RESUMO
Procalcitonin (PCT)-guided antibiotic stewardship is a successful strategy to decrease antibiotic use. We assessed if clinical judgement affected compliance with a PCT-algorithm for antibiotic prescribing in a multicenter surveillance of patients with lower respiratory tract infections (LRTI). Initiation and duration of antibiotic therapy, adherence to a PCT algorithm and outcome were monitored in consecutive adults with LRTI who were enrolled in a prospective observational quality control. We correlated initial clinical judgment of the treating physician with algorithm compliance and assessed the influence of PCT on the final decision to initiate antibiotic therapy. PCT levels correlated with physicians' estimates of the likelihood of bacterial infection (p for trend <0.02). PCT influenced the post-test probability of antibiotic initiation with a greater effect in patients with non-pneumonia LRTI (e.g., for bronchitis: -23 % if PCT ≤ 0.25 µg/L and +31 % if PCT > 0.25 µg/L), in European centers (e.g., in France -22 % if PCT ≤ 0.25 µg/L and +13 % if PCT > 0.25 µg/L) and in centers, which had previous experience with the PCT-algorithm (-16 % if PCT ≤ 0.25 µg/L and +19 % if PCT > 0.25 µg/L). Algorithm non-compliance, i.e. antibiotic prescribing despite low PCT-levels, was independently predicted by the likelihood of a bacterial infection as judged by the treating physician. Compliance was significantly associated with identification of a bacterial etiology (p = 0.01). Compliance with PCT-guided antibiotic stewardship was affected by geographically and culturally-influenced subjective clinical judgment. Initiation of antibiotic therapy was altered by PCT levels. Differential compliance with antibiotic stewardship efforts contributes to geographical differences in antibiotic prescribing habits and potentially influences antibiotic resistance rates.
Assuntos
Antibacterianos/uso terapêutico , Infecções Bacterianas/diagnóstico , Infecções Bacterianas/tratamento farmacológico , Calcitonina/sangue , Uso de Medicamentos/normas , Precursores de Proteínas/sangue , Infecções Respiratórias/tratamento farmacológico , Infecções Respiratórias/patologia , Infecções Bacterianas/patologia , Peptídeo Relacionado com Gene de Calcitonina , Farmacorresistência Bacteriana , França , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Estudos Prospectivos , Infecções Respiratórias/diagnósticoRESUMO
BACKGROUND: The role of drainage, intrapleural fibrinolytics, and/or surgery in the management of thoracic empyema is controversial. OBJECTIVES: We aimed to investigate the operational practice of empyema management at our hospital. METHODS: Between January 2001 and December 2008, all patients with thoracic empyema were retrieved. After exclusion of patients with malignant effusion, traumatic or iatrogenic empyema, and a history of pleurodesis or tuberculosis, we compared the characteristics of medically versus surgically treated empyema patients. RESULTS: Seventy-eight of 215 retrieved patients were acute bacterial empyema cases. All received intravenous antibiotics. Fifty-eight (74.4%) initially received tube thoracostomy, 34 (43.6%) were treated with intrapleural urokinase, and 30 (38.5%) were operated on. Of 20 patients without initial tube thoracostomy, 15 (75%) were operated on, compared to 9 (37.5%) who were initially treated by tube thoracostomy without intrapleural fibrinolytics (OR 5; 95% CI 1.4-18.5, p = 0.01) and 6 (17.7%) who were initially treated with tube thoracostomy and intrapleural urokinase (OR 14; 95% CI 3.6-53.6, p < 0.001). The surgery patients were not different in demographic and clinical characteristics but were more likely to describe significant chest pain 12 months after discharge. CONCLUSIONS: In this retrospective cohort study of thoracic empyema patients, initial chest tube insertion and intrapleural fibrinolytics were associated with less surgical therapy. Other predictors of the need for surgery could not be identified. Surgery patients were more likely to suffer from residual chest pain 12 months after discharge. Initial treatment with IV antibiotics, chest tube, and intrapleural fibrinolytics was successful in the majority of patients.
Assuntos
Antibacterianos/uso terapêutico , Empiema Pleural/tratamento farmacológico , Empiema Pleural/cirurgia , Idoso , Dor no Peito/etiologia , Empiema Pleural/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Suíça/epidemiologia , Toracotomia/efeitos adversosRESUMO
BACKGROUND AND AIMS: High-frequency miniprobes (HFPs) and conventional radial endoscopic ultrasonography (crEUS) are considered valuable tools in the staging of early Barrett's cancer. However, there is some controversy on whether HFPs are superior in the T staging of Barrett's cancer or whether the same level of accuracy can be achieved by the sole use of crEUS. PATIENTS AND METHODS: Patients referred for endoscopic treatment for Barrett's cancer were included in this prospective crossover trial and were randomly assigned to either HFPs or crEUS as the initial diagnostic method. Afterwards, all of the patients were re-examined with the alternative procedure. The staging results obtained with each method were documented prospectively. RESULTS: A total of 43 patients (median age 66 years [interquartile range: 58 - 73]; 34-male) were included. A total of 23 mucosal and 16 submucosal Barrett's cancers were confirmed at histology. Histological confirmation was not possible in four patients. Assessment of the T category was not possible with HFPs in 7 % of patients, compared with 33 % with crEUS ( P < 0.0001) due to positioning problems. T category was correctly assessed with HFP in 64 % of patients and with crEUS in 49 %. CONCLUSIONS: HFPs are significantly superior to crEUS for local staging of Barrett's cancer. However, the accuracy of assessment of the T category was unsatisfactory with both techniques.
