Jeff Evans

BETHESDA, MD. — Community-associated methicillin-resistant Staphylococcus aureus infections in gay men might be associated with drug use and low levels of hygiene, especially after having sex.

Based on reports from a commercial laboratory that handles about half of the cases sent to the bureau of communicable diseases at the New York City Department of Health and Mental Hygiene, Melissa A. Marx, Ph.D., and her colleagues identified 188 men who have sex with men (MSM) with CA-MRSA infections out of 2,813 patients from New York who had S. aureus skin infections during April 2005 to September 2007.

In the first year of the study, Dr. Marx and her colleagues conducted telephone interviews with the 188 men using a structured questionnaire. After the first year, the researchers interviewed 195 MSM patients to serve as controls. They had been diagnosed with amebiasis or giardiasis during July 2006 to October 2007. These gastrointestinal infections are found commonly in MSM because of sexual transmission, said Dr. Marx, director of the department's antibiotic resistance unit.

Patients in the control group were more likely to be non-Hispanic white, but the overall profile of both groups was a “white, educated [resident of] Manhattan, [an] affluent community in New York City,” Dr. Marx said at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

Because the results of laboratory testing for CA-MRSA had not yet been completed, the researchers defined “community-associated” by the patients' lack of exposure during the past 3 months to hospital stays, residence in a long-term care facilities, invasive outpatient procedures, or hemodialysis.

Factors that were significant, independent predictors of CA-MRSA infection included having sex at a private party in the year before infection, routinely waiting more than 30 minutes to wash after sex, physical contact with someone with a skin infection within the past 3 months, having HIV/ AIDS, and crystal methamphetamine use.

Dr. Marx cautioned that the patients in the study were from private physician offices and therefore do not represent patients without insurance who seek care at emergency departments or public clinics.

The goal of the Department of Health and Mental Hygiene's research on risk factors for MRSA in groups at high risk for the condition is to develop “prevention advice and interventions for populations at high risk,” Dr. Marx said. But, “it's been hard to get a hold of what the risk groups are for community-associated MRSA because we've seen outbreaks in communities as diverse as sports participants, inmates, military recruits, men who have sex with men.”

Previous studies of groups at high risk for CA-MRSA showed skin-to-skin infection transmission is affected by crowding, compromised skin, and lack of cleanliness.

BETHESDA, MD. — Community-associated methicillin-resistant Staphylococcus aureus infections in gay men might be associated with drug use and low levels of hygiene, especially after having sex.

Based on reports from a commercial laboratory that handles about half of the cases sent to the bureau of communicable diseases at the New York City Department of Health and Mental Hygiene, Melissa A. Marx, Ph.D., and her colleagues identified 188 men who have sex with men (MSM) with CA-MRSA infections out of 2,813 patients from New York who had S. aureus skin infections during April 2005 to September 2007.

In the first year of the study, Dr. Marx and her colleagues conducted telephone interviews with the 188 men using a structured questionnaire. After the first year, the researchers interviewed 195 MSM patients to serve as controls. They had been diagnosed with amebiasis or giardiasis during July 2006 to October 2007. These gastrointestinal infections are found commonly in MSM because of sexual transmission, said Dr. Marx, director of the department's antibiotic resistance unit.

Patients in the control group were more likely to be non-Hispanic white, but the overall profile of both groups was a “white, educated [resident of] Manhattan, [an] affluent community in New York City,” Dr. Marx said at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

Because the results of laboratory testing for CA-MRSA had not yet been completed, the researchers defined “community-associated” by the patients' lack of exposure during the past 3 months to hospital stays, residence in a long-term care facilities, invasive outpatient procedures, or hemodialysis.

Factors that were significant, independent predictors of CA-MRSA infection included having sex at a private party in the year before infection, routinely waiting more than 30 minutes to wash after sex, physical contact with someone with a skin infection within the past 3 months, having HIV/ AIDS, and crystal methamphetamine use.

Dr. Marx cautioned that the patients in the study were from private physician offices and therefore do not represent patients without insurance who seek care at emergency departments or public clinics.

The goal of the Department of Health and Mental Hygiene's research on risk factors for MRSA in groups at high risk for the condition is to develop “prevention advice and interventions for populations at high risk,” Dr. Marx said. But, “it's been hard to get a hold of what the risk groups are for community-associated MRSA because we've seen outbreaks in communities as diverse as sports participants, inmates, military recruits, men who have sex with men.”

Previous studies of groups at high risk for CA-MRSA showed skin-to-skin infection transmission is affected by crowding, compromised skin, and lack of cleanliness.

BETHESDA, MD. — Community-associated methicillin-resistant Staphylococcus aureus infections in gay men might be associated with drug use and low levels of hygiene, especially after having sex.

Based on reports from a commercial laboratory that handles about half of the cases sent to the bureau of communicable diseases at the New York City Department of Health and Mental Hygiene, Melissa A. Marx, Ph.D., and her colleagues identified 188 men who have sex with men (MSM) with CA-MRSA infections out of 2,813 patients from New York who had S. aureus skin infections during April 2005 to September 2007.

In the first year of the study, Dr. Marx and her colleagues conducted telephone interviews with the 188 men using a structured questionnaire. After the first year, the researchers interviewed 195 MSM patients to serve as controls. They had been diagnosed with amebiasis or giardiasis during July 2006 to October 2007. These gastrointestinal infections are found commonly in MSM because of sexual transmission, said Dr. Marx, director of the department's antibiotic resistance unit.

Patients in the control group were more likely to be non-Hispanic white, but the overall profile of both groups was a “white, educated [resident of] Manhattan, [an] affluent community in New York City,” Dr. Marx said at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

Because the results of laboratory testing for CA-MRSA had not yet been completed, the researchers defined “community-associated” by the patients' lack of exposure during the past 3 months to hospital stays, residence in a long-term care facilities, invasive outpatient procedures, or hemodialysis.

Factors that were significant, independent predictors of CA-MRSA infection included having sex at a private party in the year before infection, routinely waiting more than 30 minutes to wash after sex, physical contact with someone with a skin infection within the past 3 months, having HIV/ AIDS, and crystal methamphetamine use.

Dr. Marx cautioned that the patients in the study were from private physician offices and therefore do not represent patients without insurance who seek care at emergency departments or public clinics.

The goal of the Department of Health and Mental Hygiene's research on risk factors for MRSA in groups at high risk for the condition is to develop “prevention advice and interventions for populations at high risk,” Dr. Marx said. But, “it's been hard to get a hold of what the risk groups are for community-associated MRSA because we've seen outbreaks in communities as diverse as sports participants, inmates, military recruits, men who have sex with men.”

Previous studies of groups at high risk for CA-MRSA showed skin-to-skin infection transmission is affected by crowding, compromised skin, and lack of cleanliness.

Optimal medical treatment—with or without percutaneous coronary intervention—improved quality of life significantly in most patients with stable angina, according to an analysis of the quality of life of patients in the COURAGE trial. But PCI may be worthwhile in patients with treatment-refractory symptoms who are initially treated with medical therapy alone.

The combination of PCI plus optimal medical therapy improved patients' quality of life slightly more than did optimal medical therapy alone. Patients with the most frequent symptoms accrued most of the benefits seen with combination treatment, but these were significant for only 6–24 months.

This quality of life subanalysis of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial “demonstrates that both treatment strategies can have a profoundly positive effect on patients' health status and suggests complementary roles—optimal medical therapy as first-line therapy, with PCI reserved for patients who do not have a response or who have severe baseline symptoms,” Dr. Eric D. Peterson and Dr. John S. Rumsfeld wrote in an editorial accompanying the study (N. Engl. J. Med. 2008;359:751-3).

In the trial, Dr. William S. Weintraub of the Christiana Care Health System, Newark, Del., and his associates in the COURAGE Trial Research Group randomized 2,287 patients to either treatment arm. The patients were required to have stenosis of more than 70% in at least one major epicardial coronary artery, with objective evidence of myocardial ischemia or stenosis of at least 80% in at least one coronary artery and classic angina without provocative testing.

The main findings of COURAGE, presented at the annual meeting of the American College of Cardiology in March 2007 and published simultaneously, showed no difference between PCI plus optimal medical therapy versus optimal medical therapy alone on the primary end point of death or myocardial infarction during the study's median follow-up period of 4.6 years (N. Engl. J. Med. 2007;356:1503-16).

In the present analysis, mean scores on all domains of the Seattle Angina Questionnaire significantly improved in both groups after 1–3 months, and did not change substantially thereafter. The questionnaire measures physical limitations resulting from angina; any recent change in the severity of angina; satisfaction with treatment; and quality of life. After 6–24 months of follow-up, scores on some domains of the 19-item questionnaire had improved significantly more among the patients who underwent PCI. This difference was lost at the final 36-month assessment (N. Engl. J. Med. 2008;359:677-87).

Patients who were treated with medical therapy alone (including patients who did not cross over to undergo PCI) also had “significant and rapid improvement” of scores on the Seattle Angina Questionnaire, which “shows that PCI is not always essential for the relief of symptoms in patients with stable angina,” wrote Dr. Peterson of the Duke Clinical Research Institute, Durham, N.C., and Dr. Rumsfeld of the Denver Veterans Affairs Medical Center.

For the first 6 months of follow-up, a greater percentage of PCI-treated patients had “clinically significant” improvement in the domains of physical limitation, angina frequency, and quality of life than did patients who received medical treatment alone. This difference did not persist beyond 6 months.

Baseline scores on the questionnaire were worse for 68 patients treated with medical therapy alone who crossed over to the other group to undergo PCI within 3 months after randomization, compared with the 895 patients in the trial arm who did not cross over within the first 3 months. The scores of these 68 patients rapidly improved following revascularization, “confirming that some patients have an especially marked benefit from PCI,” Dr. Weintraub and his coinvestigators wrote.

Analyses of the patients who had complete data through 36 months showed that most of the improvement in angina frequency occurred during the first 3 months. PCI-treated patients who had the most frequent angina symptoms (multiple episodes of angina per week) had the largest clinical improvement in that period. No improvement occurred among patients who rarely had angina.

During the first 24 months of follow-up, a significantly greater proportion of patients who received PCI and optimal medical therapy were totally free from angina symptoms, compared with those who received optimal medical therapy alone. (See box.) But this result was driven by patients with the most frequent angina symptoms.

In comparison with optimal medical therapy alone, Dr. Weintraub and his colleagues calculated that 11–17 patients would have to be treated with PCI plus optimal medical therapy in order for 1 patient to obtain a clinically significant improvement in angina frequency, physical function, or quality of life.

But this calculation does not take into account the harms associated with PCI, according to Dr. Peterson and Dr. Rumsfeld. The current in-hospital mortality associated with elective PCI is about 0.2%, based on data from the National Cardiovascular Data Registry. The periprocedural rate of myocardial infarction in the COURAGE trial was 2.8%. Based on the calculations of the COURAGE trial investigators and these figures, “for every 1,000 patients treated with a PCI-first strategy, approximately 2 would die, 28 would have a periprocedural myocardial infarction, 60 to 90 would have an incremental, transient gain in health status, and 800 or more would see neither harm nor benefit,” Dr. Peterson and Dr. Rumsfeld wrote. This estimation makes it “difficult to assert that a PCI-first strategy should clearly be adopted routinely in patients with stable angina.”

Measurement of the patients' general health status with the RAND 36-Item Health Survey largely corroborated the results found with the Seattle Angina Questionnaire.

