Doug Brunk

Central line–associated bloodstream infections are among four common health care–associated infections that have declined in the United States, according to an analysis of 2010 data released by the Centers for Disease Control and Prevention.

Along with central line–associated bloodstream infections (CLABSIs), health care–associated invasive methicillin-resistant Staphylococcus aureus (MRSA) infections and surgical site infections are on track to meet reduction targets set by the Department of Health and Human Services’ Action Plan to Prevent Health Care–Associated Infections. One trouble spot in the plan appears to be Clostridium difficile hospitalizations, which have shown an increase. Data are not yet available on the progress of reducing C. difficile infections and MRSA bacteremia, the CDC said.

"These successes reflect investments not only in hospital practices, but [also] in our national and state public health capacity," Dr. Denise Cardo, director of CDC’s Division of Healthcare Quality Promotion, said in a prepared statement. "Preventing infections in health care saves lives and reduces health care costs."

The nine-target initiative, which has an end goal of Dec. 31, 2013, includes collection of data submitted by hospitals to the CDC’s National Healthcare Safety Network.

"Progress is steadily taking place," according to the HHS. But, the agency, acknowledged: "Efforts must be enhanced and accelerated" to achieve the reduction target for C. diff. hospitalizations, whose projected 2010 assessment is a 6.8% increase from baseline. The 2009 data showed a 1.1% increase from baseline (of 8.8 hospitalizations/1,000 discharges in 2008).

The CDC reported that in 2010, there was a 33% reduction in central line–associated bloodstream infections: a 35% reduction among critical care patients and a 26% reduction among non–critical care patients.

Other highlights included a 7% reduction in catheter-associated urinary tract infections, a 10% reduction in surgical site infections, and an 18% reduction in the number of people developing invasive MRSA infections.

In addition, adherence to central-line insertion practices reached 94.5%.

Details of the metrics and national 5-year prevention targets from the Action Plan to Prevent Healthcare-Associated Infections include the following:

• A 50% reduction in bloodstream infections.
• 100% adherence to central-line insertion practices, 30% reduction in Clostridium difficile hospitalizations.
• 30% reduction in Clostridium difficile infections,
• 25% reduction in urinary tract infections.
• 50% reduction in methicillin resistant Staphylococcus aureus (MRSA) invasive infections
• 25% reduction in MRSA bacteremia.
• 25% reduction in surgical site infections
• 95% adherence to Surgical Care Improvement Project Measures.

HHS intends to annually review progress toward the goals of the initiative, which started in 2008. Most metrics have a 2008 baseline, and the CDC started reporting annual data in 2009, according to the CDC.

Central line–associated bloodstream infections are among four common health care–associated infections that have declined in the United States, according to an analysis of 2010 data released by the Centers for Disease Control and Prevention.

Along with central line–associated bloodstream infections (CLABSIs), health care–associated invasive methicillin-resistant Staphylococcus aureus (MRSA) infections and surgical site infections are on track to meet reduction targets set by the Department of Health and Human Services’ Action Plan to Prevent Health Care–Associated Infections. One trouble spot in the plan appears to be Clostridium difficile hospitalizations, which have shown an increase. Data are not yet available on the progress of reducing C. difficile infections and MRSA bacteremia, the CDC said.

"These successes reflect investments not only in hospital practices, but [also] in our national and state public health capacity," Dr. Denise Cardo, director of CDC’s Division of Healthcare Quality Promotion, said in a prepared statement. "Preventing infections in health care saves lives and reduces health care costs."

The nine-target initiative, which has an end goal of Dec. 31, 2013, includes collection of data submitted by hospitals to the CDC’s National Healthcare Safety Network.

"Progress is steadily taking place," according to the HHS. But, the agency, acknowledged: "Efforts must be enhanced and accelerated" to achieve the reduction target for C. diff. hospitalizations, whose projected 2010 assessment is a 6.8% increase from baseline. The 2009 data showed a 1.1% increase from baseline (of 8.8 hospitalizations/1,000 discharges in 2008).

The CDC reported that in 2010, there was a 33% reduction in central line–associated bloodstream infections: a 35% reduction among critical care patients and a 26% reduction among non–critical care patients.

Other highlights included a 7% reduction in catheter-associated urinary tract infections, a 10% reduction in surgical site infections, and an 18% reduction in the number of people developing invasive MRSA infections.

In addition, adherence to central-line insertion practices reached 94.5%.

Details of the metrics and national 5-year prevention targets from the Action Plan to Prevent Healthcare-Associated Infections include the following:

• A 50% reduction in bloodstream infections.
• 100% adherence to central-line insertion practices, 30% reduction in Clostridium difficile hospitalizations.
• 30% reduction in Clostridium difficile infections,
• 25% reduction in urinary tract infections.
• 50% reduction in methicillin resistant Staphylococcus aureus (MRSA) invasive infections
• 25% reduction in MRSA bacteremia.
• 25% reduction in surgical site infections
• 95% adherence to Surgical Care Improvement Project Measures.

HHS intends to annually review progress toward the goals of the initiative, which started in 2008. Most metrics have a 2008 baseline, and the CDC started reporting annual data in 2009, according to the CDC.

Central line–associated bloodstream infections are among four common health care–associated infections that have declined in the United States, according to an analysis of 2010 data released by the Centers for Disease Control and Prevention.

Along with central line–associated bloodstream infections (CLABSIs), health care–associated invasive methicillin-resistant Staphylococcus aureus (MRSA) infections and surgical site infections are on track to meet reduction targets set by the Department of Health and Human Services’ Action Plan to Prevent Health Care–Associated Infections. One trouble spot in the plan appears to be Clostridium difficile hospitalizations, which have shown an increase. Data are not yet available on the progress of reducing C. difficile infections and MRSA bacteremia, the CDC said.

"These successes reflect investments not only in hospital practices, but [also] in our national and state public health capacity," Dr. Denise Cardo, director of CDC’s Division of Healthcare Quality Promotion, said in a prepared statement. "Preventing infections in health care saves lives and reduces health care costs."

The nine-target initiative, which has an end goal of Dec. 31, 2013, includes collection of data submitted by hospitals to the CDC’s National Healthcare Safety Network.

"Progress is steadily taking place," according to the HHS. But, the agency, acknowledged: "Efforts must be enhanced and accelerated" to achieve the reduction target for C. diff. hospitalizations, whose projected 2010 assessment is a 6.8% increase from baseline. The 2009 data showed a 1.1% increase from baseline (of 8.8 hospitalizations/1,000 discharges in 2008).

The CDC reported that in 2010, there was a 33% reduction in central line–associated bloodstream infections: a 35% reduction among critical care patients and a 26% reduction among non–critical care patients.

Other highlights included a 7% reduction in catheter-associated urinary tract infections, a 10% reduction in surgical site infections, and an 18% reduction in the number of people developing invasive MRSA infections.

In addition, adherence to central-line insertion practices reached 94.5%.

Details of the metrics and national 5-year prevention targets from the Action Plan to Prevent Healthcare-Associated Infections include the following:

• A 50% reduction in bloodstream infections.
• 100% adherence to central-line insertion practices, 30% reduction in Clostridium difficile hospitalizations.
• 30% reduction in Clostridium difficile infections,
• 25% reduction in urinary tract infections.
• 50% reduction in methicillin resistant Staphylococcus aureus (MRSA) invasive infections
• 25% reduction in MRSA bacteremia.
• 25% reduction in surgical site infections
• 95% adherence to Surgical Care Improvement Project Measures.

HHS intends to annually review progress toward the goals of the initiative, which started in 2008. Most metrics have a 2008 baseline, and the CDC started reporting annual data in 2009, according to the CDC.

In 2006, the overall costs from excessive drinking in the United States reached $223.5 billion, according to findings from a new study conducted by the Centers for Disease Control and Prevention.

"That amounts to almost $750 for every person in the country, or about $1.90 per drink," CDC Director Thomas R. Frieden said during an Oct. 17 teleconference.

Copyright: Nikada/iStockphoto.com

Nearly three-quarters of the $223.5 billion price tag was tied to losses in workplace activity (72%), followed by health care expenses for problems caused by excessive drinking (11%), law enforcement and other criminal justice expenses (9%), motor vehicle crash costs (6%), and other effects (2%).

"While we know that excess drinking is not a new public health problem, we recognize that it has been at times easy to lose sight of the enormous impact it has on our lives and on our wallets, because binge drinking results in binge spending – not only by the person who drinks but also for families, communities, and society," Dr. Frieden said. "There are substantial costs to all of us.

"The harms of heavy drinking are far-reaching and include many different aspects of our society – chronic health problems such as cirrhosis of the liver; inflammation of the pancreas; cancer; high blood pressure; mental health problems; injuries such as motor vehicle crashes, falls, drownings, burns, and violence – including child maltreatment, homicide, suicide, and domestic violence."

For the study, which appears in the November issue of the American Journal of Preventive Medicine (Am J Prev Med 2011;41:516-24), Ellen E. Bouchery and her colleagues gathered national data from multiple sources, including the Alcohol-Related Disease Impact Application, the National Epidemiologic Survey on Alcohol-Related Conditions, and the National Survey on Drug Use and Health, in an effort to estimate the costs resulting from excessive drinking in 2006, the most recent year for which data were generally available.

A previous study by the Lewin Group, a consulting firm based in Falls Church, Va., found that the cost of alcohol misuse in the United States was about $185 billion in 1998.

In the current study, entitled "Economic Costs of Excessive Alcohol Consumption in the U.S., 2006," Ms. Bouchery and her colleagues defined excessive alcohol consumption as binge drinking (four or more drinks per occasion for a woman, and five or more drinks per occasion for a man); heavy drinking (more than one drink per day on average for a woman, and more than two drinks per day on average for a man); and any alcohol consumption by pregnant women or underage youth. They found that about $94.2 billion (42%) of the total economic costs of excessive alcohol consumption were borne by federal, state, and local governments while $92.9 billion (41.5 %) was borne by excessive drinkers and their family members.

Government agencies paid most of the health care expenses attributable to excessive alcohol use (61%), while drinkers and their families bore most of the cost of lost productivity (55%), primarily in the form of lower household income.

According to Dr. Frieden, binge drinking is reported by about one out of seven adults in the United States "and by far is the most common pattern of alcohol consumption in underage youth. However, most binge drinkers are not alcohol dependent, and there are a number of scientifically proven strategies that can reduce excess drinking, including binge drinking. This is possible both at the community level as well as [in] clinical settings, where it’s possible that doctors, nurses, and others can intervene to advise patients in ways that will reduce their risk of progressing to harmful drinking over time."

He concluded his remarks by saying that he hopes the release of the study’s findings "will remind us of the public health impact of excess alcohol consumption and challenge us to implement evidence-based methods of ensuring that we reduce these substantial harms in future years," Dr. Frieden said. "It’s possible that by implementing evidence-based policies we can not only save money but also save lives and promote stability in our community."

The study is scheduled to appear in the November 2011 issue of the journal.

The study was developed in collaboration with the CDC and the Lewin Group and was funded by a grant from the Robert Wood Johnson Foundation to the CDC Foundation.

In 2006, the overall costs from excessive drinking in the United States reached $223.5 billion, according to findings from a new study conducted by the Centers for Disease Control and Prevention.

"That amounts to almost $750 for every person in the country, or about $1.90 per drink," CDC Director Thomas R. Frieden said during an Oct. 17 teleconference.

Copyright: Nikada/iStockphoto.com

Nearly three-quarters of the $223.5 billion price tag was tied to losses in workplace activity (72%), followed by health care expenses for problems caused by excessive drinking (11%), law enforcement and other criminal justice expenses (9%), motor vehicle crash costs (6%), and other effects (2%).

"While we know that excess drinking is not a new public health problem, we recognize that it has been at times easy to lose sight of the enormous impact it has on our lives and on our wallets, because binge drinking results in binge spending – not only by the person who drinks but also for families, communities, and society," Dr. Frieden said. "There are substantial costs to all of us.