Assuntos
Esôfago de Barrett/diagnóstico por imagem , Endossonografia/métodos , Miniaturização/instrumentação , Idoso , Estudos Cross-Over , Diagnóstico Diferencial , Desenho de Equipamento , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos TestesRESUMO
BACKGROUND AND STUDY AIM: Endoscopic ultrasound (EUS) has been regarded as the most accurate staging tool in esophageal cancer. Staging results have a strong impact on the decision as to whether a patient should undergo endoscopic treatment, surgery alone, or neoadjuvant therapy. This retrospective study was conducted to analyze the accuracy of esophageal cancer staging using EUS. METHODS: All patients who received EUS for staging of esophageal cancer before esophagectomy from February 2003 to December 2007 at a high volume academic tertiary care center were included. RESULTS: 179 consecutive patients (mean age 64.4 +/- 9.5 years; 142 men) underwent esophageal resection for Barrett's adenocarcinoma (n = 134) and squamous cell cancer (n = 45). Postoperatively, 99 patients were staged as having T1 cancers (55 %), 30 patients T2 (17%), 46 patients T3 (26%), and four patients T4 (2%). The sensitivity and specificity of EUS relative to the T stage were 82% and 91%, respectively, for T1; 43% and 85% for T2; and 83% and 86% for T3. The overall accuracy for EUS in identifying the correct T stage was 74% (95%CI 66-80). Positive lymph nodes were diagnosed histologically in 68 patients (38%). The sensitivity, specificity and accuracy of EUS for the diagnosis of N1 were 71%, 74% and 73% (95%CI 65-79), respectively. CONCLUSIONS: The diagnostic accuracy of EUS in patients with esophageal cancer is still unsatisfactory. T2 cancers in particular are frequently overstaged, with a significant effect on the subsequent treatment strategy.
Assuntos
Adenocarcinoma/diagnóstico por imagem , Esôfago de Barrett/diagnóstico por imagem , Carcinoma de Células Escamosas/diagnóstico por imagem , Endossonografia , Neoplasias Esofágicas/diagnóstico por imagem , Adenocarcinoma/etiologia , Adenocarcinoma/cirurgia , Idoso , Esôfago de Barrett/complicações , Esôfago de Barrett/cirurgia , Carcinoma de Células Escamosas/cirurgia , Neoplasias Esofágicas/cirurgia , Esofagectomia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias/métodos , Cuidados Pré-Operatórios , Reprodutibilidade dos Testes , Estudos Retrospectivos , Sensibilidade e EspecificidadeRESUMO
All published evidence on procalcitonin (PCT)-guided antibiotic therapy was obtained in trials where physicians knew that they were being monitored, possibly resulting in higher adherence to the PCT algorithm. This study investigates the effectiveness of PCT guidance in an observational quality control survey. We monitored antibiotic therapy and algorithm adherence in consecutive patients with respiratory tract infections admitted to the Kantonsspital Aarau, Switzerland, between May 2008 and February 2009. The results were compared to the site-specific results of the former ProHOSP study. Overall and more pronounced for patients with community-acquired pneumonia, the median duration of antibiotic treatment in this survey was shorter than the ProHOSP control patients (6 vs. 7 days, P = 0.048 and 7 vs. 9 days, P < 0.001). In 72.5% of patients, antibiotics were administered according to the prespecified PCT algorithm. No significant differences concerning adverse medical outcome could be detected. This study mirrors the use of PCT-guided antibiotic therapy in clinical practice, outside of trial conditions. If algorithm adherence is reinforced, antibiotic exposure can be markedly reduced with subsequent reduction of antibiotic-associated side effects and antibiotic resistance. The integration of the PCT algorithm into daily practice requires ongoing reinforcement and involves a learning process of the prescribing physicians.
Assuntos
Algoritmos , Antibacterianos/administração & dosagem , Calcitonina/administração & dosagem , Tratamento Farmacológico/normas , Fidelidade a Diretrizes , Precursores de Proteínas/administração & dosagem , Infecções Respiratórias/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/efeitos adversos , Calcitonina/efeitos adversos , Peptídeo Relacionado com Gene de Calcitonina , Infecções Comunitárias Adquiridas/tratamento farmacológico , Tratamento Farmacológico/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia Bacteriana/tratamento farmacológico , Estudos Prospectivos , Precursores de Proteínas/efeitos adversos , Infecções Respiratórias/microbiologia , Estatísticas não Paramétricas , Resultado do TratamentoRESUMO
BACKGROUND: Current medical scores have limited efficiency and safety profiles to enable assignment to the most appropriate treatment site in patients with lower respiratory tract infections (LRTIs). We describe our current triage practice and assess the potential of a combination of CURB65 with proadrenomedullin (ProADM) levels for triage decisions. METHODS: Consecutive patients with LRTIs presenting to our emergency department were prospectively followed and retrospectively classified according to CURB65 and ProADM levels (CURB65-A). Low medical risk patients were further subgrouped according to biopsychosocial and functional risks. We compared the proportion of patients virtually allocated to triage sites with actual triage decisions and assessed the added impact of ProADM in a subgroup. RESULTS: Overall, 93% of 146 patients were hospitalised. Among the 138 patients with available CURB65-A, 17.4% had a low medical risk indicating possible treatment in an outpatient or non-acute medical setting; 34.1% had an intermediate medical risk (short-hospitalisation); and 48.6% had a high medical risk (hospitalisation). Fewer patients were in a low CURB65-A class (I) than a low CURB65 class (0,1) (17.4% vs. 46.3%, p <0.001). Mean length of hospitalisation was 9.8 days including 3.6 days after reaching medical stability. In 60.3% of patients, hospitalisation was prolonged after medical stability mainly for medical reasons. CONCLUSIONS: Current rates of hospitalisation are high in patients with LRTI and length of stay frequently extended beyond time of medical stabilization. The lower proportion of patients reclassified as low risk by adding ProADM to the CURB65 score might improve confidence in the triage algorithm.