Nearly 25% of the follow-up assessments were not available for analysis, but the investigators performed sensitivity analyses, which did not detect any potential biases.

Dr. Peterson reported receiving consulting fees from Bayer and Pfizer Inc., and grant support from Sanofi-Aventis, Bristol-Myers Squibb Co., Schering-Plough Corp., and Merck & Co. Dr. Rumsfeld disclosed that he is a scientific advisory board member at UnitedHealthcare and is chief science officer of the National Cardiovascular Data Registry.

Dr. Weintraub and some of his coinvestigators reported financial ties to a variety of pharmaceutical companies, which provided funding for the trial. The U.S. Department of Veterans Affairs Cooperative Studies Program and the Canadian Institutes of Health Research also funded the study.

Percutaneous coronary intervention is not always essential for the relief of stable angina symptoms. DR. PETERSON

ELSEVIER GLOBAL MEDICAL NEWS

Optimal medical treatment—with or without percutaneous coronary intervention—improved quality of life significantly in most patients with stable angina, according to an analysis of the quality of life of patients in the COURAGE trial. But PCI may be worthwhile in patients with treatment-refractory symptoms who are initially treated with medical therapy alone.

The combination of PCI plus optimal medical therapy improved patients' quality of life slightly more than did optimal medical therapy alone. Patients with the most frequent symptoms accrued most of the benefits seen with combination treatment, but these were significant for only 6–24 months.

This quality of life subanalysis of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial “demonstrates that both treatment strategies can have a profoundly positive effect on patients' health status and suggests complementary roles—optimal medical therapy as first-line therapy, with PCI reserved for patients who do not have a response or who have severe baseline symptoms,” Dr. Eric D. Peterson and Dr. John S. Rumsfeld wrote in an editorial accompanying the study (N. Engl. J. Med. 2008;359:751-3).

In the trial, Dr. William S. Weintraub of the Christiana Care Health System, Newark, Del., and his associates in the COURAGE Trial Research Group randomized 2,287 patients to either treatment arm. The patients were required to have stenosis of more than 70% in at least one major epicardial coronary artery, with objective evidence of myocardial ischemia or stenosis of at least 80% in at least one coronary artery and classic angina without provocative testing.

The main findings of COURAGE, presented at the annual meeting of the American College of Cardiology in March 2007 and published simultaneously, showed no difference between PCI plus optimal medical therapy versus optimal medical therapy alone on the primary end point of death or myocardial infarction during the study's median follow-up period of 4.6 years (N. Engl. J. Med. 2007;356:1503-16).

In the present analysis, mean scores on all domains of the Seattle Angina Questionnaire significantly improved in both groups after 1–3 months, and did not change substantially thereafter. The questionnaire measures physical limitations resulting from angina; any recent change in the severity of angina; satisfaction with treatment; and quality of life. After 6–24 months of follow-up, scores on some domains of the 19-item questionnaire had improved significantly more among the patients who underwent PCI. This difference was lost at the final 36-month assessment (N. Engl. J. Med. 2008;359:677-87).

Patients who were treated with medical therapy alone (including patients who did not cross over to undergo PCI) also had “significant and rapid improvement” of scores on the Seattle Angina Questionnaire, which “shows that PCI is not always essential for the relief of symptoms in patients with stable angina,” wrote Dr. Peterson of the Duke Clinical Research Institute, Durham, N.C., and Dr. Rumsfeld of the Denver Veterans Affairs Medical Center.

For the first 6 months of follow-up, a greater percentage of PCI-treated patients had “clinically significant” improvement in the domains of physical limitation, angina frequency, and quality of life than did patients who received medical treatment alone. This difference did not persist beyond 6 months.

Baseline scores on the questionnaire were worse for 68 patients treated with medical therapy alone who crossed over to the other group to undergo PCI within 3 months after randomization, compared with the 895 patients in the trial arm who did not cross over within the first 3 months. The scores of these 68 patients rapidly improved following revascularization, “confirming that some patients have an especially marked benefit from PCI,” Dr. Weintraub and his coinvestigators wrote.

Analyses of the patients who had complete data through 36 months showed that most of the improvement in angina frequency occurred during the first 3 months. PCI-treated patients who had the most frequent angina symptoms (multiple episodes of angina per week) had the largest clinical improvement in that period. No improvement occurred among patients who rarely had angina.

During the first 24 months of follow-up, a significantly greater proportion of patients who received PCI and optimal medical therapy were totally free from angina symptoms, compared with those who received optimal medical therapy alone. (See box.) But this result was driven by patients with the most frequent angina symptoms.

In comparison with optimal medical therapy alone, Dr. Weintraub and his colleagues calculated that 11–17 patients would have to be treated with PCI plus optimal medical therapy in order for 1 patient to obtain a clinically significant improvement in angina frequency, physical function, or quality of life.

But this calculation does not take into account the harms associated with PCI, according to Dr. Peterson and Dr. Rumsfeld. The current in-hospital mortality associated with elective PCI is about 0.2%, based on data from the National Cardiovascular Data Registry. The periprocedural rate of myocardial infarction in the COURAGE trial was 2.8%. Based on the calculations of the COURAGE trial investigators and these figures, “for every 1,000 patients treated with a PCI-first strategy, approximately 2 would die, 28 would have a periprocedural myocardial infarction, 60 to 90 would have an incremental, transient gain in health status, and 800 or more would see neither harm nor benefit,” Dr. Peterson and Dr. Rumsfeld wrote. This estimation makes it “difficult to assert that a PCI-first strategy should clearly be adopted routinely in patients with stable angina.”

Measurement of the patients' general health status with the RAND 36-Item Health Survey largely corroborated the results found with the Seattle Angina Questionnaire.

Nearly 25% of the follow-up assessments were not available for analysis, but the investigators performed sensitivity analyses, which did not detect any potential biases.

Dr. Peterson reported receiving consulting fees from Bayer and Pfizer Inc., and grant support from Sanofi-Aventis, Bristol-Myers Squibb Co., Schering-Plough Corp., and Merck & Co. Dr. Rumsfeld disclosed that he is a scientific advisory board member at UnitedHealthcare and is chief science officer of the National Cardiovascular Data Registry.

Dr. Weintraub and some of his coinvestigators reported financial ties to a variety of pharmaceutical companies, which provided funding for the trial. The U.S. Department of Veterans Affairs Cooperative Studies Program and the Canadian Institutes of Health Research also funded the study.

Percutaneous coronary intervention is not always essential for the relief of stable angina symptoms. DR. PETERSON

ELSEVIER GLOBAL MEDICAL NEWS

Optimal medical treatment—with or without percutaneous coronary intervention—improved quality of life significantly in most patients with stable angina, according to an analysis of the quality of life of patients in the COURAGE trial. But PCI may be worthwhile in patients with treatment-refractory symptoms who are initially treated with medical therapy alone.

The combination of PCI plus optimal medical therapy improved patients' quality of life slightly more than did optimal medical therapy alone. Patients with the most frequent symptoms accrued most of the benefits seen with combination treatment, but these were significant for only 6–24 months.

This quality of life subanalysis of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial “demonstrates that both treatment strategies can have a profoundly positive effect on patients' health status and suggests complementary roles—optimal medical therapy as first-line therapy, with PCI reserved for patients who do not have a response or who have severe baseline symptoms,” Dr. Eric D. Peterson and Dr. John S. Rumsfeld wrote in an editorial accompanying the study (N. Engl. J. Med. 2008;359:751-3).

In the trial, Dr. William S. Weintraub of the Christiana Care Health System, Newark, Del., and his associates in the COURAGE Trial Research Group randomized 2,287 patients to either treatment arm. The patients were required to have stenosis of more than 70% in at least one major epicardial coronary artery, with objective evidence of myocardial ischemia or stenosis of at least 80% in at least one coronary artery and classic angina without provocative testing.

The main findings of COURAGE, presented at the annual meeting of the American College of Cardiology in March 2007 and published simultaneously, showed no difference between PCI plus optimal medical therapy versus optimal medical therapy alone on the primary end point of death or myocardial infarction during the study's median follow-up period of 4.6 years (N. Engl. J. Med. 2007;356:1503-16).

In the present analysis, mean scores on all domains of the Seattle Angina Questionnaire significantly improved in both groups after 1–3 months, and did not change substantially thereafter. The questionnaire measures physical limitations resulting from angina; any recent change in the severity of angina; satisfaction with treatment; and quality of life. After 6–24 months of follow-up, scores on some domains of the 19-item questionnaire had improved significantly more among the patients who underwent PCI. This difference was lost at the final 36-month assessment (N. Engl. J. Med. 2008;359:677-87).

Patients who were treated with medical therapy alone (including patients who did not cross over to undergo PCI) also had “significant and rapid improvement” of scores on the Seattle Angina Questionnaire, which “shows that PCI is not always essential for the relief of symptoms in patients with stable angina,” wrote Dr. Peterson of the Duke Clinical Research Institute, Durham, N.C., and Dr. Rumsfeld of the Denver Veterans Affairs Medical Center.

For the first 6 months of follow-up, a greater percentage of PCI-treated patients had “clinically significant” improvement in the domains of physical limitation, angina frequency, and quality of life than did patients who received medical treatment alone. This difference did not persist beyond 6 months.

Baseline scores on the questionnaire were worse for 68 patients treated with medical therapy alone who crossed over to the other group to undergo PCI within 3 months after randomization, compared with the 895 patients in the trial arm who did not cross over within the first 3 months. The scores of these 68 patients rapidly improved following revascularization, “confirming that some patients have an especially marked benefit from PCI,” Dr. Weintraub and his coinvestigators wrote.

Analyses of the patients who had complete data through 36 months showed that most of the improvement in angina frequency occurred during the first 3 months. PCI-treated patients who had the most frequent angina symptoms (multiple episodes of angina per week) had the largest clinical improvement in that period. No improvement occurred among patients who rarely had angina.

During the first 24 months of follow-up, a significantly greater proportion of patients who received PCI and optimal medical therapy were totally free from angina symptoms, compared with those who received optimal medical therapy alone. (See box.) But this result was driven by patients with the most frequent angina symptoms.

In comparison with optimal medical therapy alone, Dr. Weintraub and his colleagues calculated that 11–17 patients would have to be treated with PCI plus optimal medical therapy in order for 1 patient to obtain a clinically significant improvement in angina frequency, physical function, or quality of life.

But this calculation does not take into account the harms associated with PCI, according to Dr. Peterson and Dr. Rumsfeld. The current in-hospital mortality associated with elective PCI is about 0.2%, based on data from the National Cardiovascular Data Registry. The periprocedural rate of myocardial infarction in the COURAGE trial was 2.8%. Based on the calculations of the COURAGE trial investigators and these figures, “for every 1,000 patients treated with a PCI-first strategy, approximately 2 would die, 28 would have a periprocedural myocardial infarction, 60 to 90 would have an incremental, transient gain in health status, and 800 or more would see neither harm nor benefit,” Dr. Peterson and Dr. Rumsfeld wrote. This estimation makes it “difficult to assert that a PCI-first strategy should clearly be adopted routinely in patients with stable angina.”

Measurement of the patients' general health status with the RAND 36-Item Health Survey largely corroborated the results found with the Seattle Angina Questionnaire.

Nearly 25% of the follow-up assessments were not available for analysis, but the investigators performed sensitivity analyses, which did not detect any potential biases.