"The harms of heavy drinking are far-reaching and include many different aspects of our society – chronic health problems such as cirrhosis of the liver; inflammation of the pancreas; cancer; high blood pressure; mental health problems; injuries such as motor vehicle crashes, falls, drownings, burns, and violence – including child maltreatment, homicide, suicide, and domestic violence."

For the study, which appears in the November issue of the American Journal of Preventive Medicine (Am J Prev Med 2011;41:516-24), Ellen E. Bouchery and her colleagues gathered national data from multiple sources, including the Alcohol-Related Disease Impact Application, the National Epidemiologic Survey on Alcohol-Related Conditions, and the National Survey on Drug Use and Health, in an effort to estimate the costs resulting from excessive drinking in 2006, the most recent year for which data were generally available.

A previous study by the Lewin Group, a consulting firm based in Falls Church, Va., found that the cost of alcohol misuse in the United States was about $185 billion in 1998.

In the current study, entitled "Economic Costs of Excessive Alcohol Consumption in the U.S., 2006," Ms. Bouchery and her colleagues defined excessive alcohol consumption as binge drinking (four or more drinks per occasion for a woman, and five or more drinks per occasion for a man); heavy drinking (more than one drink per day on average for a woman, and more than two drinks per day on average for a man); and any alcohol consumption by pregnant women or underage youth. They found that about $94.2 billion (42%) of the total economic costs of excessive alcohol consumption were borne by federal, state, and local governments while $92.9 billion (41.5 %) was borne by excessive drinkers and their family members.

Government agencies paid most of the health care expenses attributable to excessive alcohol use (61%), while drinkers and their families bore most of the cost of lost productivity (55%), primarily in the form of lower household income.

According to Dr. Frieden, binge drinking is reported by about one out of seven adults in the United States "and by far is the most common pattern of alcohol consumption in underage youth. However, most binge drinkers are not alcohol dependent, and there are a number of scientifically proven strategies that can reduce excess drinking, including binge drinking. This is possible both at the community level as well as [in] clinical settings, where it’s possible that doctors, nurses, and others can intervene to advise patients in ways that will reduce their risk of progressing to harmful drinking over time."

He concluded his remarks by saying that he hopes the release of the study’s findings "will remind us of the public health impact of excess alcohol consumption and challenge us to implement evidence-based methods of ensuring that we reduce these substantial harms in future years," Dr. Frieden said. "It’s possible that by implementing evidence-based policies we can not only save money but also save lives and promote stability in our community."

The study is scheduled to appear in the November 2011 issue of the journal.

The study was developed in collaboration with the CDC and the Lewin Group and was funded by a grant from the Robert Wood Johnson Foundation to the CDC Foundation.

In 2006, the overall costs from excessive drinking in the United States reached $223.5 billion, according to findings from a new study conducted by the Centers for Disease Control and Prevention.

"That amounts to almost $750 for every person in the country, or about $1.90 per drink," CDC Director Thomas R. Frieden said during an Oct. 17 teleconference.

Copyright: Nikada/iStockphoto.com

Nearly three-quarters of the $223.5 billion price tag was tied to losses in workplace activity (72%), followed by health care expenses for problems caused by excessive drinking (11%), law enforcement and other criminal justice expenses (9%), motor vehicle crash costs (6%), and other effects (2%).

"While we know that excess drinking is not a new public health problem, we recognize that it has been at times easy to lose sight of the enormous impact it has on our lives and on our wallets, because binge drinking results in binge spending – not only by the person who drinks but also for families, communities, and society," Dr. Frieden said. "There are substantial costs to all of us.

"The harms of heavy drinking are far-reaching and include many different aspects of our society – chronic health problems such as cirrhosis of the liver; inflammation of the pancreas; cancer; high blood pressure; mental health problems; injuries such as motor vehicle crashes, falls, drownings, burns, and violence – including child maltreatment, homicide, suicide, and domestic violence."

For the study, which appears in the November issue of the American Journal of Preventive Medicine (Am J Prev Med 2011;41:516-24), Ellen E. Bouchery and her colleagues gathered national data from multiple sources, including the Alcohol-Related Disease Impact Application, the National Epidemiologic Survey on Alcohol-Related Conditions, and the National Survey on Drug Use and Health, in an effort to estimate the costs resulting from excessive drinking in 2006, the most recent year for which data were generally available.

A previous study by the Lewin Group, a consulting firm based in Falls Church, Va., found that the cost of alcohol misuse in the United States was about $185 billion in 1998.

In the current study, entitled "Economic Costs of Excessive Alcohol Consumption in the U.S., 2006," Ms. Bouchery and her colleagues defined excessive alcohol consumption as binge drinking (four or more drinks per occasion for a woman, and five or more drinks per occasion for a man); heavy drinking (more than one drink per day on average for a woman, and more than two drinks per day on average for a man); and any alcohol consumption by pregnant women or underage youth. They found that about $94.2 billion (42%) of the total economic costs of excessive alcohol consumption were borne by federal, state, and local governments while $92.9 billion (41.5 %) was borne by excessive drinkers and their family members.

Government agencies paid most of the health care expenses attributable to excessive alcohol use (61%), while drinkers and their families bore most of the cost of lost productivity (55%), primarily in the form of lower household income.

According to Dr. Frieden, binge drinking is reported by about one out of seven adults in the United States "and by far is the most common pattern of alcohol consumption in underage youth. However, most binge drinkers are not alcohol dependent, and there are a number of scientifically proven strategies that can reduce excess drinking, including binge drinking. This is possible both at the community level as well as [in] clinical settings, where it’s possible that doctors, nurses, and others can intervene to advise patients in ways that will reduce their risk of progressing to harmful drinking over time."

He concluded his remarks by saying that he hopes the release of the study’s findings "will remind us of the public health impact of excess alcohol consumption and challenge us to implement evidence-based methods of ensuring that we reduce these substantial harms in future years," Dr. Frieden said. "It’s possible that by implementing evidence-based policies we can not only save money but also save lives and promote stability in our community."

The study is scheduled to appear in the November 2011 issue of the journal.

The study was developed in collaboration with the CDC and the Lewin Group and was funded by a grant from the Robert Wood Johnson Foundation to the CDC Foundation.

CHICAGO – The course of Clostridium difficile–associated colitis differs considerably among immunosuppressed patients, compared with those who are immunocompetent, results from a German study suggest.

"Besides the known risk factor of antibiotic therapy, immunosuppression must also be regarded as an independent risk factor" for C. difficile-associated infections, Dr. Christoph Lübbert said during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"Immunosuppressive or immmodulatory treatment results in a higher rate of asymptomatic colonization with C. difficile and a minor clinical manifestation (less diarrhea episodes), probably due to the anti-inflammatory effects of steroids in particular. An increasing proportion of symptomatic C. difficile infections, especially in immunosuppressed patients, develops without any history of prior antibiotic treatment."

Between 2005 and 2009, Dr. Lübbert, of the department of medicine at University Hospital, Martin Luther University Halle-Wittenberg, Germany, and his associates evaluated the symptoms and clinical features of 105 inpatients with demonstration of the C. difficile toxin in stool specimens by enzyme immunoassay. Of the 105 patients, 55 were immunosuppressed, which was defined as a neutrophil count of less than 1,000 leukocytes per mL and/or drug immunosuppression by cytostatic agents, glucocorticoids, azathioprine, methotrexate, monoclonal antibodies, and cyclosporin A. The remaining 50 patients in the study were immunocompetent.

Immunosuppressed patients were significantly younger than immunocompetent patients (a mean of 60 vs. 70 years of age, respectively). They were also more likely to be colonized with C. difficile without obvious clinical manifestation of illness (22% vs. 2%), and more likely to relapse (15% vs. 6%).

The researchers also reported that antibiotic use among immunosuppressed patients was 53%, compared with 84% among immunocompetent patients.

"You have to look for C. difficile-associated disease in hospitalized patients on immunosuppressive treatment, even if they don’t take antibiotics," Dr. Lübbert said in an interview at the meeting, which was sponsored by the American Society for Microbiology. "Look for fever, elevated leukocyte count, and for morphologic changes in the intestinal wall. You can have inflammation in the intestine but no significant diarrhea. That is possible."

Dr. Lübbert said that he had no relevant conflicts to disclose.

CHICAGO – The course of Clostridium difficile–associated colitis differs considerably among immunosuppressed patients, compared with those who are immunocompetent, results from a German study suggest.

"Besides the known risk factor of antibiotic therapy, immunosuppression must also be regarded as an independent risk factor" for C. difficile-associated infections, Dr. Christoph Lübbert said during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"Immunosuppressive or immmodulatory treatment results in a higher rate of asymptomatic colonization with C. difficile and a minor clinical manifestation (less diarrhea episodes), probably due to the anti-inflammatory effects of steroids in particular. An increasing proportion of symptomatic C. difficile infections, especially in immunosuppressed patients, develops without any history of prior antibiotic treatment."

Between 2005 and 2009, Dr. Lübbert, of the department of medicine at University Hospital, Martin Luther University Halle-Wittenberg, Germany, and his associates evaluated the symptoms and clinical features of 105 inpatients with demonstration of the C. difficile toxin in stool specimens by enzyme immunoassay. Of the 105 patients, 55 were immunosuppressed, which was defined as a neutrophil count of less than 1,000 leukocytes per mL and/or drug immunosuppression by cytostatic agents, glucocorticoids, azathioprine, methotrexate, monoclonal antibodies, and cyclosporin A. The remaining 50 patients in the study were immunocompetent.

Immunosuppressed patients were significantly younger than immunocompetent patients (a mean of 60 vs. 70 years of age, respectively). They were also more likely to be colonized with C. difficile without obvious clinical manifestation of illness (22% vs. 2%), and more likely to relapse (15% vs. 6%).

The researchers also reported that antibiotic use among immunosuppressed patients was 53%, compared with 84% among immunocompetent patients.

"You have to look for C. difficile-associated disease in hospitalized patients on immunosuppressive treatment, even if they don’t take antibiotics," Dr. Lübbert said in an interview at the meeting, which was sponsored by the American Society for Microbiology. "Look for fever, elevated leukocyte count, and for morphologic changes in the intestinal wall. You can have inflammation in the intestine but no significant diarrhea. That is possible."

Dr. Lübbert said that he had no relevant conflicts to disclose.

CHICAGO – The course of Clostridium difficile–associated colitis differs considerably among immunosuppressed patients, compared with those who are immunocompetent, results from a German study suggest.

"Besides the known risk factor of antibiotic therapy, immunosuppression must also be regarded as an independent risk factor" for C. difficile-associated infections, Dr. Christoph Lübbert said during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"Immunosuppressive or immmodulatory treatment results in a higher rate of asymptomatic colonization with C. difficile and a minor clinical manifestation (less diarrhea episodes), probably due to the anti-inflammatory effects of steroids in particular. An increasing proportion of symptomatic C. difficile infections, especially in immunosuppressed patients, develops without any history of prior antibiotic treatment."

Between 2005 and 2009, Dr. Lübbert, of the department of medicine at University Hospital, Martin Luther University Halle-Wittenberg, Germany, and his associates evaluated the symptoms and clinical features of 105 inpatients with demonstration of the C. difficile toxin in stool specimens by enzyme immunoassay. Of the 105 patients, 55 were immunosuppressed, which was defined as a neutrophil count of less than 1,000 leukocytes per mL and/or drug immunosuppression by cytostatic agents, glucocorticoids, azathioprine, methotrexate, monoclonal antibodies, and cyclosporin A. The remaining 50 patients in the study were immunocompetent.

Immunosuppressed patients were significantly younger than immunocompetent patients (a mean of 60 vs. 70 years of age, respectively). They were also more likely to be colonized with C. difficile without obvious clinical manifestation of illness (22% vs. 2%), and more likely to relapse (15% vs. 6%).

The researchers also reported that antibiotic use among immunosuppressed patients was 53%, compared with 84% among immunocompetent patients.

