Infections in open heart surgery.

More than 250,000 open heart surgical procedures are performed annually in the United States. The majority of these procedures are coronary artery bypass grafts (CABG) and valve replacements. In this forum our authors discuss the kinds of infections that occur in patients following open heart surgery, as well as the documented risk factors and microbiology of these infections. We also asked each author to outline the criteria used to diagnose post open heart surgery infections, and to address associated consequences and complications. Finally, we were interested in each author's definition of the infection control practitioner's role in the prevention of this particular subset of nosocomial infections.

Improving compliance with preventive medicine procedures in a house staff training program.

Performance of health maintenance procedures by internal medicine house staff is inadequate, yet little has been published outlining means to improve performance rates. We prospectively studied the effectiveness of a reminder system to improve screening by Pap smear, rectal examination with stool guaiac test, breast examination, and pneumococcal vaccine administration in two resident outpatient clinics. Performance of these preventive health measures was determined during a six-week baseline period and again after five months of chart reminders to residents in one clinic, and after six months without reminders. For the intervention, a physician's assistant screened each chart and attached a reminder to the front indicating which procedures were overdue based on published recommendations. Health screening behavior was not significantly different between the two resident clinics during baseline. After the five-month reminder intervention, residents in both groups moderately increased their preventive health activities over baseline; however, only the reminded group showed significant improvement (chi 2 = 11.60, P less than .001). Six months after remainders were discontinued there was no difference in overall performance between the two clinics (chi 2 = 2.79, NS). The reminded group did preserve its significant improvement over the baseline phase (chi 2 = 6.12, P less than .01). This simple reminder system had a modest but statistically significant positive impact on health screening behavior. Despite this improvement, absolute rates of screening remained below 50% in both clinics.

Patient-initiated postmarketing surveillance: a validation study.

A new patient-initiated, pharmacy-based postmarketing surveillance system is described. At the time a new prescription for a targeted drug was filled, 2705 outpatients (experimentals) randomly assigned to the new system had a printed notice attached to their medication bags: the information requested them to report any "new or unusual symptoms" during the next 2 weeks by a toll-free telephone number to a trained nonprofessional who conducted a standardized adverse drug reaction (ADR) interview. To help validate the new system, another sample of 1109 patients (controls) did not receive a request for self-monitoring but were interviewed by telephone 2 weeks later. Target drugs were chosen from two classes for which side effect profiles are well identified: oral antibiotics and tricyclic antidepressants. Results show that within both drug classes, all patient-initiated reports closely matched those obtained from controls; the experimental and control groups also reported predictably high relative frequencies for the most commonly expected ADRs. Additional analyses suggest that a patient-initiated monitoring system could prove to be a promising complement to existing physician-based surveillance systems.

Long-term versus short-term amitriptyline side effects as measured by a postmarketing surveillance system.

As part of a large-scale postmarketing surveillance study, the adverse clinical events (ACEs) reported by 85 outpatients taking amitriptyline were investigated. Two discrete groups of patients were identified based on their duration of amitriptyline treatment: 45 had started the drug within 2 weeks of their interview (mean = 10.1 days, SD = 1.6 days), while 40 were much longer term tricyclic antidepressant patients (mean = 227.2 days, SD = 135 days). Our analysis of amitriptyline side effects reported by each of these two discrete groups challenges the common clinical impression that tricyclic side effects, in general, abate with continued treatment. Shorter term patients were much better able to correctly attribute their adverse clinical events to their drug therapy. Anticholinergic side effects were reported as new symptoms by the long-term patients just as frequently with similar ratings of subjective severity. These reports of adverse drug reactions of recent onset by long-term amitriptyline users may reflect the fact that such symptoms fluctuate in their occurrence and may not be recognized as potentially drug-induced until some threshold for patient tolerance is exceeded.

Increased frequency of doxycycline side effects.

