Limited data exist on recent demographic and microbiological changes in infective endocarditis (IE) and the impact of these changes on patient survival. Therefore, Cabell et al sought to identify changes in demographic and microbiological characteristics in patients with endocarditis and to determine relationships between changing characteristics and survival. Data were collected from all patients with definite or possible IE at Duke University Medical Center from 1993 to 1999. Among the 329 study patients, rates of hemodialysis dependence, immune suppression, and Staphylococcus aureus infection increased during the study period, while rates of infection due to viridans group streptococci decreased. Patients with S aureus IE had a higher 1-year mortality rate (43.9% vs 32.5%) that persisted after adjustment for other illness severity characteristics. In this study, Cabell et al found that the demographic and microbiological characteristics of IE at their institution have changed over the past decade in ways that suggest a link between medical practice and IE characteristics. S aureus has emerged as a dominant cause of IE and is an independent predictor of mortality. These findings identify clinical settings that may warrant closer surveillance and more aggressive measures in the identification and prevention of endocarditis.
Changing characteristics from 1993 to 1999 of 329 patients with infective endocarditis.
Nine randomized controlled trials with 10 treatment arms and 504 patients were included. Seven treatment arms included patients with major depression. Two continuous outcomes (change in back pain severity and ability to perform activities of daily living) were measured. Patients treated with antidepressants were more likely to improve pain severity than those treated with placebo (standardized mean difference, 0.41; 95% confidence interval, 0.22-0.61) but not in activities of daily living (standardized mean difference, 0.24; 95% confidence interval, 0.21-0.69). Patients treated with antidepressants experienced greater adverse effects (22% vs 15%, P = .01). Antidepressants are more effective than placebo in reducing pain severity but not functional status in patients with chronic back pain.
There are no data to support the routine use of supplemental oxygen in patients who have an ischemic stroke. More recently, supplemental oxygen has been suggested to be potentially detrimental. The authors of this study evaluated the extent of oxygen use in ischemic stroke and whether patients receiving oxygen had indications for its use. Using a literature-based list of criteria for supplemental oxygen use, only 45.6% of inpatient days that patients were receiving oxygen were justified in an ischemic stroke population. The findings from this study demonstrate that oxygen therapy is commonly given to ischemic stroke patients without clear indication and that opportunities exist for substantial resource conservation.
Trimethoprim-sulfamethoxazole has consistently been the recommended drug of choice for uncomplicated urinary tract infections (UTIs) in women. Using a national survey of practicing physicians from 1989 through 1998, Huang and Stafford examined trends in the antibiotics prescribed for women (aged 18 to 75 years) diagnosed as having an uncomplicated UTI. The authors found that the proportion of trimethoprim-sulfamethoxazole prescriptions declined from 48% in 1989-1990 to 24% in 1997-1998. Conversely, fluoroquinolone use increased (19% to 29%) as did nitrofurantoin prescribing (14% to 30%). In the analysis of predictors of antibiotic choice, the authors found that among primary care physicians, internists were the most likely to prescribe fluoroquinolones, while obstetricians were the most likely to prescribe nitrofurantoin. Current prescribing trends may increase antimicrobial resistance to multiple agents and incur unnecessary health care costs. Further exploration of the reasons for subspecialty variation in UTI may be a crucial first step to improving antibiotic prescribing practices.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2002;162(1):17. doi:10.1001/archinte.162.1.17