"You have to look for C. difficile-associated disease in hospitalized patients on immunosuppressive treatment, even if they don’t take antibiotics," Dr. Lübbert said in an interview at the meeting, which was sponsored by the American Society for Microbiology. "Look for fever, elevated leukocyte count, and for morphologic changes in the intestinal wall. You can have inflammation in the intestine but no significant diarrhea. That is possible."

Dr. Lübbert said that he had no relevant conflicts to disclose.

Urinary incontinence may rank as the most embarrassing condition a woman will face in her lifetime, but the good news is that 80%-90% of patients who seek treatment will experience symptom relief.

"That is what makes my job so great – the fact that I can bring back quality of life to these women," said Dr. Cheryl Iglesia, who directs the Section of Female Pelvic Medicine and Reconstructive Surgery at Washington (D.C.) Hospital Center. "Urinary incontinence affects their confidence, sexuality, level of activity, and self-esteem."

Treatments for stress, urge, and mixed urinary incontinence have expanded and advanced in recent years. Botox is the newest kid on the block, approved on Aug. 24 for women with urge incontinence who have an inadequate response to or are intolerant of antimuscarinic medications.

"Like most of our therapies, Botox doesn’t work for everyone but it can be very effective," said Dr. Dee Ellen Fenner, professor of obstetrics and gynecology at the University of Michigan, Ann Arbor. "Overall, I think women tolerate it very well. It’s done in the office with a cystoscope with injections into the bladder muscle."

Before considering medical and surgical treatments for urinary incontinence, advise your patients to try conservative therapies first, such as limiting fluid intake ("let thirst be your guide"), cutting back on the intake of caffeine and other bladder irritants, and voiding on a schedule.

Strengthening the pelvic floor muscles with Kegel exercises also can be helpful. "There are a growing number of physical therapists across the country who have training in pelvic floor work," Dr. Fenner noted. "They provide an expertise and can really help women in terms of rehabilitating their pelvic floor. That can be good for all types of urinary incontinence."

Treatments for urinary incontinence differ depending on a woman’s goals and her symptoms. For some women with stress incontinence, vaginal insertion of an incontinence dish pessary or an incontinence ring pessary will suffice. These devices act as a backstop to the urinary sphincter. "They’re not as strong as surgery," said Dr. Linda Brubaker, who directs the Division of Female Pelvic Medicine and Reconstructive Surgery at Loyola University Chicago, Maywood, Ill. "More people who have surgery will be satisfied and have better symptom control. But for a woman who doesn’t want surgery or isn’t ready for surgery who has symptoms only when she takes her Jazzercise class or goes for a run, a ring might work just fine."

Dr. Fenner, who is also director of gynecology for the University of Michigan Health System, often recommends incontinence rings for mothers who experience urinary leakage after having a baby "because the tissues, muscles, and nerves in her pelvic region are healing for 9-12 months. Wearing that incontinence ring can be great."

Other treatment options for stress incontinence include:

• Urethral bulking agents. Food and Drug Administration-approved urethral bulking agents include collagen (Contigen), calcium hydroxylapatite (Coaptite), and carbon bead particles (Durasphere). These substances are injected along the urethra during an office procedure. "It doesn’t take much anesthesia and patients can go home the same day," said Dr. Iglesia. "Most people with a bulking agent will need a touch-up."

• Sling-type procedures. The mid-urethral mesh sling, most often made of polypropylene mesh, is the current standard. There are three different types: a retropubic sling that travels behind the pubic bone, forming a U shape; a transobturator sling, which exits through the groin crease near the thigh, forming more of an H shape; and newer mini slings, "which have no exit wounds at all; they’re inserted into muscle via a single vaginal incision," Dr. Iglesia said. Data on the retropubic sling surpassing 12 years "shows over 80% effectiveness in that patients are really satisfied – maybe not cured – but significantly improved with this procedure," she said.

Mid-urethral slings for urinary incontinence "work very well but there are problems anytime you use an artificial material," said Dr. Brubaker, who is also interim dean of medicine at Loyola University Chicago. "There are low but persistent rates of foreign body problems, but [these are] not much of an issue."

Data on safety and effectiveness for retropubic and transobturator slings are robust but there is very limited data on long-term effectiveness of mini slings.

On July 13, the FDA issued a safety alert on serious complications associated with transvaginal placement of surgical mesh for pelvic organ prolapse. Prolapse mesh refers to much larger sheets of mesh compared with the straps of mesh used in slings. In a prepared statement, the American Urogynecologic Society pointed out that the conclusions and recommendations of the report "do not apply to the use of synthetic mesh for treatment of stress urinary incontinence ... where the benefits of mesh are more clearly delineated and the risks are less." The FDA Obstetrics and Gynecology Devices Panel of the Medical Devices Advisory Committee met on Sept. 8-9, and drew similar conclusions for slings.

The statement also noted that the American Urogynecologic Society "supports an improved approval process for these devices – one that includes better and longer term randomized trials of new surgical devices and materials before going to market," as well as improved postmarket surveillance through registries and national databases.

• Retropubic urethropexy (Burch procedure). Head-to-head studies have found the Burch procedure to be equally effective, compared with the synthetic retropubic sling, "but it’s a little more invasive," Dr. Iglesia said. "It requires skin incisions from above, through which the bladder neck is sutured to a ligament by the pubic bone. The Burch has not been found to be more durable than the synthetic retropubic sling. That’s why the full-length synthetic slings have become the gold standard. But in the wrong hands, these synthetic mesh slings can become problematic, with bladder perforation, vaginal mesh exposure, voiding difficulty, worsening urgency, urinary tract infections, and pain being some potential complications. You want to make sure you refer your patients to someone who’s done a lot of these procedures and knows how to deal with potential complications."

Symptoms associated with stress incontinence may also respond to certain medications, including duloxetine, imipramine, and estrogen applied via cream or patch.

In addition to Botox and pelvic floor strengthening exercises, treatment options for urge incontinence include the following:

• Medications. According to a 2010 review from the Agency for Healthcare Quality and Research, options include the antimuscarinic drugs tolterodine, trospium, solifenacin, darifenacin, and fesoterodine. Drugs with mixed actions include oxybutynin, propiverine, and flavoxate. "There’s no one drug that’s been the best," Dr. Iglesia commented. "Many of the drugs have similar side effects, including constipation and dry mouth, and some of them are pricey. I’ll generally start with what is covered by the patient’s insurance, and I like medications that I can titrate up until I get the desired effect."

• Neuromodulation. InterStim Therapy by Medtronic is an implantable device which stimulates the sacral nerve with mild energy pulses. Typically reserved for patients who have not responded to medical therapy, this approach uses low-voltage electrical stimulation to downregulate nerves that are causing overactive bladder symptoms or urge incontinence. "Over 100,000 InterStim devices have been implanted worldwide with up to 80% improvement," Dr. Iglesia said. "There’s also a tampon-like stimulator [transvaginal electrical stimulation] that you can place in the vagina twice a day for about 12 weeks. You can also apply energy with posterior tibial nerve stimulation, which is a once-a-week treatment for 12 weeks."

Dr. Fenner disclosed that she receives research support from American Medical Systems and that she receives honorarium from UpToDate.

Dr. Iglesia disclosed that she was a member of the FDA Obstetrics and Gynecology Devices Panel of the Medical Devices Advisory Committee which met on Sept. 8-9.

Dr. Brubaker said that she had no relevant financial disclosures.

Urinary incontinence may rank as the most embarrassing condition a woman will face in her lifetime, but the good news is that 80%-90% of patients who seek treatment will experience symptom relief.

"That is what makes my job so great – the fact that I can bring back quality of life to these women," said Dr. Cheryl Iglesia, who directs the Section of Female Pelvic Medicine and Reconstructive Surgery at Washington (D.C.) Hospital Center. "Urinary incontinence affects their confidence, sexuality, level of activity, and self-esteem."

Treatments for stress, urge, and mixed urinary incontinence have expanded and advanced in recent years. Botox is the newest kid on the block, approved on Aug. 24 for women with urge incontinence who have an inadequate response to or are intolerant of antimuscarinic medications.

"Like most of our therapies, Botox doesn’t work for everyone but it can be very effective," said Dr. Dee Ellen Fenner, professor of obstetrics and gynecology at the University of Michigan, Ann Arbor. "Overall, I think women tolerate it very well. It’s done in the office with a cystoscope with injections into the bladder muscle."

Before considering medical and surgical treatments for urinary incontinence, advise your patients to try conservative therapies first, such as limiting fluid intake ("let thirst be your guide"), cutting back on the intake of caffeine and other bladder irritants, and voiding on a schedule.

Strengthening the pelvic floor muscles with Kegel exercises also can be helpful. "There are a growing number of physical therapists across the country who have training in pelvic floor work," Dr. Fenner noted. "They provide an expertise and can really help women in terms of rehabilitating their pelvic floor. That can be good for all types of urinary incontinence."

Treatments for urinary incontinence differ depending on a woman’s goals and her symptoms. For some women with stress incontinence, vaginal insertion of an incontinence dish pessary or an incontinence ring pessary will suffice. These devices act as a backstop to the urinary sphincter. "They’re not as strong as surgery," said Dr. Linda Brubaker, who directs the Division of Female Pelvic Medicine and Reconstructive Surgery at Loyola University Chicago, Maywood, Ill. "More people who have surgery will be satisfied and have better symptom control. But for a woman who doesn’t want surgery or isn’t ready for surgery who has symptoms only when she takes her Jazzercise class or goes for a run, a ring might work just fine."

Dr. Fenner, who is also director of gynecology for the University of Michigan Health System, often recommends incontinence rings for mothers who experience urinary leakage after having a baby "because the tissues, muscles, and nerves in her pelvic region are healing for 9-12 months. Wearing that incontinence ring can be great."

Other treatment options for stress incontinence include:

• Urethral bulking agents. Food and Drug Administration-approved urethral bulking agents include collagen (Contigen), calcium hydroxylapatite (Coaptite), and carbon bead particles (Durasphere). These substances are injected along the urethra during an office procedure. "It doesn’t take much anesthesia and patients can go home the same day," said Dr. Iglesia. "Most people with a bulking agent will need a touch-up."

• Sling-type procedures. The mid-urethral mesh sling, most often made of polypropylene mesh, is the current standard. There are three different types: a retropubic sling that travels behind the pubic bone, forming a U shape; a transobturator sling, which exits through the groin crease near the thigh, forming more of an H shape; and newer mini slings, "which have no exit wounds at all; they’re inserted into muscle via a single vaginal incision," Dr. Iglesia said. Data on the retropubic sling surpassing 12 years "shows over 80% effectiveness in that patients are really satisfied – maybe not cured – but significantly improved with this procedure," she said.

Mid-urethral slings for urinary incontinence "work very well but there are problems anytime you use an artificial material," said Dr. Brubaker, who is also interim dean of medicine at Loyola University Chicago. "There are low but persistent rates of foreign body problems, but [these are] not much of an issue."

Data on safety and effectiveness for retropubic and transobturator slings are robust but there is very limited data on long-term effectiveness of mini slings.

On July 13, the FDA issued a safety alert on serious complications associated with transvaginal placement of surgical mesh for pelvic organ prolapse. Prolapse mesh refers to much larger sheets of mesh compared with the straps of mesh used in slings. In a prepared statement, the American Urogynecologic Society pointed out that the conclusions and recommendations of the report "do not apply to the use of synthetic mesh for treatment of stress urinary incontinence ... where the benefits of mesh are more clearly delineated and the risks are less." The FDA Obstetrics and Gynecology Devices Panel of the Medical Devices Advisory Committee met on Sept. 8-9, and drew similar conclusions for slings.

The statement also noted that the American Urogynecologic Society "supports an improved approval process for these devices – one that includes better and longer term randomized trials of new surgical devices and materials before going to market," as well as improved postmarket surveillance through registries and national databases.