As part of a study investigating new methods of detecting adverse drug reactions, adult outpatients receiving new prescriptions for 1 of 4 antibiotics (doxycycline, penicillin VK, ampicillin, or tetracycline) were assigned to 1 of 2 methods of monitoring adverse drug reactions. Data were collected from a total of 457 staff-initiated interviews and from 1467 patients who were asked to telephone to report possible adverse effects. Doxycycline is considered by authoritative sources to be generally comparable in side effects to other tetracyclines and penicillins, with the exception that it increases photosensitivity. Results from both monitoring methods consistently indicated at least a 3-fold higher frequency of nausea or vomiting with doxycycline relative to the other antibiotics. Complaints of skin rash also were at least 4 times more frequent with doxycycline, depending on the particular sample.

New approaches to postmarketing surveillance.

As part of a large-scale ongoing project exploring new pharmacy-based methods of postmarketing surveillance, we are comparing a patient-initiated monitoring system to a staff-initiated approach. Here we report data only from staff-initiated, computer-directed telephone interviews with 231 outpatients approximately 2 weeks after they had been prescribed a target drug chosen from two markedly different pharmacological classes for which adverse drug reactions (ADRs) are well-documented. Our results indicate that spontaneous patient reports of "new or unusual symptoms" obtained from a standardized staff-initiated telephone interview can be quite reliable, leading to accurate detection of known tricyclic antidepressant and antibiotic ADRs.

Inhibition of protein synthesis and lymphokine production by tetracycline.

This study was designed to examine the effects of tetracycline on DNA and protein synthesis by human lymphocytes treated with Con A. The effects of the drug were also assessed in terms of the in vitro production of the lymphokine, migration inhibitory factor (MIF). The results indicate that marked suppression of protein synthesis occurred in presence of tetracycline at all concentrations including clinically achievable doses. The group mean values of DNA synthesis did not show significant inhibition with lower concentrations of the drug. The marked decline in protein synthesis in tetracycline treated cultures was accompanied by a significant suppression of MIF production. Accelerated migration of macrophages was observed when the lymphocyte supernatant was produced in presence of the higher concentrations of tetracycline (75-100 microliter/ml). These observations suggest that tetracycline interfered with the in vitro correlates of cellular immunity in humans. This raises a possibility that indiscriminate use of the drug might compromise host defenses especially where long-term therapy is prescribed.

Suppression of the production of migration inhibitory factor in humans by tetracycline.

The role of Tc in the suppression of immunity has not been widely evaluated although this antibiotic is often prescribed as a long-term therapy [1]. Sporadic reports have indicated that Tc suppresses cellular immunity [2]. However, no data are available concerning the effects of Tc on lymphokine production, especially in human subjects. Peripheral blood mononuclear cells (2 X 10(6)/ml) were obtained from seven normal volunteers and pulsed with 150 micrograms of con A/ml of medium for 3 hr at 37 C. The procedure was carried out in the presence or absence of Tc in RPMI medium under an atmosphere of 5% CO2. The cells were then pelleted, washed, and resuspended in RPMI medium with or without similar concentrations of Tc. Following incubation for 48 hr, the cells were removed and the supernatant was assayed for MIF activities with the use of guinea pig peritoneal macrophages as indicator cells. A change of greater than or equal to 20% in migration was considered significant [3]. Remarkable inhibition of MIF production was noted in cells obtained from five of seven volunteers in the presence of 3 micrograms and 100 micrograms of Tc/ml. ConA-induced inhibition of migration was almost abolished in cell cultures in the presence of 3 micrograms of Tc/ml. Negative inhibition (accelerated migration) was observed in the presence of 100 micrograms of Tc/ml. Macrophage migration in the presence of 100 micrograms of Tc/ml was greater than the migration of control cells. Thus, it appeared that Tc not only interfered with MIF production but also modulated factors involved in the control of normal cell migration.(ABSTRACT TRUNCATED AT 250 WORDS)