Dr. Peterson reported receiving consulting fees from Bayer and Pfizer Inc., and grant support from Sanofi-Aventis, Bristol-Myers Squibb Co., Schering-Plough Corp., and Merck & Co. Dr. Rumsfeld disclosed that he is a scientific advisory board member at UnitedHealthcare and is chief science officer of the National Cardiovascular Data Registry.

Dr. Weintraub and some of his coinvestigators reported financial ties to a variety of pharmaceutical companies, which provided funding for the trial. The U.S. Department of Veterans Affairs Cooperative Studies Program and the Canadian Institutes of Health Research also funded the study.

Percutaneous coronary intervention is not always essential for the relief of stable angina symptoms. DR. PETERSON

ELSEVIER GLOBAL MEDICAL NEWS

PHILADELPHIA — Morbidly obese patients who undergo laparoscopic sleeve gastrectomy may lose significantly more weight in a shorter time period than those who undergo laparoscopic adjustable gastric banding, according to a retrospective study of 123 patients.

Both groups had similar rates of complications, although sleeve gastrectomy patients had a significantly longer mean operative time (169 minutes vs. 122 minutes) and mean length of stay in the hospital (2.5 days vs. 1.2 days) than did patients who underwent banding, Dr. Scott Q. Nguyen reported in a poster session at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

Dr. Nguyen and his colleagues at Mount Sinai Medical Center, New York, reviewed patients in their early to mid-40s (about three-fourths of whom were women) undergoing the procedures at one center during 2003–2007. Of the 123 patients studied, 49 had sleeve gastrectomy and 74 underwent laparoscopic adjustable gastric banding.

The mean body mass index values between the two groups were significantly different at both preoperative and postoperative measurements. For sleeve gastrectomy patients, the mean BMI dropped from 52 to 44 kg/m

Significantly greater values for mean weight loss and mean percentage of excess weight loss were recorded for the sleeve gastrectomy patients than for the banding patients (58 vs. 33 pounds and 30% vs. 25%, respectively).

Overall, there were 6 complications in the sleeve gastrectomy patients and 12 complications in the banding patients.

PHILADELPHIA — Morbidly obese patients who undergo laparoscopic sleeve gastrectomy may lose significantly more weight in a shorter time period than those who undergo laparoscopic adjustable gastric banding, according to a retrospective study of 123 patients.

Both groups had similar rates of complications, although sleeve gastrectomy patients had a significantly longer mean operative time (169 minutes vs. 122 minutes) and mean length of stay in the hospital (2.5 days vs. 1.2 days) than did patients who underwent banding, Dr. Scott Q. Nguyen reported in a poster session at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

Dr. Nguyen and his colleagues at Mount Sinai Medical Center, New York, reviewed patients in their early to mid-40s (about three-fourths of whom were women) undergoing the procedures at one center during 2003–2007. Of the 123 patients studied, 49 had sleeve gastrectomy and 74 underwent laparoscopic adjustable gastric banding.

The mean body mass index values between the two groups were significantly different at both preoperative and postoperative measurements. For sleeve gastrectomy patients, the mean BMI dropped from 52 to 44 kg/m

Significantly greater values for mean weight loss and mean percentage of excess weight loss were recorded for the sleeve gastrectomy patients than for the banding patients (58 vs. 33 pounds and 30% vs. 25%, respectively).

Overall, there were 6 complications in the sleeve gastrectomy patients and 12 complications in the banding patients.

PHILADELPHIA — Morbidly obese patients who undergo laparoscopic sleeve gastrectomy may lose significantly more weight in a shorter time period than those who undergo laparoscopic adjustable gastric banding, according to a retrospective study of 123 patients.

Both groups had similar rates of complications, although sleeve gastrectomy patients had a significantly longer mean operative time (169 minutes vs. 122 minutes) and mean length of stay in the hospital (2.5 days vs. 1.2 days) than did patients who underwent banding, Dr. Scott Q. Nguyen reported in a poster session at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

Dr. Nguyen and his colleagues at Mount Sinai Medical Center, New York, reviewed patients in their early to mid-40s (about three-fourths of whom were women) undergoing the procedures at one center during 2003–2007. Of the 123 patients studied, 49 had sleeve gastrectomy and 74 underwent laparoscopic adjustable gastric banding.

The mean body mass index values between the two groups were significantly different at both preoperative and postoperative measurements. For sleeve gastrectomy patients, the mean BMI dropped from 52 to 44 kg/m

Significantly greater values for mean weight loss and mean percentage of excess weight loss were recorded for the sleeve gastrectomy patients than for the banding patients (58 vs. 33 pounds and 30% vs. 25%, respectively).

Overall, there were 6 complications in the sleeve gastrectomy patients and 12 complications in the banding patients.

PHILADELPHIA — Patients with slow or no gastric pouch emptying on an upper GI study 1 day after undergoing laparoscopic Roux-en-Y gastric bypass may have less weight loss at 1 year than would patients with normal, prompt pouch emptying, according to a prospective study of 405 patients.

The study's findings could add another reason to perform a routine upper GI procedure, Dr. Ehab A. El Akkary said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

On evaluation, some gastric bypass patients show no or very slow emptying of contrast agent from the gastric pouch to the Roux limb of the jejunum, while others show fast emptying.

Dr. El Akkary and his associates conducted a prospective study of 405 patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) performed by one surgeon with a linear stapler technique during 2002–2006. All patients underwent an upper GI study on postoperative day 1.

Of 304 patients with 1 year of follow-up, 188 had normal, prompt pouch emptying and 116 had slow or nonemptying pouches, said Dr. El Akkary, a fellow in the gastrointestinal surgery division at Yale University, New Haven, Conn.

At 1 year after LRYGB, patients with prompt pouch emptying lost significantly more weight than did patients with delayed pouch emptying (111 pounds vs. 104 pounds), and had a lower mean body mass index (31.7 vs. 35.6 kg/m

The gastric pouches were roughly the same size in the two groups, Dr. El Akkary said. None of the patients required dilatation or a reoperation, and none had dumping syndrome.

Because the two groups were similar in terms of age, operative time, length of hospital stay, and initial weight and BMI, Dr. El Akkary and his colleagues noted that an increase in peptide YY might explain the findings. Peptide YY is known to reduce appetite in response to eating. Although no hormonal data are available to support this hypothesis, the next phase of the study will measure the level of peptide YY to “see if it can explain this discrepancy in weight loss,” said Dr. El Akkary, who reported having no conflicts of interest.

An audience member cautioned that although the data were intriguing, the actual difference in weight loss was small and the size of the pouch may have changed over the course of the year. Dr. El Akkary agreed that the lack of a repeat upper GI procedure at 1 year was a limitation of the study, adding that it would be especially helpful in detecting patients with slow gastric emptying caused by edema at the gastrojejunostomy.

The investigators did not measure the patients' preoperative rate of gastric emptying, but another audience member suggested that it would be “very important because it could be predictive of outcome.”

PHILADELPHIA — Patients with slow or no gastric pouch emptying on an upper GI study 1 day after undergoing laparoscopic Roux-en-Y gastric bypass may have less weight loss at 1 year than would patients with normal, prompt pouch emptying, according to a prospective study of 405 patients.

The study's findings could add another reason to perform a routine upper GI procedure, Dr. Ehab A. El Akkary said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

On evaluation, some gastric bypass patients show no or very slow emptying of contrast agent from the gastric pouch to the Roux limb of the jejunum, while others show fast emptying.

Dr. El Akkary and his associates conducted a prospective study of 405 patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) performed by one surgeon with a linear stapler technique during 2002–2006. All patients underwent an upper GI study on postoperative day 1.

Of 304 patients with 1 year of follow-up, 188 had normal, prompt pouch emptying and 116 had slow or nonemptying pouches, said Dr. El Akkary, a fellow in the gastrointestinal surgery division at Yale University, New Haven, Conn.

At 1 year after LRYGB, patients with prompt pouch emptying lost significantly more weight than did patients with delayed pouch emptying (111 pounds vs. 104 pounds), and had a lower mean body mass index (31.7 vs. 35.6 kg/m

The gastric pouches were roughly the same size in the two groups, Dr. El Akkary said. None of the patients required dilatation or a reoperation, and none had dumping syndrome.

Because the two groups were similar in terms of age, operative time, length of hospital stay, and initial weight and BMI, Dr. El Akkary and his colleagues noted that an increase in peptide YY might explain the findings. Peptide YY is known to reduce appetite in response to eating. Although no hormonal data are available to support this hypothesis, the next phase of the study will measure the level of peptide YY to “see if it can explain this discrepancy in weight loss,” said Dr. El Akkary, who reported having no conflicts of interest.

An audience member cautioned that although the data were intriguing, the actual difference in weight loss was small and the size of the pouch may have changed over the course of the year. Dr. El Akkary agreed that the lack of a repeat upper GI procedure at 1 year was a limitation of the study, adding that it would be especially helpful in detecting patients with slow gastric emptying caused by edema at the gastrojejunostomy.

The investigators did not measure the patients' preoperative rate of gastric emptying, but another audience member suggested that it would be “very important because it could be predictive of outcome.”

PHILADELPHIA — Patients with slow or no gastric pouch emptying on an upper GI study 1 day after undergoing laparoscopic Roux-en-Y gastric bypass may have less weight loss at 1 year than would patients with normal, prompt pouch emptying, according to a prospective study of 405 patients.

The study's findings could add another reason to perform a routine upper GI procedure, Dr. Ehab A. El Akkary said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

On evaluation, some gastric bypass patients show no or very slow emptying of contrast agent from the gastric pouch to the Roux limb of the jejunum, while others show fast emptying.

Dr. El Akkary and his associates conducted a prospective study of 405 patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) performed by one surgeon with a linear stapler technique during 2002–2006. All patients underwent an upper GI study on postoperative day 1.

Of 304 patients with 1 year of follow-up, 188 had normal, prompt pouch emptying and 116 had slow or nonemptying pouches, said Dr. El Akkary, a fellow in the gastrointestinal surgery division at Yale University, New Haven, Conn.

At 1 year after LRYGB, patients with prompt pouch emptying lost significantly more weight than did patients with delayed pouch emptying (111 pounds vs. 104 pounds), and had a lower mean body mass index (31.7 vs. 35.6 kg/m

The gastric pouches were roughly the same size in the two groups, Dr. El Akkary said. None of the patients required dilatation or a reoperation, and none had dumping syndrome.

Because the two groups were similar in terms of age, operative time, length of hospital stay, and initial weight and BMI, Dr. El Akkary and his colleagues noted that an increase in peptide YY might explain the findings. Peptide YY is known to reduce appetite in response to eating. Although no hormonal data are available to support this hypothesis, the next phase of the study will measure the level of peptide YY to “see if it can explain this discrepancy in weight loss,” said Dr. El Akkary, who reported having no conflicts of interest.

An audience member cautioned that although the data were intriguing, the actual difference in weight loss was small and the size of the pouch may have changed over the course of the year. Dr. El Akkary agreed that the lack of a repeat upper GI procedure at 1 year was a limitation of the study, adding that it would be especially helpful in detecting patients with slow gastric emptying caused by edema at the gastrojejunostomy.

The investigators did not measure the patients' preoperative rate of gastric emptying, but another audience member suggested that it would be “very important because it could be predictive of outcome.”

NATIONAL HARBOR, MD. — Disabled Medicare patients who undergo bariatric surgery may have higher operative mortality and a greater rate of complications than those outside of the federal program, but these risks appear to be counterbalanced by a substantial improvement in health, according to a single-center, retrospective study.