• Retropubic urethropexy (Burch procedure). Head-to-head studies have found the Burch procedure to be equally effective, compared with the synthetic retropubic sling, "but it’s a little more invasive," Dr. Iglesia said. "It requires skin incisions from above, through which the bladder neck is sutured to a ligament by the pubic bone. The Burch has not been found to be more durable than the synthetic retropubic sling. That’s why the full-length synthetic slings have become the gold standard. But in the wrong hands, these synthetic mesh slings can become problematic, with bladder perforation, vaginal mesh exposure, voiding difficulty, worsening urgency, urinary tract infections, and pain being some potential complications. You want to make sure you refer your patients to someone who’s done a lot of these procedures and knows how to deal with potential complications."

Symptoms associated with stress incontinence may also respond to certain medications, including duloxetine, imipramine, and estrogen applied via cream or patch.

In addition to Botox and pelvic floor strengthening exercises, treatment options for urge incontinence include the following:

• Medications. According to a 2010 review from the Agency for Healthcare Quality and Research, options include the antimuscarinic drugs tolterodine, trospium, solifenacin, darifenacin, and fesoterodine. Drugs with mixed actions include oxybutynin, propiverine, and flavoxate. "There’s no one drug that’s been the best," Dr. Iglesia commented. "Many of the drugs have similar side effects, including constipation and dry mouth, and some of them are pricey. I’ll generally start with what is covered by the patient’s insurance, and I like medications that I can titrate up until I get the desired effect."

• Neuromodulation. InterStim Therapy by Medtronic is an implantable device which stimulates the sacral nerve with mild energy pulses. Typically reserved for patients who have not responded to medical therapy, this approach uses low-voltage electrical stimulation to downregulate nerves that are causing overactive bladder symptoms or urge incontinence. "Over 100,000 InterStim devices have been implanted worldwide with up to 80% improvement," Dr. Iglesia said. "There’s also a tampon-like stimulator [transvaginal electrical stimulation] that you can place in the vagina twice a day for about 12 weeks. You can also apply energy with posterior tibial nerve stimulation, which is a once-a-week treatment for 12 weeks."

Dr. Fenner disclosed that she receives research support from American Medical Systems and that she receives honorarium from UpToDate.

Dr. Iglesia disclosed that she was a member of the FDA Obstetrics and Gynecology Devices Panel of the Medical Devices Advisory Committee which met on Sept. 8-9.

Dr. Brubaker said that she had no relevant financial disclosures.

Urinary incontinence may rank as the most embarrassing condition a woman will face in her lifetime, but the good news is that 80%-90% of patients who seek treatment will experience symptom relief.

"That is what makes my job so great – the fact that I can bring back quality of life to these women," said Dr. Cheryl Iglesia, who directs the Section of Female Pelvic Medicine and Reconstructive Surgery at Washington (D.C.) Hospital Center. "Urinary incontinence affects their confidence, sexuality, level of activity, and self-esteem."

Treatments for stress, urge, and mixed urinary incontinence have expanded and advanced in recent years. Botox is the newest kid on the block, approved on Aug. 24 for women with urge incontinence who have an inadequate response to or are intolerant of antimuscarinic medications.

"Like most of our therapies, Botox doesn’t work for everyone but it can be very effective," said Dr. Dee Ellen Fenner, professor of obstetrics and gynecology at the University of Michigan, Ann Arbor. "Overall, I think women tolerate it very well. It’s done in the office with a cystoscope with injections into the bladder muscle."

Before considering medical and surgical treatments for urinary incontinence, advise your patients to try conservative therapies first, such as limiting fluid intake ("let thirst be your guide"), cutting back on the intake of caffeine and other bladder irritants, and voiding on a schedule.

Strengthening the pelvic floor muscles with Kegel exercises also can be helpful. "There are a growing number of physical therapists across the country who have training in pelvic floor work," Dr. Fenner noted. "They provide an expertise and can really help women in terms of rehabilitating their pelvic floor. That can be good for all types of urinary incontinence."

Treatments for urinary incontinence differ depending on a woman’s goals and her symptoms. For some women with stress incontinence, vaginal insertion of an incontinence dish pessary or an incontinence ring pessary will suffice. These devices act as a backstop to the urinary sphincter. "They’re not as strong as surgery," said Dr. Linda Brubaker, who directs the Division of Female Pelvic Medicine and Reconstructive Surgery at Loyola University Chicago, Maywood, Ill. "More people who have surgery will be satisfied and have better symptom control. But for a woman who doesn’t want surgery or isn’t ready for surgery who has symptoms only when she takes her Jazzercise class or goes for a run, a ring might work just fine."

Dr. Fenner, who is also director of gynecology for the University of Michigan Health System, often recommends incontinence rings for mothers who experience urinary leakage after having a baby "because the tissues, muscles, and nerves in her pelvic region are healing for 9-12 months. Wearing that incontinence ring can be great."

Other treatment options for stress incontinence include:

• Urethral bulking agents. Food and Drug Administration-approved urethral bulking agents include collagen (Contigen), calcium hydroxylapatite (Coaptite), and carbon bead particles (Durasphere). These substances are injected along the urethra during an office procedure. "It doesn’t take much anesthesia and patients can go home the same day," said Dr. Iglesia. "Most people with a bulking agent will need a touch-up."

• Sling-type procedures. The mid-urethral mesh sling, most often made of polypropylene mesh, is the current standard. There are three different types: a retropubic sling that travels behind the pubic bone, forming a U shape; a transobturator sling, which exits through the groin crease near the thigh, forming more of an H shape; and newer mini slings, "which have no exit wounds at all; they’re inserted into muscle via a single vaginal incision," Dr. Iglesia said. Data on the retropubic sling surpassing 12 years "shows over 80% effectiveness in that patients are really satisfied – maybe not cured – but significantly improved with this procedure," she said.

Mid-urethral slings for urinary incontinence "work very well but there are problems anytime you use an artificial material," said Dr. Brubaker, who is also interim dean of medicine at Loyola University Chicago. "There are low but persistent rates of foreign body problems, but [these are] not much of an issue."

Data on safety and effectiveness for retropubic and transobturator slings are robust but there is very limited data on long-term effectiveness of mini slings.

On July 13, the FDA issued a safety alert on serious complications associated with transvaginal placement of surgical mesh for pelvic organ prolapse. Prolapse mesh refers to much larger sheets of mesh compared with the straps of mesh used in slings. In a prepared statement, the American Urogynecologic Society pointed out that the conclusions and recommendations of the report "do not apply to the use of synthetic mesh for treatment of stress urinary incontinence ... where the benefits of mesh are more clearly delineated and the risks are less." The FDA Obstetrics and Gynecology Devices Panel of the Medical Devices Advisory Committee met on Sept. 8-9, and drew similar conclusions for slings.

The statement also noted that the American Urogynecologic Society "supports an improved approval process for these devices – one that includes better and longer term randomized trials of new surgical devices and materials before going to market," as well as improved postmarket surveillance through registries and national databases.

• Retropubic urethropexy (Burch procedure). Head-to-head studies have found the Burch procedure to be equally effective, compared with the synthetic retropubic sling, "but it’s a little more invasive," Dr. Iglesia said. "It requires skin incisions from above, through which the bladder neck is sutured to a ligament by the pubic bone. The Burch has not been found to be more durable than the synthetic retropubic sling. That’s why the full-length synthetic slings have become the gold standard. But in the wrong hands, these synthetic mesh slings can become problematic, with bladder perforation, vaginal mesh exposure, voiding difficulty, worsening urgency, urinary tract infections, and pain being some potential complications. You want to make sure you refer your patients to someone who’s done a lot of these procedures and knows how to deal with potential complications."

Symptoms associated with stress incontinence may also respond to certain medications, including duloxetine, imipramine, and estrogen applied via cream or patch.

In addition to Botox and pelvic floor strengthening exercises, treatment options for urge incontinence include the following:

• Medications. According to a 2010 review from the Agency for Healthcare Quality and Research, options include the antimuscarinic drugs tolterodine, trospium, solifenacin, darifenacin, and fesoterodine. Drugs with mixed actions include oxybutynin, propiverine, and flavoxate. "There’s no one drug that’s been the best," Dr. Iglesia commented. "Many of the drugs have similar side effects, including constipation and dry mouth, and some of them are pricey. I’ll generally start with what is covered by the patient’s insurance, and I like medications that I can titrate up until I get the desired effect."

• Neuromodulation. InterStim Therapy by Medtronic is an implantable device which stimulates the sacral nerve with mild energy pulses. Typically reserved for patients who have not responded to medical therapy, this approach uses low-voltage electrical stimulation to downregulate nerves that are causing overactive bladder symptoms or urge incontinence. "Over 100,000 InterStim devices have been implanted worldwide with up to 80% improvement," Dr. Iglesia said. "There’s also a tampon-like stimulator [transvaginal electrical stimulation] that you can place in the vagina twice a day for about 12 weeks. You can also apply energy with posterior tibial nerve stimulation, which is a once-a-week treatment for 12 weeks."

Dr. Fenner disclosed that she receives research support from American Medical Systems and that she receives honorarium from UpToDate.

Dr. Iglesia disclosed that she was a member of the FDA Obstetrics and Gynecology Devices Panel of the Medical Devices Advisory Committee which met on Sept. 8-9.

Dr. Brubaker said that she had no relevant financial disclosures.

CHICAGO – Plazomicin, an investigational aminoglycoside previously know as ACHN-490, is a promising new agent for treating gram-negative infections, according to George G. Zhanel, Ph.D.

"There’s something exciting about working with an agent that’s a modification of something you know a lot about, because you think you’ll be able to predict some of the problems," Dr. Zhanel said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC).

"But let’s be clear: We have no human efficacy and safety data. We need the data to see that this agent works for aminoglycoside-resistant infections, and we need to see that data on nephrotoxicity and ototoxicity. We need to be monitoring the spread of rRNA methylases."

Aminoglycosides have well-described pharmacokinetics and proven efficacy alone and in combination with other agents, "but you are not using them very much because there is worldwide resistance, primarily due to aminoglycoside-modifying enzymes but also well-described nephrotoxicity and ototoxicity," said Dr. Zhanel of the department of medical microbiology and infectious diseases at the University of Manitoba, Winnipeg. "However, clearly there is a need for these agents and other new antimicrobials."

In the past decade, many researchers have been working to further develop aminoglycosides, including arbekacin analogues, gentamicin analogues, isepamicin analogues, streptomycin analogues, and plazomicin, which is an analogue of sisomicin and is manufactured by San Francisco–based Achaogen. A recent study from the United Kingdom found that plazomicin MIC₉₀ (minimum inhibitory concentration required to inhibit the growth of 90% of organisms) was less than or equal to 2 mg/L against carbapenem-resistant Enterobacteriaceae (J. Antimicrob. Chemother. 2011;66:48-53). The researchers also found that plazomicin was 16 times more active than amikacin and 8 times more active than gentamicin. "Importantly, none of the aminoglycosides, including plazomicin, were active against NDM-carrying strains with both metallo-beta-lactamase and methyltransferase," said Dr. Zhanel, who is director of the Canadian Antimicrobial Resistance Alliance.

Plazomicin demonstrates synergy with other agents, he continued. In vitro time-kill studies of methicillin-resistant Staphylococcus aureus demonstrated 91.5% efficacy for plazomicin plus daptomycin, compared with 36.2% for plazomicin plus ceftobiprole and 12.8% for plazomicin plus linezolid (Antimicrob. Agents Chemother. 2010;54:2258-61).

In vitro time-kill studies of Pseudomonas aeruginosa demonstrated 92% synergy for plazomicin plus piperacillin/tazobactam, compared with 80% for plazomicin plus cefepime and 80% for plazomicin plus doripenem (Antimicrob. Agents Chemother. 2011;55:2463-5).

In a poster presented at the 2010 ICAAC meeting, researchers presented findings from a phase I pharmacokinetics and safety study of plazomicin administered to eight subjects at a dose of 15 mg/kg IV once daily for 5 days. The study, sponsored by Achaogen, found that the mean C_max was 113 mcg/mL, the mean AUC (0-24 hr) was 239 mcg/mL per hour, the mean C_min was 0.4 mcg/mL, and the mean half-life was 3 hours. There was no evidence of nephrotoxicity or ototoxicity, and all adverse events were reported as mild to moderate.

