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Biomedical subjects

B A Lipsky

Publications and source records attributed to B A Lipsky.

At least 37 records · Page 2Linked to original sources
PubMed1999

Urinary catheters: what type do men and their nurses prefer?

OBJECTIVES: Urinary catheters are used frequently, but the relative risks and benefits of different types of devices are not clear. We sought to determine the beliefs of both older male patients and nursing staff about the relative merits and problems of condom and indwelling catheters. DESIGN: Patient and nurse survey using convenience sampling. SETTING: A University-affiliated Veterans Affairs medical center. PARTICIPANTS: Men hospitalized on medical, rehabilitation and nursing home units using either an indwelling or a condom catheter were invited to participate as were all members of the nursing staff on these units. Of 116 eligible patients, 104 were interviewed (response rate = 90%). Of 107 eligible nursing staff members, 99 completed the questionnaires (response rate = 92%). INTERVENTION AND MEASUREMENTS: Consenting patients were interviewed personally about their urinary catheter. The nursing staff were asked to complete a self-administered questionnaire. RESULTS: Patients were mostly older and predominantly hospitalized on the medical service. Compared with those using an indwelling catheter, patients using a condom catheter were more likely to believe that their catheter was comfortable (86 vs 58%, P = .04) and less likely to believe it was painful (14 vs 48%, P = .008) or to restrict their activity (24 vs 61%, P = .002). The nursing staff had a mean of 13 years nursing experience, and the majority worked in the nursing home unit. Most of the nursing staff respondents believed that condom catheters were less painful and restrictive for patients and were easier to apply, but they also believed that they fell off and leaked more often and required more nursing time. CONCLUSIONS: Both patients and nursing staff prefer condom to indwelling catheters for patient comfort, but they recognize that dislodgment and leaking are major drawbacks of condom catheters. A more secure condom catheter would greatly improve the management of male incontinence.

Aged↗
PubMed1999

Evidence-based antibiotic therapy of diabetic foot infections.

In addition to proper cleansing, debridement and local wound care, foot infections in diabetic patients require carefully selected antibiotic therapy. Serious infections necessitate hospitalization for initial parenteral broad-spectrum antibiotic therapy. Appropriately selected patients with mild infections can be treated as outpatients with oral (or even topical) therapy. Initial antibiotic selection is usually empirical, but definitive therapy may be modified based on culture results and the clinical response. Therapy should nearly always be active against staphylococci and streptococci, with broader-spectrum agents indicated if Gram-negative or anaerobic organisms are likely. In infected foot tissues levels of most antibiotics, except fluoroquinolones, are often subtherapeutic. The duration of therapy ranges from a week (for mild soft tissue infections) to over 6 weeks (for osteomyelitis). Recent antibiotic trials have shown that several intravenously or orally administered agents are effective in treating these infections, with no one agent or combination emerging as optimal. Suggested regimens based on the severity of infection are provided.

Anti-Bacterial Agents↗
PubMed1999

The increased prevalence of severe necrotizing infections caused by non-group A streptococci.

The authors report on 20 patients who were admitted to the University of Texas Health Science Center at San Antonio during a recent 4-month period with foot infections caused predominantly by non-group A streptococci. This number of patients was significantly greater than the number admitted to the same institution with the same diagnosis during the preceding 3 years. All patients had type 2 diabetes mellitus. In each case, a rapidly spreading cellulitis followed trauma to the foot, which necessitated emergent incision and drainage. Five patients required extensive fascial and skin debridement because of soft-tissue destruction, and two patients needed below-the-knee amputation because of uncontrolled infection. These cases suggest that non-group A streptococci, like group A streptococci, can cause serious skin and soft-tissue infections in patients with diabetes that may require aggressive surgical debridement despite appropriate antibiotic therapy.

Cellulitis↗
PubMed1998

The burden of diabetic foot ulcers.