Perceptions of the risks and benefits of bariatric surgery in Medicare patients (or older patients in general) have tipped back and forth in various studies since 2004, when a report found that patients older than 55 years had elevated 30-day mortality from the procedures, especially at low-volume centers (Ann. Surg. 2004;240:586-93), said Dr. James W. Maher of the division of general surgery at Virginia Commonwealth University (VCU), Richmond.

At the annual meeting of the American Society for Metabolic and Bariatric Surgery, Dr. Maher reviewed the results of bariatric procedures performed at VCU during 1981–2006. Prior to 1999, most bariatric procedures at VCU consisted of open Roux-en-Y gastric bypass (RYGB) or vertical banded gastroplasty. Since then, the university's surgeons have performed mostly laparoscopic RYGB and a small number of laparoscopic adjustable gastric banding procedures.

Dr. Maher and his coinvestigators compared the outcomes of 282 Medicare patients with those of 3,169 non-Medicare patients.

All but 27 of the Medicare patients were on disability. Of the 282 Medicare patients, 175 had received open RYGB and 107 had received laparoscopic RYGB.

Compared with non-Medicare patients at baseline, Medicare patients had a significantly higher mean age and mean body mass index, as well as significantly higher rates of hypertension, diabetes, obstructive sleep apnea, and obesity-hypoventilation (pickwickian) syndrome, according to Dr. Maher.

Among all patients, those with Medicare coverage lost a significantly lower percentage of excess weight than did those who were not covered by Medicare (60% vs. 66%, respectively). Hypertension resolved more often among non-Medicare patients than among Medicare patients (65% vs. 49%), but diabetes resolved at similar rates between the groups (77% vs. 65%).

Men in both groups lost a similar percentage of excess weight, and diabetes resolved at similar rates (30% for Medicare vs. 23% for non-Medicare). But hypertension was resolved in 56% of men with Medicare coverage, compared with 30% of men not covered by Medicare, a significant difference.

Mortality at 30 days was significantly higher among Medicare patients than among non-Medicare patients (2.5% vs. 0.8%). There was an even greater disparity in mortality between male Medicare patients than male non-Medicare patients (5.6% vs. 1.5%). Of the 27 Medicare patients not on disability, no one older than 65 years died.

Compared with non-Medicare patients, those who were covered had a slightly higher rate of anastomotic leak but a lower rate of pulmonary embolism, possibly because they had a higher rate of preoperative insertion of inferior vena cava filters, Dr. Maher said.

NATIONAL HARBOR, MD. — Disabled Medicare patients who undergo bariatric surgery may have higher operative mortality and a greater rate of complications than those outside of the federal program, but these risks appear to be counterbalanced by a substantial improvement in health, according to a single-center, retrospective study.

Perceptions of the risks and benefits of bariatric surgery in Medicare patients (or older patients in general) have tipped back and forth in various studies since 2004, when a report found that patients older than 55 years had elevated 30-day mortality from the procedures, especially at low-volume centers (Ann. Surg. 2004;240:586-93), said Dr. James W. Maher of the division of general surgery at Virginia Commonwealth University (VCU), Richmond.

At the annual meeting of the American Society for Metabolic and Bariatric Surgery, Dr. Maher reviewed the results of bariatric procedures performed at VCU during 1981–2006. Prior to 1999, most bariatric procedures at VCU consisted of open Roux-en-Y gastric bypass (RYGB) or vertical banded gastroplasty. Since then, the university's surgeons have performed mostly laparoscopic RYGB and a small number of laparoscopic adjustable gastric banding procedures.

Dr. Maher and his coinvestigators compared the outcomes of 282 Medicare patients with those of 3,169 non-Medicare patients.

All but 27 of the Medicare patients were on disability. Of the 282 Medicare patients, 175 had received open RYGB and 107 had received laparoscopic RYGB.

Compared with non-Medicare patients at baseline, Medicare patients had a significantly higher mean age and mean body mass index, as well as significantly higher rates of hypertension, diabetes, obstructive sleep apnea, and obesity-hypoventilation (pickwickian) syndrome, according to Dr. Maher.

Among all patients, those with Medicare coverage lost a significantly lower percentage of excess weight than did those who were not covered by Medicare (60% vs. 66%, respectively). Hypertension resolved more often among non-Medicare patients than among Medicare patients (65% vs. 49%), but diabetes resolved at similar rates between the groups (77% vs. 65%).

Men in both groups lost a similar percentage of excess weight, and diabetes resolved at similar rates (30% for Medicare vs. 23% for non-Medicare). But hypertension was resolved in 56% of men with Medicare coverage, compared with 30% of men not covered by Medicare, a significant difference.

Mortality at 30 days was significantly higher among Medicare patients than among non-Medicare patients (2.5% vs. 0.8%). There was an even greater disparity in mortality between male Medicare patients than male non-Medicare patients (5.6% vs. 1.5%). Of the 27 Medicare patients not on disability, no one older than 65 years died.

Compared with non-Medicare patients, those who were covered had a slightly higher rate of anastomotic leak but a lower rate of pulmonary embolism, possibly because they had a higher rate of preoperative insertion of inferior vena cava filters, Dr. Maher said.

NATIONAL HARBOR, MD. — Disabled Medicare patients who undergo bariatric surgery may have higher operative mortality and a greater rate of complications than those outside of the federal program, but these risks appear to be counterbalanced by a substantial improvement in health, according to a single-center, retrospective study.

Perceptions of the risks and benefits of bariatric surgery in Medicare patients (or older patients in general) have tipped back and forth in various studies since 2004, when a report found that patients older than 55 years had elevated 30-day mortality from the procedures, especially at low-volume centers (Ann. Surg. 2004;240:586-93), said Dr. James W. Maher of the division of general surgery at Virginia Commonwealth University (VCU), Richmond.

At the annual meeting of the American Society for Metabolic and Bariatric Surgery, Dr. Maher reviewed the results of bariatric procedures performed at VCU during 1981–2006. Prior to 1999, most bariatric procedures at VCU consisted of open Roux-en-Y gastric bypass (RYGB) or vertical banded gastroplasty. Since then, the university's surgeons have performed mostly laparoscopic RYGB and a small number of laparoscopic adjustable gastric banding procedures.

Dr. Maher and his coinvestigators compared the outcomes of 282 Medicare patients with those of 3,169 non-Medicare patients.

All but 27 of the Medicare patients were on disability. Of the 282 Medicare patients, 175 had received open RYGB and 107 had received laparoscopic RYGB.

Compared with non-Medicare patients at baseline, Medicare patients had a significantly higher mean age and mean body mass index, as well as significantly higher rates of hypertension, diabetes, obstructive sleep apnea, and obesity-hypoventilation (pickwickian) syndrome, according to Dr. Maher.

Among all patients, those with Medicare coverage lost a significantly lower percentage of excess weight than did those who were not covered by Medicare (60% vs. 66%, respectively). Hypertension resolved more often among non-Medicare patients than among Medicare patients (65% vs. 49%), but diabetes resolved at similar rates between the groups (77% vs. 65%).

Men in both groups lost a similar percentage of excess weight, and diabetes resolved at similar rates (30% for Medicare vs. 23% for non-Medicare). But hypertension was resolved in 56% of men with Medicare coverage, compared with 30% of men not covered by Medicare, a significant difference.

Mortality at 30 days was significantly higher among Medicare patients than among non-Medicare patients (2.5% vs. 0.8%). There was an even greater disparity in mortality between male Medicare patients than male non-Medicare patients (5.6% vs. 1.5%). Of the 27 Medicare patients not on disability, no one older than 65 years died.

Compared with non-Medicare patients, those who were covered had a slightly higher rate of anastomotic leak but a lower rate of pulmonary embolism, possibly because they had a higher rate of preoperative insertion of inferior vena cava filters, Dr. Maher said.

Initial antiretroviral treatment of HIV infection in asymptomatic adults should begin before CD4 cell counts drop below 350/mcL, according to new treatment guidelines announced at the 2008 International AIDS Conference in Mexico City.

The guidelines, issued by the International AIDS Society-USA Panel, update 2006 recommendations. The change reflects improvements in drug pharmacokinetics and treatment response, as well as the need to stem increases in the relative burden of diseases that are not traditionally associated with HIV infection, such as non-AIDS cancers and end-organ damage (JAMA 2008;300:555–70).

Updates to the 2006 guidelines were necessary because of the Food and Drug Administration's approval of several new antiretroviral drugs as well as the availability of new data to use in choosing drugs for initial therapy and managing treatment failure, according to the panel.

More than 30 individual antiretroviral agents and fixed-dose combinations have been approved by the Food and Drug Administration since the first antiretroviral drug was approved 21 years ago, Dr. Scott M. Hammer, chair of the IAS-USA panel, said at a media briefing on HIV/AIDS sponsored by JAMA.

The 14-member panel emphasized that the guidelines are most applicable to "developed and selected mid-level economies," but that their core principle—"pathogenesis-directed therapy with regimens designed to achieve full virologic suppression with minimal toxicity and maximal simplicity"—also is relevant to the developing world.

The specific time at which antiretroviral treatment should begin in asymptomatic adults should be based on comorbidities, risk of disease progression, and patient willingness and ability to adhere to long-term treatment. Early treatment of asymptomatic individuals is favorable when there is a rapid decline in CD4 cell count; plasma HIV-1 RNA level is greater than 100,000 copies/mL; and in the presence of active hepatitis B or C, HIV-associated nephropathy, or cardiovascular disease risk factors.

"There is no upper CD4 cell limit for starting therapy when 1 or more of these considerations are present," the panelists wrote, although "no definitive evidence has emerged that supports routine initiation of antiretroviral therapy in primary HIV infection."

Dr. Hammer, chief of the division of infectious diseases at Columbia University, New York, commented that "we've had cutoffs because it's convenient for guidelines. It has been convenient to look at cohort studies and very convenient for randomized, controlled trials. But there is no difference in a patient with a CD4 count of 360 and 340 or 210 and 190."

The guidelines advocate initial treatment regimens that consist of two nucleoside reverse transcriptase inhibitors (NRTIs) plus either the non-nucleoside reverse transcriptase inhibitor (NNRTI) efavirenz or a ritonavir-boosted protease inhibitor (PI/r).

The guidelines advise a treatment goal of less than 50 copies/mL of HIV-1 RNA. Until the viral load is suppressed, its levels should be monitored—along with CD4 cell count—at 2, 4, and 8 weeks and every 4 weeks thereafter until the concentration drops below the assay detection limits. Afterward, the viral load and CD4 cell count can be assessed every 3–4 months. Cell count monitoring can be reduced to every 6 months when measurements are consistently at levels of at least 350/mcL. Comorbidity and toxicity assessment should occur before and throughout treatment.

Genotypic testing for resistance is necessary in all treatment-naive patients. In addition, it should be considered whenever a new treatment regimen is introduced if the trajectory of viral load reduction is not optimal, the panel recommended.

Many of the panel members disclosed financial ties to multiple manufacturers of antiretroviral drugs, including the manufacturers of maraviroc (Pfizer Inc.), raltegravir (Merck & Co.), and etravirine (Tibotec).

Initial antiretroviral treatment of HIV infection in asymptomatic adults should begin before CD4 cell counts drop below 350/mcL, according to new treatment guidelines announced at the 2008 International AIDS Conference in Mexico City.

