDI In the March 13, 2012 Morbidity & Mortality Weekly Report, Dr. McDonald and colleagues published a study that sought to identify healthcare exposures for CDI, determine the pro­portion of CDI occurring outside hospital settings, and assess whether prevention programs can effectively reduce CDI. The research team analyzed population-based data from the Emerging Infections Program as well as present-on-admission and hospital-onset, laboratory-identified CDI events that were reported to the National Healthcare Safety Network (NHSN). When analyzing data from the Emerging Infec­tions Program, 10,342 CDIs were identified. “Overall, 94% of all CDIs were related to various precedent and concurrent healthcare exposures,” says Dr. McDonald. “About three-fourths of CDIs had their onset occur outside of hospitals [Figure 1]. It should also be noted that some cases occurred in...
First-Ever Guidelines for Acute Bacterial Rhinosinusitis

First-Ever Guidelines for Acute Bacterial Rhinosinusitis

The first-ever recommendations for the diagnosis and management of acute bacterial rhinosinusitis (ABRS) infections were published by the Infectious Diseases Society of America. Posted online at the end of March, they will appear in the April 15, 2012 issue of Clinical Infectious Diseases. Rhinosinusitis is the 5th leading indication for antimicrobial prescriptions by doctors in a practice. Due to a lack of existing clinical criteria to accurately differentiate bacterial from viral acute rhinosinusitis, excessive and inappropriate antibiotic prescriptions occur. Clinicians are forced to rely on clinical presentations to distinguish bacterial from viral rhinosinusitis. The new ABRS guidelines suggest that the infection is probably bacterial if any of the following are present: Persistent symptoms or signs of acute rhinosinusitis last for 10 days or more. Severe symptoms or signs of high fever (102°F) and purulent nasal discharge or facial pain lasting for at least 3-4 consecutive days at the beginning of an illness Worsening symptoms or signs characterized by new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection that lasted 5-6 days and initially improved (“double-sickening”) First-line therapy: Once a clinical diagnosis of ABRS is established, it is recommended that empiric antimicrobial therapy be initiated immediately with amoxicillin-clavulanate (rather than amoxicillin alone) for both adults and children. High-dose (2 g orally twice daily or 90 mg/kg/day orally twice daily) amoxicillin-clavulanate is recommended for children and adults with ABRS from geographic regions with high endemic rates of invasive penicillin-nonsusceptible S. pneumoniae, those with severe infection, attendance at daycare, age <2 or >65 years, recent hospitalization, antibiotic use within the past month, or who...
Assessing Options for Pneumonia Hospitalizations

Assessing Options for Pneumonia Hospitalizations

Community-acquired pneumonia (CAP) affects approximately 4 million patients in the United States each year. Around 20% of these patients are admitted to hospitals for treatment. In patients requiring inpatient treatment, overall mortality is approximately 12%. However, it can be much higher in CAP patients requiring admission to the ICU. When parenteral antimicrobials are required for the treatment of hospitalized patients, the mainstay of therapy for many years has included either a combination of a β-lactam antibiotic with a macrolide antibiotic, or the use of a respiratory fluoroquinolone alone. β-lactam antibiotics do not have antibacterial activity against the so-called “atypical bacteria,” including species of Mycoplasma, Chlamydia, andLegionella, which are important pathogens in CAP. Classes of antibiotics active against these atypical pathogens include macrolides, fluoroquinolones, and tetracyclines. Urgent Need of New Antimicrobial Agents Two important realities are beginning to impact the traditional recommendations for antimicrobial therapy in CAP. First, there is an urgent need for the development of new antimicrobial agents that are more active against resistant bacterial pathogens. Second, the rapid development of antimicrobial-resistant bacterial pathogens has compromised many of our existing antimicrobials. “Antimicrobial resistance continues to increase in a dramatic fashion.” While there are many reasons for the slowing of new antimicrobial discoveries and the rapid development of antimicrobial resistance, the major factors appear to be overuse and misuse of antibiotics in both man and animals and the inability of the pharmaceutical industry to realize significant financial return on investment from new antimicrobial development. This lack of new agents has been called one of the three greatest threats to human health by the Infectious Diseases Society of America (IDSA). Yet, antimicrobial...
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