Journal of hospital medicine : an official publication of the Society of Hospital Medicine
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Shortening the duration of antimicrobial therapy is an important strategy for optimizing patient care and reducing the spread of antimicrobial resistance. It is best used in the context of an overall approach to infection management that includes a focus on selecting the right initial drug and dosing regimen for empiric therapy, and de-escalation to a more narrowly focused drug regimen (or termination) based on subsequent culture results and clinical data. In addition to reducing resistance, other potential benefits of shorter antimicrobial courses include lowered antimicrobial costs, reduced risk of superinfections (including Clostridium difficile-associated diarrhea), reduced risk of antimicrobial-related organ toxicity, and improved drug compliance. ⋯ Professional organizations have compiled these data and used them to develop clinical practice guidelines to aid clinicians in choosing optimal treatment durations for individual patients. Many patients with hospital-acquired pneumonia, ventilator-associated pneumonia, or healthcare-associated pneumonia can be treated for 7-8 days, while 4-7 days and 14-day treatment durations may suffice for many patients with complicated intra-abdominal infections and uncomplicated CRBSI, respectively. This article first provides a general background on the rationale and data supporting shortened courses of antimicrobial therapy, before using 3 case studies to explore the practical implications of current knowledge and treatment guidelines when making decisions about treatment duration for individual patients with healthcare-associated pneumonia, complicated intra-abdominal infection, and CRBSI.
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Review
Infections, bacterial resistance, and antimicrobial stewardship: the emerging role of hospitalists.
The care of patients with serious infections both within and outside healthcare settings is increasingly complicated by the high prevalence of resistant or multidrug-resistant (MDR) pathogens. Moreover, infections caused by MDR versus susceptible bacteria or other pathogens are associated with significantly higher mortality, length of hospital stay, and healthcare costs. Antimicrobial misuse or overuse is the primary driver for development of antimicrobial resistance, suggesting that better use of antimicrobials will translate into improved patient outcomes, more efficient use of hospital resources, and lowered healthcare costs. ⋯ Hospitalists are increasingly involved in the care of hospitalized patients throughout the United States. Expertise in managing conditions requiring hospitalization, and experience in quality improvement across a wide range of clinical conditions, make hospitalists well positioned to participate in the development and implementation of hospital-based antimicrobial stewardship programs designed to improve patient outcomes, reduce antimicrobial resistance, and provide more efficient and lower-cost hospital care. Journal of Hospital Medicine 2012;7:S34-S43. © 2012 Society of Hospital Medicine.
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Comparative Study Observational Study
Comparing the pulmonary embolism severity index and the prognosis in pulmonary embolism scores as risk stratification tools.
Multiple risk stratification scoring systems exist to forecast outcomes in patients with acute pulmonary embolism (PE). ⋯ The PREP score performed comparably to the PESI score for identifying PE patients at low risk for short-term and intermediate-term mortality.
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Transferring complex patients between settings can be fraught with poor communication and adverse outcomes, yet few medical students nationwide are trained in specific skills to improve care transitions. ⋯ This curriculum showed that students could acquire the needed skills to prepare quality discharge summaries and communicate well with patients at discharge, as well as improve their overall knowledge surrounding care transitions.
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No study has assessed the ability of pneumonia severity scores to identify the risk for early intensive care unit (ICU) transfer in patients with community-acquired pneumonia (CAP) admitted to general wards (GW). We aimed to compare the ability of CURB-65 (confusion, urea level, respiratory rate, blood pressure, and age ≥65 years) and SMRT-CO (systolic blood pressure, multilobar chest radiography involvement, respiratory rate, tachycardia, confusion, and oxygenation) scores to predict early ICU transfers in these patients. ⋯ Composite SMRT-CO had a better combination of sensitivity and specificity than CURB-65 for predicting early ICU transfers. Prospective studies to confirm our findings are needed.