The guidelines, issued by the International AIDS Society-USA Panel, update 2006 recommendations. The change reflects improvements in drug pharmacokinetics and treatment response, as well as the need to stem increases in the relative burden of diseases that are not traditionally associated with HIV infection, such as non-AIDS cancers and end-organ damage (JAMA 2008;300:555–70).

Updates to the 2006 guidelines were necessary because of the Food and Drug Administration's approval of several new antiretroviral drugs as well as the availability of new data to use in choosing drugs for initial therapy and managing treatment failure, according to the panel.

More than 30 individual antiretroviral agents and fixed-dose combinations have been approved by the Food and Drug Administration since the first antiretroviral drug was approved 21 years ago, Dr. Scott M. Hammer, chair of the IAS-USA panel, said at a media briefing on HIV/AIDS sponsored by JAMA.

The 14-member panel emphasized that the guidelines are most applicable to "developed and selected mid-level economies," but that their core principle—"pathogenesis-directed therapy with regimens designed to achieve full virologic suppression with minimal toxicity and maximal simplicity"—also is relevant to the developing world.

The specific time at which antiretroviral treatment should begin in asymptomatic adults should be based on comorbidities, risk of disease progression, and patient willingness and ability to adhere to long-term treatment. Early treatment of asymptomatic individuals is favorable when there is a rapid decline in CD4 cell count; plasma HIV-1 RNA level is greater than 100,000 copies/mL; and in the presence of active hepatitis B or C, HIV-associated nephropathy, or cardiovascular disease risk factors.

"There is no upper CD4 cell limit for starting therapy when 1 or more of these considerations are present," the panelists wrote, although "no definitive evidence has emerged that supports routine initiation of antiretroviral therapy in primary HIV infection."

Dr. Hammer, chief of the division of infectious diseases at Columbia University, New York, commented that "we've had cutoffs because it's convenient for guidelines. It has been convenient to look at cohort studies and very convenient for randomized, controlled trials. But there is no difference in a patient with a CD4 count of 360 and 340 or 210 and 190."

The guidelines advocate initial treatment regimens that consist of two nucleoside reverse transcriptase inhibitors (NRTIs) plus either the non-nucleoside reverse transcriptase inhibitor (NNRTI) efavirenz or a ritonavir-boosted protease inhibitor (PI/r).

The guidelines advise a treatment goal of less than 50 copies/mL of HIV-1 RNA. Until the viral load is suppressed, its levels should be monitored—along with CD4 cell count—at 2, 4, and 8 weeks and every 4 weeks thereafter until the concentration drops below the assay detection limits. Afterward, the viral load and CD4 cell count can be assessed every 3–4 months. Cell count monitoring can be reduced to every 6 months when measurements are consistently at levels of at least 350/mcL. Comorbidity and toxicity assessment should occur before and throughout treatment.

Genotypic testing for resistance is necessary in all treatment-naive patients. In addition, it should be considered whenever a new treatment regimen is introduced if the trajectory of viral load reduction is not optimal, the panel recommended.

Many of the panel members disclosed financial ties to multiple manufacturers of antiretroviral drugs, including the manufacturers of maraviroc (Pfizer Inc.), raltegravir (Merck & Co.), and etravirine (Tibotec).

Initial antiretroviral treatment of HIV infection in asymptomatic adults should begin before CD4 cell counts drop below 350/mcL, according to new treatment guidelines announced at the 2008 International AIDS Conference in Mexico City.

The guidelines, issued by the International AIDS Society-USA Panel, update 2006 recommendations. The change reflects improvements in drug pharmacokinetics and treatment response, as well as the need to stem increases in the relative burden of diseases that are not traditionally associated with HIV infection, such as non-AIDS cancers and end-organ damage (JAMA 2008;300:555–70).

Updates to the 2006 guidelines were necessary because of the Food and Drug Administration's approval of several new antiretroviral drugs as well as the availability of new data to use in choosing drugs for initial therapy and managing treatment failure, according to the panel.

More than 30 individual antiretroviral agents and fixed-dose combinations have been approved by the Food and Drug Administration since the first antiretroviral drug was approved 21 years ago, Dr. Scott M. Hammer, chair of the IAS-USA panel, said at a media briefing on HIV/AIDS sponsored by JAMA.

The 14-member panel emphasized that the guidelines are most applicable to "developed and selected mid-level economies," but that their core principle—"pathogenesis-directed therapy with regimens designed to achieve full virologic suppression with minimal toxicity and maximal simplicity"—also is relevant to the developing world.

The specific time at which antiretroviral treatment should begin in asymptomatic adults should be based on comorbidities, risk of disease progression, and patient willingness and ability to adhere to long-term treatment. Early treatment of asymptomatic individuals is favorable when there is a rapid decline in CD4 cell count; plasma HIV-1 RNA level is greater than 100,000 copies/mL; and in the presence of active hepatitis B or C, HIV-associated nephropathy, or cardiovascular disease risk factors.

"There is no upper CD4 cell limit for starting therapy when 1 or more of these considerations are present," the panelists wrote, although "no definitive evidence has emerged that supports routine initiation of antiretroviral therapy in primary HIV infection."

Dr. Hammer, chief of the division of infectious diseases at Columbia University, New York, commented that "we've had cutoffs because it's convenient for guidelines. It has been convenient to look at cohort studies and very convenient for randomized, controlled trials. But there is no difference in a patient with a CD4 count of 360 and 340 or 210 and 190."

The guidelines advocate initial treatment regimens that consist of two nucleoside reverse transcriptase inhibitors (NRTIs) plus either the non-nucleoside reverse transcriptase inhibitor (NNRTI) efavirenz or a ritonavir-boosted protease inhibitor (PI/r).

The guidelines advise a treatment goal of less than 50 copies/mL of HIV-1 RNA. Until the viral load is suppressed, its levels should be monitored—along with CD4 cell count—at 2, 4, and 8 weeks and every 4 weeks thereafter until the concentration drops below the assay detection limits. Afterward, the viral load and CD4 cell count can be assessed every 3–4 months. Cell count monitoring can be reduced to every 6 months when measurements are consistently at levels of at least 350/mcL. Comorbidity and toxicity assessment should occur before and throughout treatment.

Genotypic testing for resistance is necessary in all treatment-naive patients. In addition, it should be considered whenever a new treatment regimen is introduced if the trajectory of viral load reduction is not optimal, the panel recommended.

Many of the panel members disclosed financial ties to multiple manufacturers of antiretroviral drugs, including the manufacturers of maraviroc (Pfizer Inc.), raltegravir (Merck & Co.), and etravirine (Tibotec).

BETHESDA, MD. — The antimicrobial stewardship program at the health sciences center of West Virginia University, Morgantown, has been successful in reducing resistance in some pathogens, while generating more questions about others, according to Dr. Arif R. Sarwari, the program's director.

In its first 5 years, the program at the tertiary care teaching hospital principally used prospective auditing methods and protocols for antibiotic cycling, coupled with educational strategies, to reduce the use of specific antibiotics and, in some instances, see a drop in rates of resistance.

Such results may not have been possible without the support and involvement of administrators and clinicians from different specialties, many of whom are members of the university's Antimicrobial Review Subcommittee and participated in the creation of the program. Cooperation is necessary because the interventions needed in various departments may differ and may cross a variety of disciplines, Dr. Sarwari said at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

The antimicrobial stewardship program began in 2003 and follows many of the recommendations formulated in guidelines issued by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (Clin. Infect. Dis. 2007;44:159–77), said Dr. Sarwari, who is a member of the committee.

It is unclear which combinations of modalities for reducing antimicrobial resistance work best, and "until I have 15 different institutions using 15 different combinations and putting their results out there, how do I know which one works and which one doesn't? This was our attempt to put out what we think is a sensible approach," Dr. Sarwari said in an interview.

Although many hospitals have programs to monitor and reduce antimicrobial resistance, most simply restrict the use of certain agents by having one person who approves or denies their use. But West Virginia University prospectively audits antimicrobial use and resistance every 6 months, and implements changes through educational interventions.

This helps to avoid an "us versus them" phenomenon and should help to sustain the program over the long term, Dr. Sarwari said. "Unless you have a buy-in from the end users, this will not work."

Although it was relatively simple to decide to define antimicrobial use through the measurement of defined daily doses per 1,000 patient-days, it took about 6 months of effort to convert data that are captured for billing purposes into data that can be used longitudinally, he said. To inform hospital administrators, the program also tracked the proportion of the pharmacy budget spent on antimicrobial drugs.

Educational programs were established to encourage or discourage the use of select antimicrobial agents, while strategies to promote the use of alcohol-based hand sanitizers were put in place. In addition, the committee made a pocket-card guide available on an educational Web site. The card featured choices of antimicrobials for various clinical scenarios, listed the susceptible proportion of microorganisms that had been identified for that particular year, and gave the top three choices of antimicrobial agents for a particular pathogen (as perceived by the institution). It also noted if a pathogen had shown a 10% or greater rise in resistance to particular drugs during the past year.

Interventions centered on the principle of cycling the selection of antimicrobial drugs based on local surveillance of resistance rates, and were tailored for different units of the hospital. For example, with help from ICU intensivists, the committee developed a ventilator-assisted pneumonia protocol that incorporated a strategy of de-escalating antibiotic therapy from broader to more specific pathogen coverage, and the bone marrow transplant unit created a febrile neutropenia protocol.

The committee members decided not to keep a very restricted formulary except for quinolones, because more than half of the Pseudomonas strains in the ICU were resistant to ciprofloxacin, Dr. Sarwari said.

During the first 5 years of the stewardship program (2003–2007), the number of defined daily doses per 1,000 patient-days of quinolones declined by 81%; the same defined measure of ceftazidime declined by 37%, he said. The committee saw a concomitant rise in the use of agents that were designated to replace quinolones and ceftazidime (aminoglycosides and cefepime, respectively). At the same time, the antimicrobial drug proportion of the pharmacy procurement budget declined from 16% to 8%.

Changes in drug resistance during the period yielded "mixed results," Dr. Sarwari said. During 2004–2006, rates of ciprofloxacin resistance for Pseudomonas declined from 38% to 22% and for Acinetobacter from 25% to 0%. In 2007, these rates rose again to 34% and 16%, respectively. In the same time period, resistance to ciprofloxacin gradually increased in Escherichia coli from 7% to 20%. Klebsiella resistance to ceftazidime remained stable at about 5%.

The proportion of nosocomial bacteremia cases caused by methicillin-resistant Staphylococcus aureus declined from 20% to 10%, whereas rates for bacteremia caused by vancomycin-resistant enterococci held steady at about 7%.

It is possible that in some cases the replacement agents continued to foster resistance to the antibiotics the hospital had stopped using, Dr. Sarwari suggested. Although this theory to explain the findings is not new, future studies may be able to discern how the use of one antibiotic affects resistance to another drug or class of drugs.

In a separate poster presentation, Dr. Sarwari and his coinvestigators reported that antibiotic use and resistance rates in an ICU were similar to the results for the hospital as a whole.

Dr. Sarwari said he thinks that a program similar to WVU's could work well at small community-based hospitals, especially if they incorporated only the most important elements of the program.

The hospital's antimicrobial stewardship program "appears to be reasonably successful in affecting institutional use and resistance, but I'm not sure it has [had much] influence on the problem of imported resistance," Dr. Sarwari said.

