Pharmacotherapy
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Review Comparative Study
Problems and dilemmas of antimicrobial resistance.
An important obstacle to the long-term efficacy of an antimicrobial agent is the appearance and spread of resistance to the agent. The fact that many antimicrobials are produced by microorganisms in nature may provide long-term selective pressure for the emergence of resistance in antibiotic-producing as well as -nonproducing organisms. Indeed, the rapidity with which many resistances have appeared after the introduction of a new antibiotic suggests that these resistance genes were already present somewhere in nature prior to clinical use. ⋯ The most important resistances seen in community-acquired organisms include beta-lactam resistance in pneumococci and combined ampicillin and chloramphenicol resistance in Haemophilus influenzae. Shigellae resistant to essentially all commonly used oral agents are also a problem, particularly in developing countries. No end is in sight to the problem of antimicrobial resistance, and thus new strategies to prevent infections and control resistant organisms continue to be necessary.
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This retrospective study was designed to identify and assess which patient-specific factors affect the relationship between the steady-state trough serum quinidine concentration (SQC) measured by fluorescence polarization immunoassay and quinidine dosage. Data were obtained from 100 hospitalized patients (72 males, 28 females) receiving quinidine for atrial or ventricular arrhythmias, or both, between ages 24 and 85 years (mean age 63 yrs). Age, lean body weight, creatinine clearance (ClCr), and sex were statistically significant factors affecting this relationship; ejection fraction, total body weight, smoking history, alcohol history, recent myocardial infarction, recent surgery, elevated liver function tests, and sampling time were not statistically significant. ⋯ Currently in clinical practice, quinidine dosage adjustments are not routinely recommended for patients with renal insufficiency. These data suggest that the calculated ClCr is important in predicting both SQC and dosage when a nonspecific quinidine assay is used. This dosing model must be evaluated prospectively.
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The patient-activated analgesic system was introduced in 1968. Early trials, although uncontrolled, supported the safety and efficacy of patient-controlled analgesia (PCA) in several kinds of pain, such as that relating to surgery, cancer, trauma, and obstetric procedures. In the past decade, prospective, randomized trials have reported several advantages of PCA over conventional analgesia in the early postoperative period. ⋯ The most significant, although infrequent, adverse effect is respiratory depression, the majority of cases occurring in patients predisposed secondary to concomitant illness or as a result of human error. The clinical use of PCA will likely see a significant increase among persons with cancer, and an increase in epidural administration. The cost benefit of PCA has yet to be assessed in inpatient and outpatient settings.
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Infection is responsible for a large percentage of morbidity and mortality in intensive care unit (ICU) patients. Conventional infection-control measures are directed at decreasing infection by exogenous sources and have had variable success in significantly reducing nosocomial infection rates. Selective gastrointestinal decontamination with topical nonabsorbable antibiotics attempts to reduce infection by eliminating intestinal mucosal colonization by pathogenic microorganisms. ⋯ In the majority of clinical trials, selective decontamination effectively reduced colonization and infection among ICU patients, with the most significant reductions observed in gram-negative respiratory infections. Resistance to the antimicrobials was not documented in the majority of trials; however, follow-up periods were minimal and may not have been adequate to detect selection of resistant strains. Reductions in infection do not alter mortality; however, patients without significant underlying disease appear to be the subgroup that will most likely benefit.