Lower extremity ulcers represent a major concern for patients with diabetes and for those who treat them, from both a quality of life and an economic standpoint. Studies to evaluate quality of life have shown that patients with foot ulcers have decreased physical, emotional, and social function. Analyses of economic impact have shown (1) the majority of costs occur in the inpatient setting, (2) a lack of financial benefit when comparing primary amputation with an aggressive approach to limb salvaging including vascular reconstruction, and (3) private insurance provides greater reimbursement for inpatient care than does Medicare. Results of etiologic studies suggest that hyperglycemia induces diabetes-related complications through sorbitol accumulation and protein glycation, and the resultant nerve damage manifests as peripheral neuropathy, which predisposes to ulcer development. Patients with diabetes also have an increased incidence of peripheral vascular disease, impaired wound healing, and decreased ability to fight infection. In light of these factors, it is sometimes difficult to determine the optimal course for patient management. This review is aimed at helping healthcare providers make better decisions about treatment, resource use, and strategies for future foot ulcer prevention.

Anti-Bacterial Agents↗
PubMed1997

Osteomyelitis of the foot in diabetic patients.

Osteomyelitis of the foot, a common and serious problem in diabetic patients, results from diabetes complications, especially peripheral neuropathy. Infection generally develops by spread of contiguous soft-tissue infection to underlying bone. The major diagnostic difficulty in diabetic patients is distinguishing bone infection from noninfectious neuropathic bony lesions. Certain clinical signs suggest osteomyelitis, but imaging tests are usually needed. The 111In-labeled leukocyte scan and magnetic resonance imaging are the most diagnostically useful. Staphylococcus aureus is the most common etiologic agent, followed by other aerobic gram-positive cocci. Aerobic gram-negative bacilli and anaerobes are occasionally isolated, often in mixed infections. Antimicrobial therapy is best directed by cultures of the infected bone, obtained percutaneously or at surgery. Antibiotic therapy should usually be given parenterally, at least initially, and continued for at least 6 weeks. Surgical debridement or resection of the infected bone, when feasible, improves the outcome. With appropriate therapy most cases of osteomyelitis can be successfully managed.

Diabetic Foot↗
PubMed1997

Antibiotic therapy for diabetic foot infections: comparison of two parenteral-to-oral regimens.

This prospective, randomized, multicenter trial compared the efficacy of two antibiotic regimens for treatment of foot infections in diabetic adults. Patients with infections requiring hospitalization were randomized to receive either intravenous ofloxacin followed by oral ofloxacin or intravenous ampicillin/sulbactam followed by oral amoxicillin/clavulanate (the aminopenicillin regimen) for 14-28 days. Patients with osteomyelitis were eligible for the study if the infected bone was to be removed. Of 108 patients enrolled in the study, 88 who were evaluable had various skin and soft-tissue infections, and 24% had osteomyelitis. For the ofloxacin and aminopenicillin regimens, the mean duration of intravenous therapy was 7.8 and 7.1 days, respectively, the mean duration of oral therapy was 13.2 and 12.0 days, respectively, the rate of eradication of pathogens was 78% and 88%, respectively, and the overall rate of clinical cure or improvement was 85% and 83%, respectively. Thus, about 3 weeks of therapy with either regimen was well tolerated and effective in treating these diabetic foot infections.

Administration, Oral↗
PubMed1992

Immediate and long-term efficacy of systemic antibiotics for eradicating nasal colonization with Staphylococcus aureus.

The efficacy of nine antibiotics used in different nonrandomized regimens for eradicating nasal colonization with Staphylococcus aureus was investigated in 72 patients. Dicloxacillin, erythromycin and three cephalosporins had eradicated colonization in about 75% of cases at early follow-up (less than or equal to 20 days) and in less than or equal to 50% at late follow-up (greater than or equal to 20 days). Clindamycin had eradicated colonization in all 13 patients at both follow-up times. One of two patients was successfully treated with fleroxacin, as were three of five with enoxacin. Among 21 patients treated with ofloxacin, colonization was eradicated in 20 (95%) at early follow-up and in all six of those from whom late follow-up cultures were obtained. Thus, clindamycin and ofloxacin appear to be useful systemic antibiotics for eradicating nasal colonization with Staphylococcus aureus.

Adult↗
PubMed1992

The role of age in susceptibility to pneumococcal infections.