In the future, "the big thing we want to try to introduce is some form of molecular microbiology to better get a sense of how many resistant bugs are new strains versus the same strains being passed around due to poor infection control."

Dr. Sarwari disclosed no conflicts of interest.

BETHESDA, MD. — The antimicrobial stewardship program at the health sciences center of West Virginia University, Morgantown, has been successful in reducing resistance in some pathogens, while generating more questions about others, according to Dr. Arif R. Sarwari, the program's director.

In its first 5 years, the program at the tertiary care teaching hospital principally used prospective auditing methods and protocols for antibiotic cycling, coupled with educational strategies, to reduce the use of specific antibiotics and, in some instances, see a drop in rates of resistance.

Such results may not have been possible without the support and involvement of administrators and clinicians from different specialties, many of whom are members of the university's Antimicrobial Review Subcommittee and participated in the creation of the program. Cooperation is necessary because the interventions needed in various departments may differ and may cross a variety of disciplines, Dr. Sarwari said at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

The antimicrobial stewardship program began in 2003 and follows many of the recommendations formulated in guidelines issued by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (Clin. Infect. Dis. 2007;44:159–77), said Dr. Sarwari, who is a member of the committee.

It is unclear which combinations of modalities for reducing antimicrobial resistance work best, and "until I have 15 different institutions using 15 different combinations and putting their results out there, how do I know which one works and which one doesn't? This was our attempt to put out what we think is a sensible approach," Dr. Sarwari said in an interview.

Although many hospitals have programs to monitor and reduce antimicrobial resistance, most simply restrict the use of certain agents by having one person who approves or denies their use. But West Virginia University prospectively audits antimicrobial use and resistance every 6 months, and implements changes through educational interventions.

This helps to avoid an "us versus them" phenomenon and should help to sustain the program over the long term, Dr. Sarwari said. "Unless you have a buy-in from the end users, this will not work."

Although it was relatively simple to decide to define antimicrobial use through the measurement of defined daily doses per 1,000 patient-days, it took about 6 months of effort to convert data that are captured for billing purposes into data that can be used longitudinally, he said. To inform hospital administrators, the program also tracked the proportion of the pharmacy budget spent on antimicrobial drugs.

Educational programs were established to encourage or discourage the use of select antimicrobial agents, while strategies to promote the use of alcohol-based hand sanitizers were put in place. In addition, the committee made a pocket-card guide available on an educational Web site. The card featured choices of antimicrobials for various clinical scenarios, listed the susceptible proportion of microorganisms that had been identified for that particular year, and gave the top three choices of antimicrobial agents for a particular pathogen (as perceived by the institution). It also noted if a pathogen had shown a 10% or greater rise in resistance to particular drugs during the past year.

Interventions centered on the principle of cycling the selection of antimicrobial drugs based on local surveillance of resistance rates, and were tailored for different units of the hospital. For example, with help from ICU intensivists, the committee developed a ventilator-assisted pneumonia protocol that incorporated a strategy of de-escalating antibiotic therapy from broader to more specific pathogen coverage, and the bone marrow transplant unit created a febrile neutropenia protocol.

The committee members decided not to keep a very restricted formulary except for quinolones, because more than half of the Pseudomonas strains in the ICU were resistant to ciprofloxacin, Dr. Sarwari said.

During the first 5 years of the stewardship program (2003–2007), the number of defined daily doses per 1,000 patient-days of quinolones declined by 81%; the same defined measure of ceftazidime declined by 37%, he said. The committee saw a concomitant rise in the use of agents that were designated to replace quinolones and ceftazidime (aminoglycosides and cefepime, respectively). At the same time, the antimicrobial drug proportion of the pharmacy procurement budget declined from 16% to 8%.

Changes in drug resistance during the period yielded "mixed results," Dr. Sarwari said. During 2004–2006, rates of ciprofloxacin resistance for Pseudomonas declined from 38% to 22% and for Acinetobacter from 25% to 0%. In 2007, these rates rose again to 34% and 16%, respectively. In the same time period, resistance to ciprofloxacin gradually increased in Escherichia coli from 7% to 20%. Klebsiella resistance to ceftazidime remained stable at about 5%.

The proportion of nosocomial bacteremia cases caused by methicillin-resistant Staphylococcus aureus declined from 20% to 10%, whereas rates for bacteremia caused by vancomycin-resistant enterococci held steady at about 7%.

It is possible that in some cases the replacement agents continued to foster resistance to the antibiotics the hospital had stopped using, Dr. Sarwari suggested. Although this theory to explain the findings is not new, future studies may be able to discern how the use of one antibiotic affects resistance to another drug or class of drugs.

In a separate poster presentation, Dr. Sarwari and his coinvestigators reported that antibiotic use and resistance rates in an ICU were similar to the results for the hospital as a whole.

Dr. Sarwari said he thinks that a program similar to WVU's could work well at small community-based hospitals, especially if they incorporated only the most important elements of the program.

The hospital's antimicrobial stewardship program "appears to be reasonably successful in affecting institutional use and resistance, but I'm not sure it has [had much] influence on the problem of imported resistance," Dr. Sarwari said.

In the future, "the big thing we want to try to introduce is some form of molecular microbiology to better get a sense of how many resistant bugs are new strains versus the same strains being passed around due to poor infection control."

Dr. Sarwari disclosed no conflicts of interest.

BETHESDA, MD. — The antimicrobial stewardship program at the health sciences center of West Virginia University, Morgantown, has been successful in reducing resistance in some pathogens, while generating more questions about others, according to Dr. Arif R. Sarwari, the program's director.

In its first 5 years, the program at the tertiary care teaching hospital principally used prospective auditing methods and protocols for antibiotic cycling, coupled with educational strategies, to reduce the use of specific antibiotics and, in some instances, see a drop in rates of resistance.

Such results may not have been possible without the support and involvement of administrators and clinicians from different specialties, many of whom are members of the university's Antimicrobial Review Subcommittee and participated in the creation of the program. Cooperation is necessary because the interventions needed in various departments may differ and may cross a variety of disciplines, Dr. Sarwari said at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

The antimicrobial stewardship program began in 2003 and follows many of the recommendations formulated in guidelines issued by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (Clin. Infect. Dis. 2007;44:159–77), said Dr. Sarwari, who is a member of the committee.

It is unclear which combinations of modalities for reducing antimicrobial resistance work best, and "until I have 15 different institutions using 15 different combinations and putting their results out there, how do I know which one works and which one doesn't? This was our attempt to put out what we think is a sensible approach," Dr. Sarwari said in an interview.

Although many hospitals have programs to monitor and reduce antimicrobial resistance, most simply restrict the use of certain agents by having one person who approves or denies their use. But West Virginia University prospectively audits antimicrobial use and resistance every 6 months, and implements changes through educational interventions.

This helps to avoid an "us versus them" phenomenon and should help to sustain the program over the long term, Dr. Sarwari said. "Unless you have a buy-in from the end users, this will not work."

Although it was relatively simple to decide to define antimicrobial use through the measurement of defined daily doses per 1,000 patient-days, it took about 6 months of effort to convert data that are captured for billing purposes into data that can be used longitudinally, he said. To inform hospital administrators, the program also tracked the proportion of the pharmacy budget spent on antimicrobial drugs.

Educational programs were established to encourage or discourage the use of select antimicrobial agents, while strategies to promote the use of alcohol-based hand sanitizers were put in place. In addition, the committee made a pocket-card guide available on an educational Web site. The card featured choices of antimicrobials for various clinical scenarios, listed the susceptible proportion of microorganisms that had been identified for that particular year, and gave the top three choices of antimicrobial agents for a particular pathogen (as perceived by the institution). It also noted if a pathogen had shown a 10% or greater rise in resistance to particular drugs during the past year.

Interventions centered on the principle of cycling the selection of antimicrobial drugs based on local surveillance of resistance rates, and were tailored for different units of the hospital. For example, with help from ICU intensivists, the committee developed a ventilator-assisted pneumonia protocol that incorporated a strategy of de-escalating antibiotic therapy from broader to more specific pathogen coverage, and the bone marrow transplant unit created a febrile neutropenia protocol.

The committee members decided not to keep a very restricted formulary except for quinolones, because more than half of the Pseudomonas strains in the ICU were resistant to ciprofloxacin, Dr. Sarwari said.

During the first 5 years of the stewardship program (2003–2007), the number of defined daily doses per 1,000 patient-days of quinolones declined by 81%; the same defined measure of ceftazidime declined by 37%, he said. The committee saw a concomitant rise in the use of agents that were designated to replace quinolones and ceftazidime (aminoglycosides and cefepime, respectively). At the same time, the antimicrobial drug proportion of the pharmacy procurement budget declined from 16% to 8%.

Changes in drug resistance during the period yielded "mixed results," Dr. Sarwari said. During 2004–2006, rates of ciprofloxacin resistance for Pseudomonas declined from 38% to 22% and for Acinetobacter from 25% to 0%. In 2007, these rates rose again to 34% and 16%, respectively. In the same time period, resistance to ciprofloxacin gradually increased in Escherichia coli from 7% to 20%. Klebsiella resistance to ceftazidime remained stable at about 5%.

The proportion of nosocomial bacteremia cases caused by methicillin-resistant Staphylococcus aureus declined from 20% to 10%, whereas rates for bacteremia caused by vancomycin-resistant enterococci held steady at about 7%.

It is possible that in some cases the replacement agents continued to foster resistance to the antibiotics the hospital had stopped using, Dr. Sarwari suggested. Although this theory to explain the findings is not new, future studies may be able to discern how the use of one antibiotic affects resistance to another drug or class of drugs.

In a separate poster presentation, Dr. Sarwari and his coinvestigators reported that antibiotic use and resistance rates in an ICU were similar to the results for the hospital as a whole.

Dr. Sarwari said he thinks that a program similar to WVU's could work well at small community-based hospitals, especially if they incorporated only the most important elements of the program.

The hospital's antimicrobial stewardship program "appears to be reasonably successful in affecting institutional use and resistance, but I'm not sure it has [had much] influence on the problem of imported resistance," Dr. Sarwari said.

In the future, "the big thing we want to try to introduce is some form of molecular microbiology to better get a sense of how many resistant bugs are new strains versus the same strains being passed around due to poor infection control."

Dr. Sarwari disclosed no conflicts of interest.

BETHESDA, MD. — Use of household cleaning products that contain benzalkonium chloride may decrease the susceptibility of bacteria to other antimicrobial ingredients in cleaning products and increase their resistance to antibiotics, according to the results of a randomized, double-blind study.

The study is the first randomized intervention study to assess the relationship between the use of two biocidal ingredients found in household cleaning products—benzalkonium chloride (BZK) and triclosan—and antibiotic resistance in the household setting, Allison E. Aiello, Ph.D., reported at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

Consumer antiseptics and disinfectants are products that can prevent infections by killing or inhibiting the growth of microorganisms. Biocidal ingredients in these products often are quaternary ammonium compounds (such as BZK) and triclosan.

Some studies have found triclosan in more than 75% of liquid hand-washing soaps sold in the United States. Triclosan has been used ubiquitously since the 1960s and can be found in some toothpaste and embedded in products such as cutting boards and baby diapers. Triclosan also is known to remain in treated sewage that is recycled for use in agriculture, according to Dr. Aiello, an epidemiologist at the University of Michigan, Ann Arbor.

