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Benjamin A Lipsky

Publications and source records attributed to Benjamin A Lipsky.

33 records · Page 2Linked to original sources
PubMed2004

Using maximal sterile barriers to prevent central venous catheter-related infection: a systematic evidence-based review.

BACKGROUND: Catheter-related infections cause increased morbidity, mortality, and health care costs. Infection control experts advocate using maximal sterile barriers to reduce the incidence of these infections. Low compliance rates suggest that clinicians are not convinced or are not aware that available data support adopting this more cumbersome, time-consuming, and relatively more expensive technique. Accordingly, we conducted a systematic, evidence-based review of the medical literature to determine the value of maximal sterile barriers. DATA SOURCES: We used multiple computerized databases, reference lists of identified articles, and queries of prominent investigators. STUDY SELECTION: We selected studies comparing infectious outcomes using maximal sterile barriers versus using less stringent sterile barrier techniques during central venous catheter insertion. DATA SYNTHESIS: We found only 3 primary research studies. Although each study suggests maximal sterile barriers may reduce infectious complications, the evidence supporting this conclusion is incomplete. The only randomized controlled trial limited enrollment to ambulatory oncology patients. These 3 studies differed notably in their patient populations, research designs, and health care settings. CONCLUSION: The medical literature suggests maximal sterile barriers are advantageous in at least one setting and may be useful in others. While we believe the available evidence does support the use of maximal sterile barriers during routine insertion of central venous catheters, prospective studies and economic analyses would better clarify its value.

Bacteremia↗
PubMed2004

Advances in the treatment of diabetic foot infections.

Lower extremity infections are frequent causes of substantial morbidity and mortality in the diabetic population, and these infections consume a large portion of resources expended on diabetic complications. Gram-positive cocci, particularly Staphylococcus aureus, are the most important pathogens in diabetic foot infections. These organisms are predominant both in mild infections (which are often monomicrobial), as well as in more severe and chronic infected wounds that more often have a polymicrobial cause. Appropriate clinical assessment and culturing of infections are critical in establishing the presence and severity of infection, in detecting osteomyelitis, and in directing the optimal treatment approach. Following necessary debridement and other surgical interventions (e.g., bone resection, revascularization), appropriate antibiotic therapy is a cornerstone of managing the infected lower extremity. Peripheral vascular (i.e., arterial) insufficiency and the increasing prevalence of antibiotic resistance are primary barriers to successfully managing these infections. Fortunately, alternative delivery systems (e.g., antibiotic beads, impregnated sponges) and novel antibiotics (e.g., levofloxacin, linezolid) are providing possible solutions to the challenges posed by this physically, emotionally, and financially devastating condition.

Anti-Bacterial Agents↗
PubMed2004

Complicated infections of skin and skin structures: when the infection is more than skin deep.

Skin and skin-structure infections are common, and range from minor pyodermas to severe necrotizing infections. Complicated infections are defined as involving abnormal skin or wounds, occurring in compromised hosts, or requiring surgical intervention. Classification schemes for these infections are varied and confusing. Distinguishing characteristics include the aetiological agent(s), clinical context and findings, depth of tissue involvement and rate of progression. The most common pathogens are aerobic Gram-positive cocci, but complicated infections frequently involve Gram-negative bacilli and anaerobic bacteria. Initial antibiotic therapy is usually empirical, and later modified by the results of stains and cultures of wound specimens. Broad-spectrum coverage is frequently needed for complicated infections. Ertapenem is a once-a-day parenteral Group 1 carbapenem antibiotic, recently licensed in the USA and Europe, which may assume an important role in treating some complicated skin and skin-structure infections. Surgical debridement is important for many complicated infections, and is the critical element in managing necrotizing fasciitis and myonecrosis.

Adult↗
PubMed2004

Diabetic foot infections: stepwise medical and surgical management.

