In this feature, a panel of IDSA members identifies and critiques important new studies in the current literature that have a significant impact on the practice of infectious diseases medicine.
Click here for the previous edition of Journal Club. For a review of other recent research in the infectious diseases literature, see “In the Literature,” by Stanley Deresinski, MD, FIDSA, in each issue of Clinical Infectious Diseases.
Single-Dose Aminoglycoside Therapy for Urinary Tract Infections
Reviewed by Zeina A. Kanafani, MD, MS, FIDSA
Antibiotic resistance has limited the use of several antibiotics in the management of common infections. Hence, old therapeutic strategies are being re-evaluated. A recent systematic review in Antimicrobial Agents and Chemotherapy examined whether a single dose of a parenteral aminoglycoside is effective and safe in the treatment of urinary tract infection.
The authors used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to conduct the review. They included original research studies where a single-dose of an aminoglycoside was used without other concurrent antibiotic therapy for urinary tract infection with documentation of microbiologic and/or clinical cure.
Out of 252 screened articles, 13 fulfilled the inclusion criteria and represented 13,804 patients. All articles had been published prior to 1992. The duration of patient follow-up was up to 3 years. There was a comparator arm in seven studies. Patient age was wide-ranging, from 2 weeks to 70 years, and several studies were conducted in children only. The most common clinical manifestation was lower urinary tract infection (acute cystitis) with no cases of sepsis or bacteremia.
The most commonly used aminoglycoside was netilmicin, followed by amikacin and gentamicin. All were administered intramuscularly. The most common offending pathogen was E. coli, followed by Proteus and Klebsiella spp. Microbiologic cure rates exceeded 85 percent (overall rate 94.5 percent ± 4.3 percent). Clinical cure, reported in only two studies, was 82.8 percent and 94.7 percent. The 30-day recurrence rate was 19.0 percent, and the sustained microbiologic cure at 30 days was 73.4 percent ± 9.6 percent. Initial and sustained microbiologic cure were less likely to be achieved in patients with anatomic abnormalities. The adverse event rate was 0.5 percent, while it was 3.5 percent across all non-aminoglycoside comparator groups.
A single dose of an intramuscular aminoglycoside appears to be effective and safe in patients with urinary tract infection in the absence of anatomic abnormalities.
(Goodlet et al. Antimicrob Agents Chemother. 2019;63(1):e02165-18.)
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Despite Actual Patient Harm, Inappropriate Antibiotic Prescribing Is Still Highly Prevalent
Reviewed by Nirav Patel, MD
While obvious to many infectious diseases practitioners, the harms from inappropriate antibiotic prescribing are not frequently appreciated by many clinicians. When patients develop a superinfection, such as Clostridium difficile infection (CDI), inappropriate use of antibiotics should be curtailed to reduce further risk to the patient. Whether this occurred or not in clinical practice was explored by investigators at the Veterans Administration Greater Los Angeles Healthcare System in an article recently published in the American Journal of Infection Control.
In this retrospective review, all patients with a new diagnosis of CDI from 2015-2016 were reviewed for appropriateness of antibiotic therapy. Among 140 patients included in the study, 40.6 percent of antibiotic courses were inappropriate prior to the diagnosis of CDI. After the diagnosis, 43.1 percent of antibiotic courses were inappropriate, a statistically insignificant increase. In a multivariate analysis, inappropriate antibiotics were a risk factor for the development of recurrent CDI at a 6.19 odds ratio.
Despite a strong recommendation to discontinue the inciting antibiotic in the most recent guidelines for the management of CDI, these data suggest continued challenges in applying this information to the bedside. As infectious diseases specialists, we need to develop more effective behavior modification strategies for ourselves and for other clinicians to reduce inappropriate antibiotic use and ensure patients do not experience preventable harm.
(Watson and Graber. Am J Infect Control. 2018;46(12):1370-1374.)
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|For a review of other recent research in the infectious diseases literature, see “In the Literature,” by Stanley Deresinski, MD, FIDSA, in each issue of Clinical Infectious Diseases:
- Coronavirus Infection in Hematopoietic Stem Cell Transplant Recipients
- Microbleeds in Infective Endocarditis: A Generally Benign Complication?
- Case Vignette: Streptococcal Gastric Necrosis