In 2000, Dr. Aiello and her coinvestigators provided 238 households with either antibacterial products (floor cleaner with 0.08% BZK, surface cleaner with 2.7% BZK, and liquid hand-washing soap with 0.2% triclosan) or the same products without antibacterial ingredients. They cultured the hands of household members before the study started and then after 1 year. Isolates of bacteria from the cultures were tested to determine the minimum inhibitory concentrations (MICs) of BZK and triclosan on which bacteria can grow.

The investigators defined MICs that were above the median for each biocide as "high" and those equal to or less than the median as "low." The investigators analyzed the general trends and changes over time in all bacterial species combined because they could not compare the same isolates at baseline and at the end of 1 year.

In isolates from all bacterial species combined, there were no differences between the groups in susceptibility to BZK at baseline or 1 year.

Dr. Aiello and her colleagues then analyzed isolates of bacteria from all species with a high MIC for BZK. At baseline, these isolates from either group of households had similar rates of antibiotic resistance or high MICs for triclosan. But, after 1 year, the isolates that came from households using antibacterial cleaning products had more than twice the odds of developing a high MIC for triclosan than did isolates from households that did not use products with antibacterial ingredients. At 1 year, isolates from households that used antibacterial products also had more than double the likelihood of developing resistance to antibiotics. A subanalysis showed that gram-negative bacterial isolates from households using antibacterial products had nearly fourfold higher odds of developing antibiotic resistance, compared with gram-negative isolates from households that did not use products with antibacterial ingredients.

"Potential selective pressure may result in coselection of resistance genes for other biocides and antibiotics," she concluded.

Dr. Aiello and her associates tested all gram-negative bacteria against gentamicin, imipenem, and ciprofloxacin. Certain bacterial species were tested against other types of antibiotics.

No covariates—such as use of a product before enrollment, child day care attendance, or antibiotic use—were associated with susceptibility to BZK or with households that used products containing antibacterial ingredients.

Dr. Aiello had no conflicts of interest to disclose.

BETHESDA, MD. — Use of household cleaning products that contain benzalkonium chloride may decrease the susceptibility of bacteria to other antimicrobial ingredients in cleaning products and increase their resistance to antibiotics, according to the results of a randomized, double-blind study.

The study is the first randomized intervention study to assess the relationship between the use of two biocidal ingredients found in household cleaning products—benzalkonium chloride (BZK) and triclosan—and antibiotic resistance in the household setting, Allison E. Aiello, Ph.D., reported at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

Consumer antiseptics and disinfectants are products that can prevent infections by killing or inhibiting the growth of microorganisms. Biocidal ingredients in these products often are quaternary ammonium compounds (such as BZK) and triclosan.

Some studies have found triclosan in more than 75% of liquid hand-washing soaps sold in the United States. Triclosan has been used ubiquitously since the 1960s and can be found in some toothpaste and embedded in products such as cutting boards and baby diapers. Triclosan also is known to remain in treated sewage that is recycled for use in agriculture, according to Dr. Aiello, an epidemiologist at the University of Michigan, Ann Arbor.

In 2000, Dr. Aiello and her coinvestigators provided 238 households with either antibacterial products (floor cleaner with 0.08% BZK, surface cleaner with 2.7% BZK, and liquid hand-washing soap with 0.2% triclosan) or the same products without antibacterial ingredients. They cultured the hands of household members before the study started and then after 1 year. Isolates of bacteria from the cultures were tested to determine the minimum inhibitory concentrations (MICs) of BZK and triclosan on which bacteria can grow.

The investigators defined MICs that were above the median for each biocide as "high" and those equal to or less than the median as "low." The investigators analyzed the general trends and changes over time in all bacterial species combined because they could not compare the same isolates at baseline and at the end of 1 year.

In isolates from all bacterial species combined, there were no differences between the groups in susceptibility to BZK at baseline or 1 year.

Dr. Aiello and her colleagues then analyzed isolates of bacteria from all species with a high MIC for BZK. At baseline, these isolates from either group of households had similar rates of antibiotic resistance or high MICs for triclosan. But, after 1 year, the isolates that came from households using antibacterial cleaning products had more than twice the odds of developing a high MIC for triclosan than did isolates from households that did not use products with antibacterial ingredients. At 1 year, isolates from households that used antibacterial products also had more than double the likelihood of developing resistance to antibiotics. A subanalysis showed that gram-negative bacterial isolates from households using antibacterial products had nearly fourfold higher odds of developing antibiotic resistance, compared with gram-negative isolates from households that did not use products with antibacterial ingredients.

"Potential selective pressure may result in coselection of resistance genes for other biocides and antibiotics," she concluded.

Dr. Aiello and her associates tested all gram-negative bacteria against gentamicin, imipenem, and ciprofloxacin. Certain bacterial species were tested against other types of antibiotics.

No covariates—such as use of a product before enrollment, child day care attendance, or antibiotic use—were associated with susceptibility to BZK or with households that used products containing antibacterial ingredients.

Dr. Aiello had no conflicts of interest to disclose.

BETHESDA, MD. — Use of household cleaning products that contain benzalkonium chloride may decrease the susceptibility of bacteria to other antimicrobial ingredients in cleaning products and increase their resistance to antibiotics, according to the results of a randomized, double-blind study.

The study is the first randomized intervention study to assess the relationship between the use of two biocidal ingredients found in household cleaning products—benzalkonium chloride (BZK) and triclosan—and antibiotic resistance in the household setting, Allison E. Aiello, Ph.D., reported at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

Consumer antiseptics and disinfectants are products that can prevent infections by killing or inhibiting the growth of microorganisms. Biocidal ingredients in these products often are quaternary ammonium compounds (such as BZK) and triclosan.

Some studies have found triclosan in more than 75% of liquid hand-washing soaps sold in the United States. Triclosan has been used ubiquitously since the 1960s and can be found in some toothpaste and embedded in products such as cutting boards and baby diapers. Triclosan also is known to remain in treated sewage that is recycled for use in agriculture, according to Dr. Aiello, an epidemiologist at the University of Michigan, Ann Arbor.

In 2000, Dr. Aiello and her coinvestigators provided 238 households with either antibacterial products (floor cleaner with 0.08% BZK, surface cleaner with 2.7% BZK, and liquid hand-washing soap with 0.2% triclosan) or the same products without antibacterial ingredients. They cultured the hands of household members before the study started and then after 1 year. Isolates of bacteria from the cultures were tested to determine the minimum inhibitory concentrations (MICs) of BZK and triclosan on which bacteria can grow.

The investigators defined MICs that were above the median for each biocide as "high" and those equal to or less than the median as "low." The investigators analyzed the general trends and changes over time in all bacterial species combined because they could not compare the same isolates at baseline and at the end of 1 year.

In isolates from all bacterial species combined, there were no differences between the groups in susceptibility to BZK at baseline or 1 year.

Dr. Aiello and her colleagues then analyzed isolates of bacteria from all species with a high MIC for BZK. At baseline, these isolates from either group of households had similar rates of antibiotic resistance or high MICs for triclosan. But, after 1 year, the isolates that came from households using antibacterial cleaning products had more than twice the odds of developing a high MIC for triclosan than did isolates from households that did not use products with antibacterial ingredients. At 1 year, isolates from households that used antibacterial products also had more than double the likelihood of developing resistance to antibiotics. A subanalysis showed that gram-negative bacterial isolates from households using antibacterial products had nearly fourfold higher odds of developing antibiotic resistance, compared with gram-negative isolates from households that did not use products with antibacterial ingredients.

"Potential selective pressure may result in coselection of resistance genes for other biocides and antibiotics," she concluded.

Dr. Aiello and her associates tested all gram-negative bacteria against gentamicin, imipenem, and ciprofloxacin. Certain bacterial species were tested against other types of antibiotics.

No covariates—such as use of a product before enrollment, child day care attendance, or antibiotic use—were associated with susceptibility to BZK or with households that used products containing antibacterial ingredients.

Dr. Aiello had no conflicts of interest to disclose.

NATIONAL HARBOR, MD. — Laparoscopic Roux-en-Y gastric bypass appears to rapidly resolve urinary incontinence in morbidly obese women, according to a recent prospective study.

The results of the study reinforce the importance of weight as a modifiable risk factor for urinary incontinence (UI), said Dr. Arthur M. Carlin, research director of the bariatric surgery program at Henry Ford Hospital, Detroit.

Of a total of 470 morbidly obese patients seeking bariatric surgery, UI occurred in 309 (66%), and in most of those, symptoms improved or resolved by 3 months after surgery with as little as 30 pounds of weight loss, Dr. Carlin reported at the annual meeting of the American Society for Metabolic and Bariatric Surgery.

When Dr. Carlin and his coinvestigators conducted their study in 2005-2007, they asked patients to fill out the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) at the initial preoperative visit and at 3 and 12 months after surgery. The ICIQ-SF is a validated, self-administered, one-page questionnaire that assesses UI symptoms and quality of life.

In 58 of the women who underwent laparoscopic Roux-en-Y gastric bypass and completed a follow-up questionnaire, the mean total symptom score on the ICIQ-SF improved significantly from 7.6 at baseline to 3 at 3 months and to 1.8 at 12 months. These 58 women had UI defined by stress (33%), urge (21%), or a mixture of both (46%). The greatest improvement occurred in women with stress UI caused by coughing, sneezing, or physical activity.

UI had resolved in 54% of these women at 3 months and in 64% at 12 months. When improvement was also included, these rates became 84% and 92%, respectively.

NATIONAL HARBOR, MD. — Laparoscopic Roux-en-Y gastric bypass appears to rapidly resolve urinary incontinence in morbidly obese women, according to a recent prospective study.

The results of the study reinforce the importance of weight as a modifiable risk factor for urinary incontinence (UI), said Dr. Arthur M. Carlin, research director of the bariatric surgery program at Henry Ford Hospital, Detroit.

Of a total of 470 morbidly obese patients seeking bariatric surgery, UI occurred in 309 (66%), and in most of those, symptoms improved or resolved by 3 months after surgery with as little as 30 pounds of weight loss, Dr. Carlin reported at the annual meeting of the American Society for Metabolic and Bariatric Surgery.

When Dr. Carlin and his coinvestigators conducted their study in 2005-2007, they asked patients to fill out the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) at the initial preoperative visit and at 3 and 12 months after surgery. The ICIQ-SF is a validated, self-administered, one-page questionnaire that assesses UI symptoms and quality of life.

In 58 of the women who underwent laparoscopic Roux-en-Y gastric bypass and completed a follow-up questionnaire, the mean total symptom score on the ICIQ-SF improved significantly from 7.6 at baseline to 3 at 3 months and to 1.8 at 12 months. These 58 women had UI defined by stress (33%), urge (21%), or a mixture of both (46%). The greatest improvement occurred in women with stress UI caused by coughing, sneezing, or physical activity.

UI had resolved in 54% of these women at 3 months and in 64% at 12 months. When improvement was also included, these rates became 84% and 92%, respectively.

NATIONAL HARBOR, MD. — Laparoscopic Roux-en-Y gastric bypass appears to rapidly resolve urinary incontinence in morbidly obese women, according to a recent prospective study.

The results of the study reinforce the importance of weight as a modifiable risk factor for urinary incontinence (UI), said Dr. Arthur M. Carlin, research director of the bariatric surgery program at Henry Ford Hospital, Detroit.

Of a total of 470 morbidly obese patients seeking bariatric surgery, UI occurred in 309 (66%), and in most of those, symptoms improved or resolved by 3 months after surgery with as little as 30 pounds of weight loss, Dr. Carlin reported at the annual meeting of the American Society for Metabolic and Bariatric Surgery.