Foot complications are common among diabetic patients; foot ulcers are among the more serious consequences. These ulcers frequently become infected, with potentially disastrous progression to deeper spaces and tissues. If not treated promptly and appropriately, diabetic foot infections can become incurable or even lead to septic gangrene, which may require foot amputation. Diagnosing infection in a diabetic foot ulcer is based on clinical signs and symptoms of inflammation. Properly culturing an infected lesion can disclose the pathogens and provide their antibiotic susceptibilities. Specimens for culture should be obtained after wound debridement to avoid contamination and optimise identification of pathogens. Staphylococcus aureus is the most common isolate in these infections; the increasing incidence of methicillin-resistant S. aureus over the past two decades has further complicated antibiotic treatment. While chronic infections are often polymicrobial, many acute infections in patients not previously treated with antibiotics are caused by a single pathogen, usually a gram-positive coccus. We offer a stepwise approach to treating diabetic foot infections. Most patients must first be medically stabilised and any metabolic aberrations should be addressed. Antibiotic therapy is not required for uninfected wounds but should be carefully selected for all infected lesions. Initial therapy is usually empirical but may be modified according to the culture and sensitivity results and the patient's clinical response. Surgical intervention is usually required in cases of retained purulence or advancing infection despite optimal medical therapy. Possible additional indications for surgical procedures include incision and drainage of an abscess, debridement of necrotic material, removal of any foreign bodies, arterial revascularisation and, when needed, amputation. Most foot ulcers occur on the plantar surface of the foot, thus requiring a plantar incision for any drainage procedure.

Amputation, Surgical↗
PubMed2003

Treating foot infections in diabetic patients: a randomized, multicenter, open-label trial of linezolid versus ampicillin-sulbactam/amoxicillin-clavulanate.

Foot infections in diabetic patients are predominantly caused by gram-positive cocci, many of which are now antibiotic resistant. Because linezolid is active against these pathogens, we compared the efficacy and safety of intravenous and oral formulations with that of intravenous ampicillin-sulbactam and intravenous and oral amoxicillin-clavulanate given for 7-28 days in a randomized, open-label, multicenter study of all types of foot infection in diabetic patients (ratio of linezolid to comparator drug recipients, 2:1). Among 371 patients, the clinical cure rates associated with linezolid and the comparators were statistically equivalent overall (81% vs. 71%, respectively) but were significantly higher for linezolid-treated patients with infected foot ulcers (81% vs. 68%; P=.018) and for patients without osteomyelitis (87% vs. 72%; P=.003). Cure rates were comparable for inpatients and outpatients and for both oral and intravenous formulations. Drug-related adverse events were significantly more common in the linezolid group, but they were generally mild and reversible. Linezolid was at least as effective as aminopenicillin/beta-lactamase inhibitors for treating foot infections in diabetic patients.

Acetamides↗
PubMed2003

Vascular catheter site care: the clinical and economic benefits of chlorhexidine gluconate compared with povidone iodine.

The use of chlorhexidine gluconate solution for vascular catheter insertion site care reduces the risk of catheter-related bloodstream infection by one-half, compared with povidone iodine. Our objective was to evaluate the cost-effectiveness of chlorhexidine gluconate versus povidone iodine. We used data from randomized, controlled trials, meta-analyses, and epidemiologic studies to construct a decision analysis model. We estimated that use of chlorhexidine, rather than povidone, for central catheter site care resulted in a 1.6% decrease in the incidence of catheter-related bloodstream infection, a 0.23% decrease in the incidence of death, and savings of 113 dollars per catheter used. For peripheral catheter site care, the results were similar, although the differences were smaller. The results were found to be robust on multivariate sensitivity analyses. Use of chlorhexidine gluconate in place of the current standard solution for vascular catheter site care is a simple and cost-effective method of improving patient safety in the hospital setting.

Anti-Infective Agents, Local↗
PubMed2003

Which antimicrobial impregnated central venous catheter should we use? Modeling the costs and outcomes of antimicrobial catheter use.