Dr. Zhanel said that a multicenter, randomized phase II trial of plazomicin for complicated urinary tract infections and acute pyelonephritis is underway. The comparator drug will be levofloxacin.

"Clearly, plazomicin is a promising new agent," Dr. Zhanel said at the meeting, which was sponsored by the American Society for Microbiology. "If future studies show that it is effective against aminoglycoside-susceptible and -resistant infections, and/or if the agent shows nephrotoxicity and/or ototoxicity less than the current aminoglycosides, you may want to use this compound in select cases as your aminoglycoside of choice."

Dr. Zhanel disclosed that he has received research funding from the National Institutes of Health and numerous other sources, including Achaogen and other pharmaceutical companies.

CHICAGO – Plazomicin, an investigational aminoglycoside previously know as ACHN-490, is a promising new agent for treating gram-negative infections, according to George G. Zhanel, Ph.D.

"There’s something exciting about working with an agent that’s a modification of something you know a lot about, because you think you’ll be able to predict some of the problems," Dr. Zhanel said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC).

"But let’s be clear: We have no human efficacy and safety data. We need the data to see that this agent works for aminoglycoside-resistant infections, and we need to see that data on nephrotoxicity and ototoxicity. We need to be monitoring the spread of rRNA methylases."

Aminoglycosides have well-described pharmacokinetics and proven efficacy alone and in combination with other agents, "but you are not using them very much because there is worldwide resistance, primarily due to aminoglycoside-modifying enzymes but also well-described nephrotoxicity and ototoxicity," said Dr. Zhanel of the department of medical microbiology and infectious diseases at the University of Manitoba, Winnipeg. "However, clearly there is a need for these agents and other new antimicrobials."

In the past decade, many researchers have been working to further develop aminoglycosides, including arbekacin analogues, gentamicin analogues, isepamicin analogues, streptomycin analogues, and plazomicin, which is an analogue of sisomicin and is manufactured by San Francisco–based Achaogen. A recent study from the United Kingdom found that plazomicin MIC₉₀ (minimum inhibitory concentration required to inhibit the growth of 90% of organisms) was less than or equal to 2 mg/L against carbapenem-resistant Enterobacteriaceae (J. Antimicrob. Chemother. 2011;66:48-53). The researchers also found that plazomicin was 16 times more active than amikacin and 8 times more active than gentamicin. "Importantly, none of the aminoglycosides, including plazomicin, were active against NDM-carrying strains with both metallo-beta-lactamase and methyltransferase," said Dr. Zhanel, who is director of the Canadian Antimicrobial Resistance Alliance.

Plazomicin demonstrates synergy with other agents, he continued. In vitro time-kill studies of methicillin-resistant Staphylococcus aureus demonstrated 91.5% efficacy for plazomicin plus daptomycin, compared with 36.2% for plazomicin plus ceftobiprole and 12.8% for plazomicin plus linezolid (Antimicrob. Agents Chemother. 2010;54:2258-61).

In vitro time-kill studies of Pseudomonas aeruginosa demonstrated 92% synergy for plazomicin plus piperacillin/tazobactam, compared with 80% for plazomicin plus cefepime and 80% for plazomicin plus doripenem (Antimicrob. Agents Chemother. 2011;55:2463-5).

In a poster presented at the 2010 ICAAC meeting, researchers presented findings from a phase I pharmacokinetics and safety study of plazomicin administered to eight subjects at a dose of 15 mg/kg IV once daily for 5 days. The study, sponsored by Achaogen, found that the mean C_max was 113 mcg/mL, the mean AUC (0-24 hr) was 239 mcg/mL per hour, the mean C_min was 0.4 mcg/mL, and the mean half-life was 3 hours. There was no evidence of nephrotoxicity or ototoxicity, and all adverse events were reported as mild to moderate.

Dr. Zhanel said that a multicenter, randomized phase II trial of plazomicin for complicated urinary tract infections and acute pyelonephritis is underway. The comparator drug will be levofloxacin.

"Clearly, plazomicin is a promising new agent," Dr. Zhanel said at the meeting, which was sponsored by the American Society for Microbiology. "If future studies show that it is effective against aminoglycoside-susceptible and -resistant infections, and/or if the agent shows nephrotoxicity and/or ototoxicity less than the current aminoglycosides, you may want to use this compound in select cases as your aminoglycoside of choice."

Dr. Zhanel disclosed that he has received research funding from the National Institutes of Health and numerous other sources, including Achaogen and other pharmaceutical companies.

CHICAGO – Plazomicin, an investigational aminoglycoside previously know as ACHN-490, is a promising new agent for treating gram-negative infections, according to George G. Zhanel, Ph.D.

"There’s something exciting about working with an agent that’s a modification of something you know a lot about, because you think you’ll be able to predict some of the problems," Dr. Zhanel said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC).

"But let’s be clear: We have no human efficacy and safety data. We need the data to see that this agent works for aminoglycoside-resistant infections, and we need to see that data on nephrotoxicity and ototoxicity. We need to be monitoring the spread of rRNA methylases."

Aminoglycosides have well-described pharmacokinetics and proven efficacy alone and in combination with other agents, "but you are not using them very much because there is worldwide resistance, primarily due to aminoglycoside-modifying enzymes but also well-described nephrotoxicity and ototoxicity," said Dr. Zhanel of the department of medical microbiology and infectious diseases at the University of Manitoba, Winnipeg. "However, clearly there is a need for these agents and other new antimicrobials."

In the past decade, many researchers have been working to further develop aminoglycosides, including arbekacin analogues, gentamicin analogues, isepamicin analogues, streptomycin analogues, and plazomicin, which is an analogue of sisomicin and is manufactured by San Francisco–based Achaogen. A recent study from the United Kingdom found that plazomicin MIC₉₀ (minimum inhibitory concentration required to inhibit the growth of 90% of organisms) was less than or equal to 2 mg/L against carbapenem-resistant Enterobacteriaceae (J. Antimicrob. Chemother. 2011;66:48-53). The researchers also found that plazomicin was 16 times more active than amikacin and 8 times more active than gentamicin. "Importantly, none of the aminoglycosides, including plazomicin, were active against NDM-carrying strains with both metallo-beta-lactamase and methyltransferase," said Dr. Zhanel, who is director of the Canadian Antimicrobial Resistance Alliance.

Plazomicin demonstrates synergy with other agents, he continued. In vitro time-kill studies of methicillin-resistant Staphylococcus aureus demonstrated 91.5% efficacy for plazomicin plus daptomycin, compared with 36.2% for plazomicin plus ceftobiprole and 12.8% for plazomicin plus linezolid (Antimicrob. Agents Chemother. 2010;54:2258-61).

In vitro time-kill studies of Pseudomonas aeruginosa demonstrated 92% synergy for plazomicin plus piperacillin/tazobactam, compared with 80% for plazomicin plus cefepime and 80% for plazomicin plus doripenem (Antimicrob. Agents Chemother. 2011;55:2463-5).

In a poster presented at the 2010 ICAAC meeting, researchers presented findings from a phase I pharmacokinetics and safety study of plazomicin administered to eight subjects at a dose of 15 mg/kg IV once daily for 5 days. The study, sponsored by Achaogen, found that the mean C_max was 113 mcg/mL, the mean AUC (0-24 hr) was 239 mcg/mL per hour, the mean C_min was 0.4 mcg/mL, and the mean half-life was 3 hours. There was no evidence of nephrotoxicity or ototoxicity, and all adverse events were reported as mild to moderate.

Dr. Zhanel said that a multicenter, randomized phase II trial of plazomicin for complicated urinary tract infections and acute pyelonephritis is underway. The comparator drug will be levofloxacin.

"Clearly, plazomicin is a promising new agent," Dr. Zhanel said at the meeting, which was sponsored by the American Society for Microbiology. "If future studies show that it is effective against aminoglycoside-susceptible and -resistant infections, and/or if the agent shows nephrotoxicity and/or ototoxicity less than the current aminoglycosides, you may want to use this compound in select cases as your aminoglycoside of choice."

Dr. Zhanel disclosed that he has received research funding from the National Institutes of Health and numerous other sources, including Achaogen and other pharmaceutical companies.

CHICAGO – Adults with a bloodstream infection face an increased risk of developing colorectal cancer within 1 year, results from a Canadian study showed.

The organisms associated with the highest risk of new colorectal cancer were Clostridium spp., the Bacteroides fragilis group, and other anaerobes, Dr. Sanchia Warren reported during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. However, Streptococcus bovis, which has been proposed as a marker of colorectal malignancy, was not found to be associated with increased diagnoses of the condition.

"If patients have a bloodstream infection, particularly older patients, you should definitely be looking for signs of colorectal cancer," Dr. Warren said in an interview at the meeting, which was sponsored by the American Society for Microbiology. "We did not look at premalignant conditions such as polyps. If we did, I suspect that we would have had even stronger findings."

Dr. Warren, who conducted the research during an infectious diseases fellowship at the University of Calgary (Alta.), and her associates used a regional electronic surveillance system database to identify a cohort of Calgary area adults who had an incident bloodstream infection between 2000 and 2007. They used a computer program to match the patients to the Alberta Cancer Registry.

Over the 7-year period, 10,121 bloodstream infections occurred in 8,806 patients. The mean age of the patients was 62 years, and 54% were male. During the same time frame, 3,859 residents in the region were diagnosed with colorectal cancer, of which 349 followed a bloodstream infection.

The researchers found that 71 patients had a diagnosis of colorectal cancer made at the same time as or within 1 year following a bloodstream infection, for a standardized incidence ratio of 14.4 compared with the general population. Organisms associated with the highest risk of new colorectal cancer diagnosis were Clostridium spp. (standardized incidence ratio, 115.39), the Bacteroides fragilis group (SIR, 77.2), and other gram positive anaerobes (SIR, 47.7).

Advancing age, male gender, liver disease, and a higher Charlson Index score were associated with bloodstream infections and a new diagnosis of colorectal cancer.

Dr. Warren, who is currently a medical microbiology registrar at St. Vincent’s Hospital, Fitzroy, Australia, said that she and her associates are conducting a further review of patients with a Streptococcus bovis bloodstream infection. They also hope to determine what percentage of patients underwent colonoscopy.

She acknowledged certain limitations of the study, including the potential for missed cases during database matching, as well as the relatively small sample size of patients used in the final analysis.

Dr. Warren said that she had no relevant financial conflicts to disclose.

CHICAGO – Adults with a bloodstream infection face an increased risk of developing colorectal cancer within 1 year, results from a Canadian study showed.

The organisms associated with the highest risk of new colorectal cancer were Clostridium spp., the Bacteroides fragilis group, and other anaerobes, Dr. Sanchia Warren reported during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. However, Streptococcus bovis, which has been proposed as a marker of colorectal malignancy, was not found to be associated with increased diagnoses of the condition.

"If patients have a bloodstream infection, particularly older patients, you should definitely be looking for signs of colorectal cancer," Dr. Warren said in an interview at the meeting, which was sponsored by the American Society for Microbiology. "We did not look at premalignant conditions such as polyps. If we did, I suspect that we would have had even stronger findings."

Dr. Warren, who conducted the research during an infectious diseases fellowship at the University of Calgary (Alta.), and her associates used a regional electronic surveillance system database to identify a cohort of Calgary area adults who had an incident bloodstream infection between 2000 and 2007. They used a computer program to match the patients to the Alberta Cancer Registry.

Over the 7-year period, 10,121 bloodstream infections occurred in 8,806 patients. The mean age of the patients was 62 years, and 54% were male. During the same time frame, 3,859 residents in the region were diagnosed with colorectal cancer, of which 349 followed a bloodstream infection.

The researchers found that 71 patients had a diagnosis of colorectal cancer made at the same time as or within 1 year following a bloodstream infection, for a standardized incidence ratio of 14.4 compared with the general population. Organisms associated with the highest risk of new colorectal cancer diagnosis were Clostridium spp. (standardized incidence ratio, 115.39), the Bacteroides fragilis group (SIR, 77.2), and other gram positive anaerobes (SIR, 47.7).