Whether or not age by itself increases susceptibility to pneumococcal infections separate from the effects of chronic disease is controversial. To address this issue, data collected for a retrospective cohort study of pneumococcal infections among 63 middle-aged and older veterans and 126 uninfected controls were reanalysed. Univariate analysis suggested a linear increase in risk with increasing age for patients 50 years old and older (p = 0.03). Subjects over age 80 years seemed to be at particularly high risk when compared with patients under 50 (odds ratio = 4.3, p less than 0.03). The odds of pneumococcal infection increased by an estimated factor of 1.33 (95% confidence interval = 1.03, 1.71) for each 10-year increase in age. Controlling for other risk factors did not appreciably change the point estimate of the age effect, but statistical significance was lost. This result however suggests that age has an independent association with the risk of pneumococcal infections. The potential impact of this finding on public policy urges that the association of age with the risk of pneumococcal disease be re-examined in a study of sufficient sample size to resolve the issue.

Age Factors↗
PubMed1992

Ofloxacin versus cephalexin for treating skin and soft tissue infections.

Patients with acute localized skin or soft tissue infections were randomized to receive either ofloxacin (300 mg orally, b.i.d.) or cephalexin (500 mg orally, b.i.d.). Among 401 enrolled patients, 382 were evaluable for safety and 148 for microbiologic response. Microbiologic cure occurred in 93.4% of ofloxacin-treated patients and in 94.0% of those treated with cephalexin. Clinical cure or improvement, respectively, was found in 85.2% and 11.1% of patients treated with ofloxacin, and 83.6% and 14.9% of patients receiving cephalexin. Adverse effects (primarily associated with the gastrointestinal tract and central nervous system) were considered to be drug-related in 7.9% of those receiving ofloxacin and 4.8% of those receiving cephalexin. Thus, ofloxacin is as effective and well tolerated as cephalexin and a good alternate antibiotic for treating skin and skin structure infections caused by a variety of pathogens.

Cephalexin↗
PubMed1992

A prospective study of Staphylococcus aureus nasal colonization and intravenous therapy-related phlebitis.

BACKGROUND: Intravenous (IV) therapy-associated phlebitis is common, but its causes are ill defined. Some cases may be related to bacterial colonization of the skin surrounding the IV catheter, especially by Staphylococcus aureus. This prospective study examined the association of phlebitis with anterior nares S aureus carriage, as well as with other potential risk factors. METHODS: Selected demographic and clinical data and a nares culture were collected from patients on designated wards by us and from the IV therapy team at the time of initial IV catheter placement. Patients were followed up for signs and symptoms of phlebitis for the duration of the initial catheter's use and for up to two additional IV placements. Potential risk factors were compared for patients who developed phlebitis and those who did not by the Cox multivariate proportional hazards model. RESULTS: During 10 weeks, 273 men with a total of 416 catheter placements had fully evaluable data. Phlebitis occurred during 13.7% of the catheter placements. Nasal cultures yielded S aureus from 14.3% of the patients, but none of the IV team nurses. Surprisingly, S aureus nasal colonization was related (at borderline statistical significance) to a reduction in phlebitis risk. Location of the patient on a surgical ward, the presence of infection at any site, and a larger-gauge catheter were each significant independent risk factors for phlebitis. The highest risk of phlebitis appeared to have been within 12 to 24 hours of catheter placement. CONCLUSIONS: The primary finding of this study was that nasal colonization with S aureus did not increase the risk of developing IV catheter-associated phlebitis. Our rate of IV catheter-associated phlebitis was similar to that in other studies, but the factors predisposing to phlebitis differed somewhat from those in previous studies.

Catheterization, Peripheral↗
PubMed1991

Diagnosis of osteomyelitis in the presence of soft-tissue infection and radiologic evidence of osseous abnormalities: value of leukocyte scintigraphy.