When Dr. Carlin and his coinvestigators conducted their study in 2005-2007, they asked patients to fill out the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) at the initial preoperative visit and at 3 and 12 months after surgery. The ICIQ-SF is a validated, self-administered, one-page questionnaire that assesses UI symptoms and quality of life.

In 58 of the women who underwent laparoscopic Roux-en-Y gastric bypass and completed a follow-up questionnaire, the mean total symptom score on the ICIQ-SF improved significantly from 7.6 at baseline to 3 at 3 months and to 1.8 at 12 months. These 58 women had UI defined by stress (33%), urge (21%), or a mixture of both (46%). The greatest improvement occurred in women with stress UI caused by coughing, sneezing, or physical activity.

UI had resolved in 54% of these women at 3 months and in 64% at 12 months. When improvement was also included, these rates became 84% and 92%, respectively.

BETHESDA, MD. — Use of household cleaning products that contain benzalkonium chloride may decrease the susceptibility of bacteria to other antimicrobial ingredients in cleaning products and increase their resistance to antibiotics, according to the results of a randomized, double-blind study.

This is the first randomized intervention study to assess the relationship between two biocidal ingredients found in household cleaning products—benzalkonium chloride (BZK) and triclosan—and antibiotic resistance in the household setting, Allison E. Aiello, Ph.D., reported at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

Consumer antiseptics and disinfectants are products that can prevent infections by killing or inhibiting the growth of microorganisms. Biocidal ingredients in these products often are quaternary ammonium compounds (such as BZK) and triclosan.

Some studies have found triclosan in more than 75% of liquid hand-washing soaps sold in the United States. Triclosan has been used ubiquitously since the 1960s and can be found in some toothpaste and embedded in products such as cutting boards and baby diapers. Triclosan also is known to remain in treated sewage that is recycled for use in agriculture, according to Dr. Aiello of the department of epidemiology at the University of Michigan, Ann Arbor.

In 2000, Dr. Aiello and her coinvestigators provided 238 households with either antibacterial products (floor cleaner with 0.08% BZK, surface cleaner with 2.7% BZK, and liquid hand-washing soap with 0.2% triclosan) or the same products without antibacterial ingredients. They cultured the hands of household members before the study started and then after 1 year. Isolates of bacteria from the cultures were tested to determine the minimum inhibitory concentrations (MICs) of BZK and triclosan on which bacteria can grow.

The investigators defined MICs that were above the median for each biocide as “high” and those equal to or less than the median as “low.” The investigators analyzed the general trends and changes over time in all bacterial species combined because they could not compare the same isolates at baseline and at the end of 1 year.

In isolates from all bacterial species combined, there were no differences between the groups in susceptibility to BZK at baseline or 1 year.

Dr. Aiello and her colleagues then analyzed of isolates of bacteria from all species with a high MIC for BZK. At baseline, these isolates from either group of households had similar rates of antibiotic resistance or high MICs for triclosan. But, after 1 year, the isolates that came from households using antibacterial cleaning products had more than twice the odds of developing a high MIC for triclosan than did isolates from households that did not use products with antibacterial ingredients. At 1 year, isolates from households that used antibacterial products also had more than double the likelihood of developing resistance to antibiotics. A subanalysis showed that gram-negative bacterial isolates from households using antibacterial products had nearly fourfold higher odds of developing antibiotic resistance, compared with gram-negative isolates from households that did not use products with antibacterial ingredients.

“Potential selective pressure may result in coselection of resistance genes for other biocides and antibiotics,” Dr. Aiello concluded.

Dr. Aiello and her associates tested all gram-negative bacteria against gentamicin, imipenem, and cipro-floxacin. Certain bacterial species were tested against other types of antibiotics.

No covariates—such as use of a product before enrollment, child day care attendance, or antibiotic use—were associated with susceptibility to BZK or with households that used products containing antibacterial ingredients. Previous studies have shown that both quaternary ammonium compounds and triclosan can activate efflux pumps in bacteria that transfer plasmids containing resistance genes.

The specific mechanisms of action of quaternary ammonium chlorides are unclear, but they are thought to cause generalized membrane damage. Triclosan is known to act on enoyl-acyl carrier protein reductase, called Fab1. Specific mutations in the DNA coding for this protein are known to create cross-resistance to the experimental antibiotic diazaborine and the tuberculosis drug isoniazid, said Dr. Aiello, who had no conflicts of interest to disclose.

BETHESDA, MD. — Use of household cleaning products that contain benzalkonium chloride may decrease the susceptibility of bacteria to other antimicrobial ingredients in cleaning products and increase their resistance to antibiotics, according to the results of a randomized, double-blind study.

This is the first randomized intervention study to assess the relationship between two biocidal ingredients found in household cleaning products—benzalkonium chloride (BZK) and triclosan—and antibiotic resistance in the household setting, Allison E. Aiello, Ph.D., reported at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

Consumer antiseptics and disinfectants are products that can prevent infections by killing or inhibiting the growth of microorganisms. Biocidal ingredients in these products often are quaternary ammonium compounds (such as BZK) and triclosan.

Some studies have found triclosan in more than 75% of liquid hand-washing soaps sold in the United States. Triclosan has been used ubiquitously since the 1960s and can be found in some toothpaste and embedded in products such as cutting boards and baby diapers. Triclosan also is known to remain in treated sewage that is recycled for use in agriculture, according to Dr. Aiello of the department of epidemiology at the University of Michigan, Ann Arbor.

In 2000, Dr. Aiello and her coinvestigators provided 238 households with either antibacterial products (floor cleaner with 0.08% BZK, surface cleaner with 2.7% BZK, and liquid hand-washing soap with 0.2% triclosan) or the same products without antibacterial ingredients. They cultured the hands of household members before the study started and then after 1 year. Isolates of bacteria from the cultures were tested to determine the minimum inhibitory concentrations (MICs) of BZK and triclosan on which bacteria can grow.

The investigators defined MICs that were above the median for each biocide as “high” and those equal to or less than the median as “low.” The investigators analyzed the general trends and changes over time in all bacterial species combined because they could not compare the same isolates at baseline and at the end of 1 year.

In isolates from all bacterial species combined, there were no differences between the groups in susceptibility to BZK at baseline or 1 year.

Dr. Aiello and her colleagues then analyzed of isolates of bacteria from all species with a high MIC for BZK. At baseline, these isolates from either group of households had similar rates of antibiotic resistance or high MICs for triclosan. But, after 1 year, the isolates that came from households using antibacterial cleaning products had more than twice the odds of developing a high MIC for triclosan than did isolates from households that did not use products with antibacterial ingredients. At 1 year, isolates from households that used antibacterial products also had more than double the likelihood of developing resistance to antibiotics. A subanalysis showed that gram-negative bacterial isolates from households using antibacterial products had nearly fourfold higher odds of developing antibiotic resistance, compared with gram-negative isolates from households that did not use products with antibacterial ingredients.

“Potential selective pressure may result in coselection of resistance genes for other biocides and antibiotics,” Dr. Aiello concluded.

Dr. Aiello and her associates tested all gram-negative bacteria against gentamicin, imipenem, and cipro-floxacin. Certain bacterial species were tested against other types of antibiotics.

No covariates—such as use of a product before enrollment, child day care attendance, or antibiotic use—were associated with susceptibility to BZK or with households that used products containing antibacterial ingredients. Previous studies have shown that both quaternary ammonium compounds and triclosan can activate efflux pumps in bacteria that transfer plasmids containing resistance genes.

The specific mechanisms of action of quaternary ammonium chlorides are unclear, but they are thought to cause generalized membrane damage. Triclosan is known to act on enoyl-acyl carrier protein reductase, called Fab1. Specific mutations in the DNA coding for this protein are known to create cross-resistance to the experimental antibiotic diazaborine and the tuberculosis drug isoniazid, said Dr. Aiello, who had no conflicts of interest to disclose.

BETHESDA, MD. — Use of household cleaning products that contain benzalkonium chloride may decrease the susceptibility of bacteria to other antimicrobial ingredients in cleaning products and increase their resistance to antibiotics, according to the results of a randomized, double-blind study.

This is the first randomized intervention study to assess the relationship between two biocidal ingredients found in household cleaning products—benzalkonium chloride (BZK) and triclosan—and antibiotic resistance in the household setting, Allison E. Aiello, Ph.D., reported at an annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

Consumer antiseptics and disinfectants are products that can prevent infections by killing or inhibiting the growth of microorganisms. Biocidal ingredients in these products often are quaternary ammonium compounds (such as BZK) and triclosan.

Some studies have found triclosan in more than 75% of liquid hand-washing soaps sold in the United States. Triclosan has been used ubiquitously since the 1960s and can be found in some toothpaste and embedded in products such as cutting boards and baby diapers. Triclosan also is known to remain in treated sewage that is recycled for use in agriculture, according to Dr. Aiello of the department of epidemiology at the University of Michigan, Ann Arbor.

In 2000, Dr. Aiello and her coinvestigators provided 238 households with either antibacterial products (floor cleaner with 0.08% BZK, surface cleaner with 2.7% BZK, and liquid hand-washing soap with 0.2% triclosan) or the same products without antibacterial ingredients. They cultured the hands of household members before the study started and then after 1 year. Isolates of bacteria from the cultures were tested to determine the minimum inhibitory concentrations (MICs) of BZK and triclosan on which bacteria can grow.

The investigators defined MICs that were above the median for each biocide as “high” and those equal to or less than the median as “low.” The investigators analyzed the general trends and changes over time in all bacterial species combined because they could not compare the same isolates at baseline and at the end of 1 year.

In isolates from all bacterial species combined, there were no differences between the groups in susceptibility to BZK at baseline or 1 year.

Dr. Aiello and her colleagues then analyzed of isolates of bacteria from all species with a high MIC for BZK. At baseline, these isolates from either group of households had similar rates of antibiotic resistance or high MICs for triclosan. But, after 1 year, the isolates that came from households using antibacterial cleaning products had more than twice the odds of developing a high MIC for triclosan than did isolates from households that did not use products with antibacterial ingredients. At 1 year, isolates from households that used antibacterial products also had more than double the likelihood of developing resistance to antibiotics. A subanalysis showed that gram-negative bacterial isolates from households using antibacterial products had nearly fourfold higher odds of developing antibiotic resistance, compared with gram-negative isolates from households that did not use products with antibacterial ingredients.

“Potential selective pressure may result in coselection of resistance genes for other biocides and antibiotics,” Dr. Aiello concluded.

Dr. Aiello and her associates tested all gram-negative bacteria against gentamicin, imipenem, and cipro-floxacin. Certain bacterial species were tested against other types of antibiotics.

No covariates—such as use of a product before enrollment, child day care attendance, or antibiotic use—were associated with susceptibility to BZK or with households that used products containing antibacterial ingredients. Previous studies have shown that both quaternary ammonium compounds and triclosan can activate efflux pumps in bacteria that transfer plasmids containing resistance genes.

The specific mechanisms of action of quaternary ammonium chlorides are unclear, but they are thought to cause generalized membrane damage. Triclosan is known to act on enoyl-acyl carrier protein reductase, called Fab1. Specific mutations in the DNA coding for this protein are known to create cross-resistance to the experimental antibiotic diazaborine and the tuberculosis drug isoniazid, said Dr. Aiello, who had no conflicts of interest to disclose.