Advancing age, male gender, liver disease, and a higher Charlson Index score were associated with bloodstream infections and a new diagnosis of colorectal cancer.

Dr. Warren, who is currently a medical microbiology registrar at St. Vincent’s Hospital, Fitzroy, Australia, said that she and her associates are conducting a further review of patients with a Streptococcus bovis bloodstream infection. They also hope to determine what percentage of patients underwent colonoscopy.

She acknowledged certain limitations of the study, including the potential for missed cases during database matching, as well as the relatively small sample size of patients used in the final analysis.

Dr. Warren said that she had no relevant financial conflicts to disclose.

CHICAGO – Adults with a bloodstream infection face an increased risk of developing colorectal cancer within 1 year, results from a Canadian study showed.

The organisms associated with the highest risk of new colorectal cancer were Clostridium spp., the Bacteroides fragilis group, and other anaerobes, Dr. Sanchia Warren reported during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. However, Streptococcus bovis, which has been proposed as a marker of colorectal malignancy, was not found to be associated with increased diagnoses of the condition.

"If patients have a bloodstream infection, particularly older patients, you should definitely be looking for signs of colorectal cancer," Dr. Warren said in an interview at the meeting, which was sponsored by the American Society for Microbiology. "We did not look at premalignant conditions such as polyps. If we did, I suspect that we would have had even stronger findings."

Dr. Warren, who conducted the research during an infectious diseases fellowship at the University of Calgary (Alta.), and her associates used a regional electronic surveillance system database to identify a cohort of Calgary area adults who had an incident bloodstream infection between 2000 and 2007. They used a computer program to match the patients to the Alberta Cancer Registry.

Over the 7-year period, 10,121 bloodstream infections occurred in 8,806 patients. The mean age of the patients was 62 years, and 54% were male. During the same time frame, 3,859 residents in the region were diagnosed with colorectal cancer, of which 349 followed a bloodstream infection.

The researchers found that 71 patients had a diagnosis of colorectal cancer made at the same time as or within 1 year following a bloodstream infection, for a standardized incidence ratio of 14.4 compared with the general population. Organisms associated with the highest risk of new colorectal cancer diagnosis were Clostridium spp. (standardized incidence ratio, 115.39), the Bacteroides fragilis group (SIR, 77.2), and other gram positive anaerobes (SIR, 47.7).

Advancing age, male gender, liver disease, and a higher Charlson Index score were associated with bloodstream infections and a new diagnosis of colorectal cancer.

Dr. Warren, who is currently a medical microbiology registrar at St. Vincent’s Hospital, Fitzroy, Australia, said that she and her associates are conducting a further review of patients with a Streptococcus bovis bloodstream infection. They also hope to determine what percentage of patients underwent colonoscopy.

She acknowledged certain limitations of the study, including the potential for missed cases during database matching, as well as the relatively small sample size of patients used in the final analysis.

Dr. Warren said that she had no relevant financial conflicts to disclose.

CHICAGO – The incidence of Clostridium difficile–associated disease was more than three times higher among patients using proton pump inhibitors compared with those who were not, results from a large Japanese study found.

"In addition to previous use of antimicrobials, long-term use of proton pump inhibitors [PPIs] is pointed out as a risk factor" of C. difficile–associated disease (CDAD), researchers led by Dr. Takatoshi Kitazawa reported during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "However, most previous epidemiological studies that showed [a] positive relationship between PPI use and CDAD were conducted retrospectively and in Western countries. In this study, we investigated whether the use of PPIs increases the incidence of CDAD at a single institution in Japan."

Dr. Kitazawa of Teikyo University, Tokyo, and his associates evaluated the medical records of 793 patients who were admitted to the university’s department of medicine between April and June of 2009. They defined PPI users as those who were prescribed a PPI for more than 30 days. CDAD was defined as detection of C. difficile toxin from stool samples in patients with diarrhea. Use of immunosuppressants was defined as using more than 20 mg of prednisolone and other agents in this class for more than 30 days. A long hospital stay was defined as one that extended 30 days.

PPI users were older than non-PPI users (mean, 69 years vs. 63 years, respectively; P less than .01) and a higher proportion were men (69% vs. 58%; P = .04).

The researchers identified CDAD in 19 (3.9%) of the 487 PPI users and in 4 (1.3%) of the 304 non-PPI users. This translated into a relative risk of PPI use on the incidence of CDAD that reached 3.20 (P = .04).

On multivariate analysis controlling for age; sex; use of antibiotics and H₂ receptor agonists; and long hospital and ICU stay, the researchers noted no significant differences in the incidence of CDAD between PPI users and non-PPI users because of missing data.

Dr. Kitazawa said that he had no relevant financial conflicts to disclose. The meeting was sponsored by the American Society for Microbiology.

CHICAGO – The incidence of Clostridium difficile–associated disease was more than three times higher among patients using proton pump inhibitors compared with those who were not, results from a large Japanese study found.

"In addition to previous use of antimicrobials, long-term use of proton pump inhibitors [PPIs] is pointed out as a risk factor" of C. difficile–associated disease (CDAD), researchers led by Dr. Takatoshi Kitazawa reported during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "However, most previous epidemiological studies that showed [a] positive relationship between PPI use and CDAD were conducted retrospectively and in Western countries. In this study, we investigated whether the use of PPIs increases the incidence of CDAD at a single institution in Japan."

Dr. Kitazawa of Teikyo University, Tokyo, and his associates evaluated the medical records of 793 patients who were admitted to the university’s department of medicine between April and June of 2009. They defined PPI users as those who were prescribed a PPI for more than 30 days. CDAD was defined as detection of C. difficile toxin from stool samples in patients with diarrhea. Use of immunosuppressants was defined as using more than 20 mg of prednisolone and other agents in this class for more than 30 days. A long hospital stay was defined as one that extended 30 days.

PPI users were older than non-PPI users (mean, 69 years vs. 63 years, respectively; P less than .01) and a higher proportion were men (69% vs. 58%; P = .04).

The researchers identified CDAD in 19 (3.9%) of the 487 PPI users and in 4 (1.3%) of the 304 non-PPI users. This translated into a relative risk of PPI use on the incidence of CDAD that reached 3.20 (P = .04).

On multivariate analysis controlling for age; sex; use of antibiotics and H₂ receptor agonists; and long hospital and ICU stay, the researchers noted no significant differences in the incidence of CDAD between PPI users and non-PPI users because of missing data.

Dr. Kitazawa said that he had no relevant financial conflicts to disclose. The meeting was sponsored by the American Society for Microbiology.

CHICAGO – The incidence of Clostridium difficile–associated disease was more than three times higher among patients using proton pump inhibitors compared with those who were not, results from a large Japanese study found.

"In addition to previous use of antimicrobials, long-term use of proton pump inhibitors [PPIs] is pointed out as a risk factor" of C. difficile–associated disease (CDAD), researchers led by Dr. Takatoshi Kitazawa reported during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. "However, most previous epidemiological studies that showed [a] positive relationship between PPI use and CDAD were conducted retrospectively and in Western countries. In this study, we investigated whether the use of PPIs increases the incidence of CDAD at a single institution in Japan."

Dr. Kitazawa of Teikyo University, Tokyo, and his associates evaluated the medical records of 793 patients who were admitted to the university’s department of medicine between April and June of 2009. They defined PPI users as those who were prescribed a PPI for more than 30 days. CDAD was defined as detection of C. difficile toxin from stool samples in patients with diarrhea. Use of immunosuppressants was defined as using more than 20 mg of prednisolone and other agents in this class for more than 30 days. A long hospital stay was defined as one that extended 30 days.

PPI users were older than non-PPI users (mean, 69 years vs. 63 years, respectively; P less than .01) and a higher proportion were men (69% vs. 58%; P = .04).

The researchers identified CDAD in 19 (3.9%) of the 487 PPI users and in 4 (1.3%) of the 304 non-PPI users. This translated into a relative risk of PPI use on the incidence of CDAD that reached 3.20 (P = .04).

On multivariate analysis controlling for age; sex; use of antibiotics and H₂ receptor agonists; and long hospital and ICU stay, the researchers noted no significant differences in the incidence of CDAD between PPI users and non-PPI users because of missing data.

Dr. Kitazawa said that he had no relevant financial conflicts to disclose. The meeting was sponsored by the American Society for Microbiology.

SAN DIEGO – Never underestimate the importance of providing early education and positive reinforcement to patients who have sustained a traumatic brain injury.

"If you educate them, you’ll prevent a lot of emotional upset about what’s going to be happening over the next weeks or months," Dr. Michael A. Lobatz said at a meeting on primary care medicine sponsored by the Scripps Clinic. "When I see a patient with an acute concussive injury, I will tell them, ‘It’s going to get better; 85% of patients get better. The prognosis is good. Hang in there. We’re going to shut down some of your activity, but we’re going to wait for this to get better and you’re going to heal up.’ "

He makes it a point to tell them that memory deficits are common after a TBI, and that such symptoms as dizziness, irritability, a decreased ability to process information and tasks, sleep disturbance, and impulsiveness may also occur. "If you do that, you will often avoid that shattered sense of self that people come away with when they’re left hanging, not understanding what’s actually going on with them," said Dr. Lobatz, a neurologist and the medical director at the Scripps Rehabilitation Center, Encinitas, Calif.

The Centers for Disease Control and Prevention estimates that each year, 1.7 million TBIs occur in the United States. Of these, about 1.4 million involve visits to the emergency department, 275,000 involve hospitalizations, and 52,000 result in death. Dr. Lobatz defined TBI as a bump, blow, or jolt to the head that disrupts the normal function of the brain. "This may range from mild to severe, with extended periods of loss of consciousness or prolonged periods of amnesia," he said. But most of the TBIs that occur are very mild, may resolve on their own, and might not even need medical attention.

There are at least 16 different grading systems for trying to measure severity of TBI, he said, the most recent being about 10 years old. "The good news is, the American Academy of Neurology is working on a new grading system that will probably published by November of this year," he said. "That will be very useful and most updated based on class I evidence."

According to current AAN guidelines, a grade 1 concussion is marked by spotty confusion, no loss of consciousness, and concussion symptoms that last less than 15 minutes; a grade 2 concussion is marked by spotty confusion, no loss of consciousness, and concussive symptoms or abnormalities that last longer than 15 minutes. By contrast, a grade 3 concussion is marked by any loss of consciousness whether brief (seconds) or prolonged (minutes).

The guidelines also include ratings for three different levels of posttraumatic amnesia. Mild injury is defined as a Glasgow Coma Scale (GCS) score of 13-15, with 15 being completely normal, plus a 0- to 20-minute loss of consciousness (LOC) and amnesia lasting less than 24 hours. A moderate injury is defined as LOC lasting 20 minutes to 6 hours with a GCS score of 9-12. A severe injury is defined as LOC lasting longer than 6 hours with a GCS score of 3-8. Dr. Lobatz noted that patients who have longer periods of anterograde amnesia "tend to have a more prolonged course to recovery or incomplete recovery. When you take your history, ask [patients] what they remember, not what they were told happened or what they think happened by their own logical deduction. When you preface your question like that, you’ll get more accurate information."

Sorting out preinjury vs. postinjury factors in TBI patients is no easy task. For example, preexisting factors "could be that they have some ADHD, poor school performance, or depression," he said. "Postinjury factors might include disruption of relationships, school, or work. You need an open mind when you see these patients, and you cannot do this [assessment] in 10 minutes."

The process is further complicated in the assessment of soldiers who present with a TBI and also have concomitant posttraumatic stress disorder. Distinguishing which symptoms stem from the TBI and which stem from the PTSD "is a little bit of the art of evaluating the soldier these days, trying to understand which one is more predominant," Dr. Lobatz said. "In our experience at Scripps in treating well over 100 of these soldiers, we find that it’s often mixed. They often have both problems going on. When the PTSD symptoms are overwhelming, that needs to be addressed first. When that’s cleared up, they can come back and get therapy for their concussive injury. Sometimes it’s the other way around and [both] can be addressed simultaneously with cognitive therapy."