To evaluate the usefulness of 111In-leukocyte scintigraphy for identifying osteomyelitis in the presence of soft-tissue infection, we prospectively studied 45 bone sites adjacent to soft-tissue infection in patients with abnormal findings on radiographs and 99mTc bone scans that were suggestive of osteomyelitis. 111In-leukocyte scans were analyzed in terms of the intensity of abnormal uptake and its location relative to bone. The diagnosis of osteomyelitis was established from results of percutaneous bone biopsy culture (n = 35), histologic examination of surgical specimens (n = 8), and clinical follow-up (n = 2). Osteomyelitis was present at 22 sites, including 16 of 18 sites with increased leukocyte uptake in bone, resulting in a sensitivity of 73%, specificity of 91%, and positive predictive value of 89% for this finding. Osteomyelitis was present at four of 17 sites with predominantly soft-tissue localization of leukocyte activity in the region of bone, none of seven sites with normal leukocyte scans, and two of three sites with diminished leukocyte uptake in bone. Although not helpful in distinguishing infectious from noninfectious bone abnormalities, 3- and especially 24-hr bone scans viewed in conjunction with leukocyte studies provided important correlation to aid in estimating the location of focal abnormal leukocyte uptake. The finding of soft-tissue infection with increased uptake of labeled leukocytes that extends to involve adjacent bone strongly suggests concurrent osteomyelitis. When the presence of abnormal leukocyte uptake in bone is uncertain, additional imaging and possibly biopsy may be required to establish or exclude the diagnosis of osteomyelitis.

Adult↗
PubMed1991

Treatment of lower respiratory infections in outpatients with ofloxacin compared with erythromycin.

To assess the safety and efficacy of a ten-day oral course of ofloxacin (400 mg 12 hourly) as compared with erythromycin (400 mg every 6 hours) for treatment of lower respiratory tract infections, fifty-two adult outpatients with pulmonary infiltrates (pneumonia) or with a cough and purulent sputum (bronchitis) were evaluated. Expectorated sputum specimens were Gram-stained and cultured, and antibody titres to Mycoplasma pneumoniae, Legionella pneumophilia, and in most cases Chlamydia pneumoniae were measured on acute and convalescent serum samples. Patients were evaluated clinically, microbiologically and radiographically three to five days after concluding therapy; the incidence of adverse reactions was monitored throughout the study period. The ofloxacin group (N = 25) was comprised of nineteen patients with pneumonia and six patients with bronchitis. The erythromycin group (N = 27) was comprised of thirteen patients with pneumonia and fourteen patients with bronchitis. All fifty-two patients were either clinically improved or cured after therapy. Microbiological cure was documented in all fourteen cases (27%) in which causative pathogens were identified. Clinical cure was achieved with ofloxacin in 68% of patients with pneumonia and in 83% of patients with bronchitis, while clinical cure with erythromycin was achieved in 46% of patients with pneumonia and 54% of patients with bronchitis. Adverse reactions (mostly mild gastrointestinal or central nervous system symptoms) were reported by eight patients receiving ofloxacin and four patients receiving erythromycin. While the types of adverse effects were similar, ofloxacin showed a trend toward a higher rate of cure than erythromycin. Ofloxacin is a promising new antibiotic for the treatment of acute lower respiratory infections.

Adult↗
PubMed1990

Atrial fibrillation. Thromboembolic risk and indications for anticoagulation.

The risk of embolic stroke in patients with atrial fibrillation is largely related to the underlying disorders responsible for the arrhythmia. Atrial fibrillation associated with rheumatic mitral valve disease has the highest stroke risk (about 17 times greater than unaffected controls), but even with nonvalvular heart disease, the risk is increased fivefold. The stroke risk is greater with chronic than with paroxysmal atrial fibrillation, is highest in the year after onset of the arrhythmia, and is lower in younger patients with idiopathic ("lone") atrial fibrillation. Major bleeding episodes, the most important risk of anticoagulation, occur in about 5% to 10% of patients. The decision to anticoagulate a patient with atrial fibrillation depends on the cause of the arrhythmia, especially any associated cardiovascular disease, and the individual's risk from anticoagulation. Growing evidence supports the effectiveness of anticoagulation of most patients with nonvalvular, as well as valvular, cardiac disease for the prevention of both primary and recurrent strokes.

Anticoagulants↗