All purulence is local - epidemiology and management of skin and soft tissue infections in three urban emergency departments.

BACKGROUND: Skin and soft tissue infection (SSTIs) are commonly treated in emergency departments (EDs). While the precise role of antibiotics in treating SSTIs remains unclear, most SSTI patients receive empiric antibiotics, often targeted toward methicillin-resistant Staphylococcus aureus (MRSA). The goal of this study was to assess the efficiency with which ED clinicians targeted empiric therapy against MRSA, and to identify factors that may allow ED clinicians to safely target antibiotic use. METHODS: We performed a retrospective analysis of patient visits for community-acquired SSTIs to three urban, academic EDs in one northeastern US city during the first quarter of 2010. We examined microbiologic patterns among cultured SSTIs, and relationships between clinical and demographic factors and management of SSTIs. RESULTS: Antibiotics were prescribed to 86.1% of all patients. Though S. aureus (60% MRSA) was the most common pathogen cultured, antibiotic susceptibility differed between adult and pediatric patients. Susceptibility of S. aureus from ED SSTIs differed from published local antibiograms, with greater trimethoprim resistance and less fluoroquinolone resistance than seen in S. aureus from all hospital sources. Empiric antibiotics covered the resultant pathogen in 85.3% of cases, though coverage was frequently broader than necessary. CONCLUSIONS: Though S. aureus remained the predominant pathogen in community-acquired SSTIs, ED clinicians did not accurately target therapy toward the causative pathogen. Incomplete local epidemiologic data may contribute to this degree of discordance. Future efforts should seek to identify when antibiotic use can be narrowed or withheld. Local, disease-specific antibiotic resistance patterns should be publicized with the goal of improving antibiotic stewardship.

Heterogeneity of Treatment Response to Citalopram for Patients With Alzheimer's Disease With Aggression or Agitation: The CitAD Randomized Clinical Trial.

OBJECTIVE: Pharmacological treatments for agitation and aggression in patients with Alzheimer's disease have shown limited efficacy. The authors assessed the heterogeneity of response to citalopram in the Citalopram for Agitation in Alzheimer Disease (CitAD) study to identify individuals who may be helped or harmed. METHOD: In this double-blind parallel-group multicenter trial of 186 patients with Alzheimer's disease and clinically significant agitation, participants were randomly assigned to receive citalopram or placebo for 9 weeks, with the dosage titrated to 30 mg/day over the first 3 weeks. Five planned potential predictors of treatment outcome were assessed, along with six additional predictors. The authors then used a two-stage multivariate method to select the most likely predictors; grouped participants into 10 subgroups by their index scores; and estimated the citalopram treatment effect for each. RESULTS: Five covariates were likely predictors, and treatment effect was heterogeneous across the subgroups. Patients for whom citalopram was more effective were more likely to be outpatients, have the least cognitive impairment, have moderate agitation, and be within the middle age range (76-82 years). Patients for whom placebo was more effective were more likely to be in long-term care, have more severe cognitive impairment, have more severe agitation, and be treated with lorazepam. CONCLUSIONS: Considering several covariates together allowed the identification of responders. Those with moderate agitation and with lower levels of cognitive impairment were more likely to benefit from citalopram, and those with more severe agitation and greater cognitive impairment were at greater risk for adverse responses. Considering the dosages used and the association of citalopram with cardiac QT prolongation, use of this agent to treat agitation may be limited to a subgroup of people with dementia.

Using risperidone for Alzheimer's dementia-associated psychosis.

BACKGROUND: Alzheimer's dementia (AD) occurs in 6 - 8% of persons older than 65 years. The prevalence increases to 30% among those 85 years or older. Among AD patients, the incidence of psychosis is 30 - 50%. Safe and appropriate use of psychotropic agents is a relevant clinical concern for this population. OBJECTIVE: This review addresses risks and potential benefits when risperidone is used for treating AD-associated psychosis. METHODS: Through literature review and clinical experience, the authors discuss the clinical efficacy, safety, and regulatory issues concerning risperidone treatment for this group of patients. CONCLUSION: Despite concerns about safety, risperidone remains a popular therapeutic choice for AD patients with psychosis. Subsets of these patients with more severe agitation and aggression may experience greater behavioral benefit.

Risperidone in the management of psychiatric and neurodegenerative disease in the elderly: an update.

OBJECTIVE: Neuropsychiatric disorders are common among elderly patients in long-term care facilities. Although dementia is most common, schizophrenia and schizoaffective disorder, delusional disorder, bipolar disorder, and Parkinson's disease, as well as other psychiatric and neurodegenerative disorders, can also occur in this population. Our objective was to review the literature pertaining to the safety and efficacy of risperidone in elderly patients, the atypical antipsychotic with the longest history of use in this population. We identified original studies of risperidone in elderly patients through MEDLINE and CURRENT CONTENTS database searches. Additional material was identified via abstracts presented at national and international conferences. Published data from controlled and uncontrolled trials in elderly patients support the efficacy of risperidone in controlling behavioral and psychological symptoms of dementia, as well as treating psychotic symptoms associated with schizophrenia and other disorders with psychotic features. Limited data suggest that risperidone might also be useful for management of patients with delirium and Huntington's disease. Risperidone was well tolerated in the elderly and associated with a low risk of movement disorders and anticholinergic effects. A recent change in the product information described an increased incidence of cerebrovascular events in some elderly and suggests the need for further investigations in this population. There is a substantial published database supporting safe and effective use of risperidone for treatment of psychosis, agitation, and aggression in elderly patients.