The impact of the TBI varies depending on the severity of initial injury; the rate or completeness of physiological recovery; the functions affected; the meaning of dysfunction to the individual; and the resources available to aid recovery. "We try to strengthen what is weak with repetitive activities," Dr. Lobatz said. "When we realize that we cannot strengthen what is weak – that there are permanent deficits – we teach people to adapt. That is what rehabilitation is all about: Strengthen what is possible to be strengthened and adapt to what cannot be strengthened."

In athletes who are still experiencing symptoms of a concussion, return to play is not advised. If they return before they’re fully healed and then suffer another injury, that second injury "is potentially much more severe than the first," Dr. Lobatz warned. "There may not be a loss of consciousness, but there is a much more likely possibility of swelling in the brain, and there can be as much as 50% mortality in severe cases. Furthermore, there is a much higher risk of long-term complications where patients do not return to normal. They are left with long-term deficits."

To help objectify when it’s okay to return to play, Dr. Lobatz recommended administering the ImPACT test, a computer-based assessment which provides a baseline of neurocognitive skills and takes about 30 minutes to complete. In addition, a consensus statement from the Third International Conference on Concussion in Sport provides a staged system of gradual return to physical activity (Br. J. Sports Med. 2009;43:i76-84). It calls for no activity immediately after the injury, and progresses in a stepwise fashion to light aerobic exercise, sport-specific exercise, noncontact training, full contact practice, and eventual return to play.

Early on, "you may want to pull the student out of school for a week or two, for physical rest and mental rest," Dr. Lobatz said.

He also recommended the Acute Concussion Evaluation–Physician/Clinician Office Version, a checklist that "helps you identify red flags, make a diagnosis, look at risk factors for protracted recovery," he said. It can be downloaded free of charge from the U.S. Centers for Disease Control and Prevention website.

Dr. Lobatz said that he had no relevant financial disclosures to make.

SAN DIEGO – Never underestimate the importance of providing early education and positive reinforcement to patients who have sustained a traumatic brain injury.

"If you educate them, you’ll prevent a lot of emotional upset about what’s going to be happening over the next weeks or months," Dr. Michael A. Lobatz said at a meeting on primary care medicine sponsored by the Scripps Clinic. "When I see a patient with an acute concussive injury, I will tell them, ‘It’s going to get better; 85% of patients get better. The prognosis is good. Hang in there. We’re going to shut down some of your activity, but we’re going to wait for this to get better and you’re going to heal up.’ "

He makes it a point to tell them that memory deficits are common after a TBI, and that such symptoms as dizziness, irritability, a decreased ability to process information and tasks, sleep disturbance, and impulsiveness may also occur. "If you do that, you will often avoid that shattered sense of self that people come away with when they’re left hanging, not understanding what’s actually going on with them," said Dr. Lobatz, a neurologist and the medical director at the Scripps Rehabilitation Center, Encinitas, Calif.

The Centers for Disease Control and Prevention estimates that each year, 1.7 million TBIs occur in the United States. Of these, about 1.4 million involve visits to the emergency department, 275,000 involve hospitalizations, and 52,000 result in death. Dr. Lobatz defined TBI as a bump, blow, or jolt to the head that disrupts the normal function of the brain. "This may range from mild to severe, with extended periods of loss of consciousness or prolonged periods of amnesia," he said. But most of the TBIs that occur are very mild, may resolve on their own, and might not even need medical attention.

There are at least 16 different grading systems for trying to measure severity of TBI, he said, the most recent being about 10 years old. "The good news is, the American Academy of Neurology is working on a new grading system that will probably published by November of this year," he said. "That will be very useful and most updated based on class I evidence."

According to current AAN guidelines, a grade 1 concussion is marked by spotty confusion, no loss of consciousness, and concussion symptoms that last less than 15 minutes; a grade 2 concussion is marked by spotty confusion, no loss of consciousness, and concussive symptoms or abnormalities that last longer than 15 minutes. By contrast, a grade 3 concussion is marked by any loss of consciousness whether brief (seconds) or prolonged (minutes).

The guidelines also include ratings for three different levels of posttraumatic amnesia. Mild injury is defined as a Glasgow Coma Scale (GCS) score of 13-15, with 15 being completely normal, plus a 0- to 20-minute loss of consciousness (LOC) and amnesia lasting less than 24 hours. A moderate injury is defined as LOC lasting 20 minutes to 6 hours with a GCS score of 9-12. A severe injury is defined as LOC lasting longer than 6 hours with a GCS score of 3-8. Dr. Lobatz noted that patients who have longer periods of anterograde amnesia "tend to have a more prolonged course to recovery or incomplete recovery. When you take your history, ask [patients] what they remember, not what they were told happened or what they think happened by their own logical deduction. When you preface your question like that, you’ll get more accurate information."

Sorting out preinjury vs. postinjury factors in TBI patients is no easy task. For example, preexisting factors "could be that they have some ADHD, poor school performance, or depression," he said. "Postinjury factors might include disruption of relationships, school, or work. You need an open mind when you see these patients, and you cannot do this [assessment] in 10 minutes."

The process is further complicated in the assessment of soldiers who present with a TBI and also have concomitant posttraumatic stress disorder. Distinguishing which symptoms stem from the TBI and which stem from the PTSD "is a little bit of the art of evaluating the soldier these days, trying to understand which one is more predominant," Dr. Lobatz said. "In our experience at Scripps in treating well over 100 of these soldiers, we find that it’s often mixed. They often have both problems going on. When the PTSD symptoms are overwhelming, that needs to be addressed first. When that’s cleared up, they can come back and get therapy for their concussive injury. Sometimes it’s the other way around and [both] can be addressed simultaneously with cognitive therapy."

The impact of the TBI varies depending on the severity of initial injury; the rate or completeness of physiological recovery; the functions affected; the meaning of dysfunction to the individual; and the resources available to aid recovery. "We try to strengthen what is weak with repetitive activities," Dr. Lobatz said. "When we realize that we cannot strengthen what is weak – that there are permanent deficits – we teach people to adapt. That is what rehabilitation is all about: Strengthen what is possible to be strengthened and adapt to what cannot be strengthened."

In athletes who are still experiencing symptoms of a concussion, return to play is not advised. If they return before they’re fully healed and then suffer another injury, that second injury "is potentially much more severe than the first," Dr. Lobatz warned. "There may not be a loss of consciousness, but there is a much more likely possibility of swelling in the brain, and there can be as much as 50% mortality in severe cases. Furthermore, there is a much higher risk of long-term complications where patients do not return to normal. They are left with long-term deficits."

To help objectify when it’s okay to return to play, Dr. Lobatz recommended administering the ImPACT test, a computer-based assessment which provides a baseline of neurocognitive skills and takes about 30 minutes to complete. In addition, a consensus statement from the Third International Conference on Concussion in Sport provides a staged system of gradual return to physical activity (Br. J. Sports Med. 2009;43:i76-84). It calls for no activity immediately after the injury, and progresses in a stepwise fashion to light aerobic exercise, sport-specific exercise, noncontact training, full contact practice, and eventual return to play.

Early on, "you may want to pull the student out of school for a week or two, for physical rest and mental rest," Dr. Lobatz said.

He also recommended the Acute Concussion Evaluation–Physician/Clinician Office Version, a checklist that "helps you identify red flags, make a diagnosis, look at risk factors for protracted recovery," he said. It can be downloaded free of charge from the U.S. Centers for Disease Control and Prevention website.

Dr. Lobatz said that he had no relevant financial disclosures to make.

SAN DIEGO – Never underestimate the importance of providing early education and positive reinforcement to patients who have sustained a traumatic brain injury.

"If you educate them, you’ll prevent a lot of emotional upset about what’s going to be happening over the next weeks or months," Dr. Michael A. Lobatz said at a meeting on primary care medicine sponsored by the Scripps Clinic. "When I see a patient with an acute concussive injury, I will tell them, ‘It’s going to get better; 85% of patients get better. The prognosis is good. Hang in there. We’re going to shut down some of your activity, but we’re going to wait for this to get better and you’re going to heal up.’ "

He makes it a point to tell them that memory deficits are common after a TBI, and that such symptoms as dizziness, irritability, a decreased ability to process information and tasks, sleep disturbance, and impulsiveness may also occur. "If you do that, you will often avoid that shattered sense of self that people come away with when they’re left hanging, not understanding what’s actually going on with them," said Dr. Lobatz, a neurologist and the medical director at the Scripps Rehabilitation Center, Encinitas, Calif.

The Centers for Disease Control and Prevention estimates that each year, 1.7 million TBIs occur in the United States. Of these, about 1.4 million involve visits to the emergency department, 275,000 involve hospitalizations, and 52,000 result in death. Dr. Lobatz defined TBI as a bump, blow, or jolt to the head that disrupts the normal function of the brain. "This may range from mild to severe, with extended periods of loss of consciousness or prolonged periods of amnesia," he said. But most of the TBIs that occur are very mild, may resolve on their own, and might not even need medical attention.

There are at least 16 different grading systems for trying to measure severity of TBI, he said, the most recent being about 10 years old. "The good news is, the American Academy of Neurology is working on a new grading system that will probably published by November of this year," he said. "That will be very useful and most updated based on class I evidence."

According to current AAN guidelines, a grade 1 concussion is marked by spotty confusion, no loss of consciousness, and concussion symptoms that last less than 15 minutes; a grade 2 concussion is marked by spotty confusion, no loss of consciousness, and concussive symptoms or abnormalities that last longer than 15 minutes. By contrast, a grade 3 concussion is marked by any loss of consciousness whether brief (seconds) or prolonged (minutes).

The guidelines also include ratings for three different levels of posttraumatic amnesia. Mild injury is defined as a Glasgow Coma Scale (GCS) score of 13-15, with 15 being completely normal, plus a 0- to 20-minute loss of consciousness (LOC) and amnesia lasting less than 24 hours. A moderate injury is defined as LOC lasting 20 minutes to 6 hours with a GCS score of 9-12. A severe injury is defined as LOC lasting longer than 6 hours with a GCS score of 3-8. Dr. Lobatz noted that patients who have longer periods of anterograde amnesia "tend to have a more prolonged course to recovery or incomplete recovery. When you take your history, ask [patients] what they remember, not what they were told happened or what they think happened by their own logical deduction. When you preface your question like that, you’ll get more accurate information."

Sorting out preinjury vs. postinjury factors in TBI patients is no easy task. For example, preexisting factors "could be that they have some ADHD, poor school performance, or depression," he said. "Postinjury factors might include disruption of relationships, school, or work. You need an open mind when you see these patients, and you cannot do this [assessment] in 10 minutes."

The process is further complicated in the assessment of soldiers who present with a TBI and also have concomitant posttraumatic stress disorder. Distinguishing which symptoms stem from the TBI and which stem from the PTSD "is a little bit of the art of evaluating the soldier these days, trying to understand which one is more predominant," Dr. Lobatz said. "In our experience at Scripps in treating well over 100 of these soldiers, we find that it’s often mixed. They often have both problems going on. When the PTSD symptoms are overwhelming, that needs to be addressed first. When that’s cleared up, they can come back and get therapy for their concussive injury. Sometimes it’s the other way around and [both] can be addressed simultaneously with cognitive therapy."

The impact of the TBI varies depending on the severity of initial injury; the rate or completeness of physiological recovery; the functions affected; the meaning of dysfunction to the individual; and the resources available to aid recovery. "We try to strengthen what is weak with repetitive activities," Dr. Lobatz said. "When we realize that we cannot strengthen what is weak – that there are permanent deficits – we teach people to adapt. That is what rehabilitation is all about: Strengthen what is possible to be strengthened and adapt to what cannot be strengthened."

In athletes who are still experiencing symptoms of a concussion, return to play is not advised. If they return before they’re fully healed and then suffer another injury, that second injury "is potentially much more severe than the first," Dr. Lobatz warned. "There may not be a loss of consciousness, but there is a much more likely possibility of swelling in the brain, and there can be as much as 50% mortality in severe cases. Furthermore, there is a much higher risk of long-term complications where patients do not return to normal. They are left with long-term deficits."

