Management of medications in the elderly patient is often a major challenge. Advancing age is accompanied by changes in the pharmacokinetics and pharmacodynamics of drugs, often exacerbated by renal ...effects of coexisting diseases. Some of these diseases are diabetes mellitus, congestive heart failure, and hypertension, which can predispose elderly patients to the risk of antibiotic-induced toxicity, especially drugs with a narrow therapeutic index, such as aminoglycosides. Elderly patients are often taking multiple drugs (including prescription drugs, over-the-counter medications, and supplements) that may adversely interact with antibiotics and contribute to a significant increase in the incidence of deleterious reactions. This review of the use of antibiotics in the elderly will concentrate on certain classes of antibiotics that are commonly used in the elderly or that have serious adverse events that are more commonly seen in this population.
The risks of infective endocarditis (IE) associated with various conditions and procedures are poorly defined.
This was a population-based case-control study conducted in 54 Philadelphia, Pa-area ...hospitals from 1988 to 1990. Community-acquired IE cases unassociated with intravenous drug use were compared with matched community residents. Subjects were interviewed for risk factors. Diagnoses were confirmed by expert review of medical record abstracts with risk factor data removed. Cases were more likely than controls to suffer from prior severe kidney disease (adjusted OR 95% CI=16.9 1.5 to 193, P:=0.02) and diabetes mellitus (adjusted OR 95% CI=2.7 1.4 to 5.2, P:=0.004). Cases infected with skin flora had received intravenous fluids more often (adjusted OR 95% CI=6.7 1.1 to 41, P:=0.04) and had more often had a previous skin infection (adjusted OR 95% CI=3.5 0.7 to 17, P:=0.11). No association was seen with pulmonary, gastrointestinal, cardiac, or genitourinary procedures or with surgery. Edentulous patients had a lower risk of IE from dental flora than patients who had teeth but did not floss. Daily flossing was associated with a borderline decreased IE risk.
Within the limits of the available sample size, the data showed that IE patients differ from people without IE with regard to certain important risk factors but not regarding recent procedures.
Summary Objectives We studied the clinical characteristics, in-hospital mortality, and long-term prognosis of patients with culture-negative endocarditis. Methods In total, 221 episodes of definite ...endocarditis were studied (2004–2009). We compared the clinical, laboratory, and echocardiography characteristics and the survival rates of patients with culture-negative and culture-positive endocarditis. Survival after hospital discharge was evaluated using the Kaplan–Meier method and coefficient of mortality comparisons. Results Culture-negative endocarditis occurred in 51/221 (23.1%) episodes. Compared with the culture-positive endocarditis patients, the time elapsed between admission and initiation of antibiotic therapy was longer in patients with culture-negative endocarditis ( p < 0.001), and these patients also had lower C-reactive protein levels at admission ( p < 0.001). In-hospital mortality rates were not different between culture-negative and culture-positive patients. After hospital discharge, there was also no significant difference between groups in survival curves ( p = 0.471). Severe sepsis (adjusted prevalence ratio 3.32, p = 0.010) and diabetes mellitus (adjusted prevalence ratio 2.32, p = 0.009) were independently associated with in-hospital death in culture-negative patients. Conclusions Culture-negative endocarditis patients presented with lower levels of C-reactive protein at admission and required more time for initiation of antibiotic therapy, although there was no difference in in-hospital mortality or long-term survival between culture-negative and culture-positive endocarditis patients. Diabetes mellitus and severe sepsis were associated with in-hospital death in patients with culture-negative endocarditis.
To update recommendations issued by the American Heart Association last published in 1990 for the prevention of bacterial endocarditis in individuals at risk for this disease.
An ad hoc writing group ...appointed by the American Heart Association for their expertise in endocarditis and treatment with liaison members representing the American Dental Association, the Infectious Diseases Society of America, the American Academy of Pediatrics, and the American Society for Gastrointestinal Endoscopy.
The recommendations in this article reflect analyses of relevant literature regarding procedure-related endocarditis, in vitro susceptibility data of pathogens causing endocarditis, results of prophylactic studies in animal models of endocarditis, and retrospective analyses of human endocarditis cases in terms of antibiotic prophylaxis usage patterns and apparent prophylaxis failures. MEDLINE database searches from 1936 through 1996 were done using the root words endocarditis, bacteremia, and antibiotic prophylaxis. Recommendations in this document fall into evidence level III of the US Preventive Services Task Force categories of evidence.
The recommendations were formulated by the writing group after specific therapeutic regimens were discussed. The consensus statement was subsequently reviewed by outside experts not affiliated with the writing group and by the Science Advisory and Coordinating Committee of the American Heart Association. These guidelines are meant to aid practitioners but are not intended as the standard of care or as a substitute for clinical judgment.
Major changes in the updated recommendations include the following: (1) emphasis that most cases of endocarditis are not attributable to an invasive procedure; (2) cardiac conditions are stratified into high-, moderate-, and negligible-risk categories based on potential outcome if endocarditis develops; (3) procedures that may cause bacteremia and for which prophylaxis is recommended are more clearly specified; (4) an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse; (5) for oral or dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals, but clindamycin and other alternatives are offered; and (6) for gastrointestinal or genitourinary procedures, the prophylactic regimens have been simplified. These changes were instituted to more clearly define when prophylaxis is or is not recommended, improve practitioner and patient compliance, reduce cost and potential gastrointestinal adverse effects, and approach more uniform worldwide recommendations.
Infective endocarditis (IE) is associated with substantial morbidity and mortality. Although it is relatively rare in children, its incidence may be increasing. Ferrieri et al focus on the features ...that are particularly relevant to infants and children, including important issues for the primary care physician.
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