To help objectify when it’s okay to return to play, Dr. Lobatz recommended administering the ImPACT test, a computer-based assessment which provides a baseline of neurocognitive skills and takes about 30 minutes to complete. In addition, a consensus statement from the Third International Conference on Concussion in Sport provides a staged system of gradual return to physical activity (Br. J. Sports Med. 2009;43:i76-84). It calls for no activity immediately after the injury, and progresses in a stepwise fashion to light aerobic exercise, sport-specific exercise, noncontact training, full contact practice, and eventual return to play.

Early on, "you may want to pull the student out of school for a week or two, for physical rest and mental rest," Dr. Lobatz said.

He also recommended the Acute Concussion Evaluation–Physician/Clinician Office Version, a checklist that "helps you identify red flags, make a diagnosis, look at risk factors for protracted recovery," he said. It can be downloaded free of charge from the U.S. Centers for Disease Control and Prevention website.

Dr. Lobatz said that he had no relevant financial disclosures to make.

CHICAGO – Nearly one-third of patients diagnosed with Clostridium difficile infection in the previous 2 months had positive rectal cultures during follow-up visits to outpatient clinics.

Acquisition of C. difficile spores on gloved hands occurred often, especially after contact with skin sites, Lucy A. Jury reported during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"Charts of patients who have a C. difficile infection in the past 2 months should be flagged before they come to the outpatient clinic," Ms. Jury, a nurse practitioner with the Geriatric Research Education and Clinical Center at the Cleveland Veterans Affairs Medical Center, advised in an interview. "After they leave the exam room, that room should be bleached out and providers should wash their hands between seeing patients. Clean where the patient was sitting, and any surfaces the patient came into contact with."

She and her associates performed a 4-month prospective study of 35 C. difficile patients diagnosed in the prior 2 months and subsequently seen in outpatient clinics affiliated with the Cleveland VA Medical Center. The researchers obtained rectal swab cultures from all patients, as well as gloved hand print cultures after contacting the patients’ skin (abdomen, chest, arm, and hand) and environmental sites (exam room chair, exam table, and physician work area).

The mean age of the 35 patients was 66 years, 33 (94%) were male, and 7 (20%) resided in long term care facilities. Ms. Jury reported that 7 of the patients (20%) were still on C. difficile therapy, 3 (9%) had diarrhea, and 11 (31%) had positive rectal cultures.

Acquisition of spores on gloved hands occurred often, particularly after contact with any skin site (45%), followed by the hand (23%), chest (20%), abdomen (16%), and arm (14%). Spores were also detected on environmental sites (20%), especially the examination table (19%) and the chair used by patients in the examination room (5%).

For positive glove print cultures, Ms. Jury said that the mean numbers of colonies acquired after contact with skin and environmental sites were 18 and 5, respectively.

The conference was sponsored by the American Society for Microbiology. Ms. Jury said that she had no disclosures.

CHICAGO – Nearly one-third of patients diagnosed with Clostridium difficile infection in the previous 2 months had positive rectal cultures during follow-up visits to outpatient clinics.

Acquisition of C. difficile spores on gloved hands occurred often, especially after contact with skin sites, Lucy A. Jury reported during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"Charts of patients who have a C. difficile infection in the past 2 months should be flagged before they come to the outpatient clinic," Ms. Jury, a nurse practitioner with the Geriatric Research Education and Clinical Center at the Cleveland Veterans Affairs Medical Center, advised in an interview. "After they leave the exam room, that room should be bleached out and providers should wash their hands between seeing patients. Clean where the patient was sitting, and any surfaces the patient came into contact with."

She and her associates performed a 4-month prospective study of 35 C. difficile patients diagnosed in the prior 2 months and subsequently seen in outpatient clinics affiliated with the Cleveland VA Medical Center. The researchers obtained rectal swab cultures from all patients, as well as gloved hand print cultures after contacting the patients’ skin (abdomen, chest, arm, and hand) and environmental sites (exam room chair, exam table, and physician work area).

The mean age of the 35 patients was 66 years, 33 (94%) were male, and 7 (20%) resided in long term care facilities. Ms. Jury reported that 7 of the patients (20%) were still on C. difficile therapy, 3 (9%) had diarrhea, and 11 (31%) had positive rectal cultures.

Acquisition of spores on gloved hands occurred often, particularly after contact with any skin site (45%), followed by the hand (23%), chest (20%), abdomen (16%), and arm (14%). Spores were also detected on environmental sites (20%), especially the examination table (19%) and the chair used by patients in the examination room (5%).

For positive glove print cultures, Ms. Jury said that the mean numbers of colonies acquired after contact with skin and environmental sites were 18 and 5, respectively.

The conference was sponsored by the American Society for Microbiology. Ms. Jury said that she had no disclosures.

CHICAGO – Nearly one-third of patients diagnosed with Clostridium difficile infection in the previous 2 months had positive rectal cultures during follow-up visits to outpatient clinics.

Acquisition of C. difficile spores on gloved hands occurred often, especially after contact with skin sites, Lucy A. Jury reported during a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

"Charts of patients who have a C. difficile infection in the past 2 months should be flagged before they come to the outpatient clinic," Ms. Jury, a nurse practitioner with the Geriatric Research Education and Clinical Center at the Cleveland Veterans Affairs Medical Center, advised in an interview. "After they leave the exam room, that room should be bleached out and providers should wash their hands between seeing patients. Clean where the patient was sitting, and any surfaces the patient came into contact with."

She and her associates performed a 4-month prospective study of 35 C. difficile patients diagnosed in the prior 2 months and subsequently seen in outpatient clinics affiliated with the Cleveland VA Medical Center. The researchers obtained rectal swab cultures from all patients, as well as gloved hand print cultures after contacting the patients’ skin (abdomen, chest, arm, and hand) and environmental sites (exam room chair, exam table, and physician work area).

The mean age of the 35 patients was 66 years, 33 (94%) were male, and 7 (20%) resided in long term care facilities. Ms. Jury reported that 7 of the patients (20%) were still on C. difficile therapy, 3 (9%) had diarrhea, and 11 (31%) had positive rectal cultures.

Acquisition of spores on gloved hands occurred often, particularly after contact with any skin site (45%), followed by the hand (23%), chest (20%), abdomen (16%), and arm (14%). Spores were also detected on environmental sites (20%), especially the examination table (19%) and the chair used by patients in the examination room (5%).

For positive glove print cultures, Ms. Jury said that the mean numbers of colonies acquired after contact with skin and environmental sites were 18 and 5, respectively.

The conference was sponsored by the American Society for Microbiology. Ms. Jury said that she had no disclosures.

CHICAGO – A simple clinical prediction rule effectively detected a majority of asymptomatic carriers of Clostridium difficile infection in a long-term care facility, results from a small single-center study found.

According to the rule, which was derived from an article in the infectious diseases literature, previous C. difficile infection and/or antibiotic therapy within the past 3 months is helpful in predicting asymptomatic carriers (Clin. Infect. Dis. 2007;45:992-8). During a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, which was sponsored by the American Society for Microbiology, the researchers, led by Lucy Jury, presented findings from a study that set out to test the value of the prediction rule in a long-term care setting.

Ms. Jury, a nurse practitioner with the geriatric research, education, and clinical center at the Louis Stokes Cleveland Veterans Affairs Medical Center, and her associates conducted a 5-month prospective study of 120 patients who were being transferred from the Cleveland VA hospital to an affiliated long-term care facility. Rectal swabs were cultured at the time of transfer and then weekly for up to 6 weeks. The mean age of patients was 69 years, all were men, 75% had received antibiotic therapy in the past 3 months, and 39% had an indwelling catheter.

Of the 120 patients, 14 (12%) were asymptomatically colonized upon transfer to the long-term care facility. Among 85 patients with negative cultures and at least one follow-up culture, 22 (26%) acquired colonization.

Ms. Jury and her associates determined that the prediction rule had a sensitivity of 78%, a specificity of 43%, a positive predictive value of 49%, and a negative predictive value of 73%. When the researchers limited their analysis to high-risk antibiotics – including third-generation cephalosporins, fluoroquinolones, and clindamycin – the specificity rose to 82%, but the sensitivity fell to 55%.

In their poster, the researchers concluded that the prediction rule "could be used to guide infection-control interventions designed to reduce the risk for transmission from asymptomatic carriers."

Ms. Jury said that she had no relevant financial disclosures to make.

CHICAGO – A simple clinical prediction rule effectively detected a majority of asymptomatic carriers of Clostridium difficile infection in a long-term care facility, results from a small single-center study found.

According to the rule, which was derived from an article in the infectious diseases literature, previous C. difficile infection and/or antibiotic therapy within the past 3 months is helpful in predicting asymptomatic carriers (Clin. Infect. Dis. 2007;45:992-8). During a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, which was sponsored by the American Society for Microbiology, the researchers, led by Lucy Jury, presented findings from a study that set out to test the value of the prediction rule in a long-term care setting.

Ms. Jury, a nurse practitioner with the geriatric research, education, and clinical center at the Louis Stokes Cleveland Veterans Affairs Medical Center, and her associates conducted a 5-month prospective study of 120 patients who were being transferred from the Cleveland VA hospital to an affiliated long-term care facility. Rectal swabs were cultured at the time of transfer and then weekly for up to 6 weeks. The mean age of patients was 69 years, all were men, 75% had received antibiotic therapy in the past 3 months, and 39% had an indwelling catheter.

Of the 120 patients, 14 (12%) were asymptomatically colonized upon transfer to the long-term care facility. Among 85 patients with negative cultures and at least one follow-up culture, 22 (26%) acquired colonization.

Ms. Jury and her associates determined that the prediction rule had a sensitivity of 78%, a specificity of 43%, a positive predictive value of 49%, and a negative predictive value of 73%. When the researchers limited their analysis to high-risk antibiotics – including third-generation cephalosporins, fluoroquinolones, and clindamycin – the specificity rose to 82%, but the sensitivity fell to 55%.

In their poster, the researchers concluded that the prediction rule "could be used to guide infection-control interventions designed to reduce the risk for transmission from asymptomatic carriers."

Ms. Jury said that she had no relevant financial disclosures to make.

CHICAGO – A simple clinical prediction rule effectively detected a majority of asymptomatic carriers of Clostridium difficile infection in a long-term care facility, results from a small single-center study found.

According to the rule, which was derived from an article in the infectious diseases literature, previous C. difficile infection and/or antibiotic therapy within the past 3 months is helpful in predicting asymptomatic carriers (Clin. Infect. Dis. 2007;45:992-8). During a poster session at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy, which was sponsored by the American Society for Microbiology, the researchers, led by Lucy Jury, presented findings from a study that set out to test the value of the prediction rule in a long-term care setting.

Ms. Jury, a nurse practitioner with the geriatric research, education, and clinical center at the Louis Stokes Cleveland Veterans Affairs Medical Center, and her associates conducted a 5-month prospective study of 120 patients who were being transferred from the Cleveland VA hospital to an affiliated long-term care facility. Rectal swabs were cultured at the time of transfer and then weekly for up to 6 weeks. The mean age of patients was 69 years, all were men, 75% had received antibiotic therapy in the past 3 months, and 39% had an indwelling catheter.

Of the 120 patients, 14 (12%) were asymptomatically colonized upon transfer to the long-term care facility. Among 85 patients with negative cultures and at least one follow-up culture, 22 (26%) acquired colonization.

Ms. Jury and her associates determined that the prediction rule had a sensitivity of 78%, a specificity of 43%, a positive predictive value of 49%, and a negative predictive value of 73%. When the researchers limited their analysis to high-risk antibiotics – including third-generation cephalosporins, fluoroquinolones, and clindamycin – the specificity rose to 82%, but the sensitivity fell to 55%.

In their poster, the researchers concluded that the prediction rule "could be used to guide infection-control interventions designed to reduce the risk for transmission from asymptomatic carriers."

Ms. Jury said that she had no relevant financial disclosures to make.