BACKGROUND: Catheter-related bloodstream infections are costly and associated with substantial morbidity and mortality. Trials suggest that central venous catheters impregnated with minocycline/rifampin, although more expensive, are clinically superior to chlorhexidine/silver sulfadiazine impregnated catheters. It remains unclear whether minocycline/rifampin catheters are cost-effective for all high-risk patients or only those requiring longer-term catheterization. METHODS: We developed a series of decision models with patient-level clinical trial data to determine whether minocycline/rifampin catheters are cost-effective for patients requiring various durations of catheterization. We calculated incremental cost-effectiveness ratios for patients catheterized for durations ranging from 1 to 25 days. RESULTS: The data were too sparse to estimate cost-effectiveness for patients catheterized less than 8 days. The probability that minocycline/rifampin catheters were cost-effective compared with chlorhexidine/silver sulfadiazine catheters in patients catheterized for 8 days was 91%. The probability that the minocycline/rifampin catheters in patients catheterized 13 days or longer resulted in cost savings was more than 95%. CONCLUSIONS: Our analysis suggests that central venous catheters coated with minocycline/rifampin are cost-effective for patients catheterized for at least 1 week and lead to overall cost savings when patients are catheterized for 2 weeks or longer. Policies for the use of antimicrobial catheters in high-risk patients should reflect patients' expected duration of catheterization.

Anti-Infective Agents↗
PubMed2002

Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis.

PURPOSE: Bloodstream infections related to use of catheters, particularly central-line catheters, are an important cause of patient morbidity, mortality, and increased health care costs. This study evaluated the efficacy of skin disinfection with chlorhexidine gluconate compared with povidone-iodine solution in preventing catheter-related bloodstream infection. DATA SOURCES: Multiple computerized databases (1966 to 2001), reference lists of identified articles, and queries of principal investigators and antiseptic manufacturers. STUDY SELECTION: Randomized, controlled trials comparing chlorhexidine gluconate with povidone-iodine solutions for catheter-site care. DATA EXTRACTION: Using a standardized form, two reviewers abstracted data on study design, patient population, intervention, and incidence of catheter-related bloodstream infection from all included studies. DATA SYNTHESIS: Eight studies involving a total of 4143 catheters met the inclusion criteria. All studies were conducted in a hospital setting, and various catheter types were used. The summary risk ratio for catheter-related bloodstream infection was 0.49 (95% CI, 0.28 to 0.88) in patients whose catheter sites were disinfected with chlorhexidine gluconate instead of povidone-iodine. Among patients with a central vascular catheter, chlorhexidine gluconate reduced the risk for catheter-related bloodstream infection by 49% (risk ratio, 0.51 [CI, 0.27 to 0.97]). CONCLUSIONS: These results suggest that incidence of bloodstream infections is significantly reduced in patients with central vascular lines who receive chlorhexidine gluconate versus povidone-iodine for insertion-site skin disinfection. Use of chlorhexidine gluconate is a simple and effective means of reducing vascular catheter-related infections.

Aged↗
PubMedDate not supplied

Diagnosing and treating diabetic foot infections.

Foot infections are a common, complex and costly complication of diabetes. We have made considerable progress in establishing consensus definitions for defining infection. Similarly, we have learned much about the appropriate ways to diagnose both soft tissue and bone infections. Accompanying these advances have been improvements in our knowledge of the proper approaches to antibiotic (and surgical) therapy for diabetic foot infections. Furthermore, investigators have explored the value of various adjunctive therapies, especially granulocyte colony stimulating factors and hyperbaric oxygen, for improving outcomes. This paper presents a summary of a minisymposium on infection of the diabetic foot that was held at the fourth International Symposium on the Diabetic Foot, in Noordwijkerhout, The Netherlands.

Diabetic Foot↗
PubMedDate not supplied

A report from the international consensus on diagnosing and treating the infected diabetic foot.

In persons with diabetes, foot infection, that is, invasion and multiplication of microorganisms in tissues accompanied by tissue destruction or a host inflammatory response, usually begins with skin trauma or ulceration 1. While most foot infections remain superficial, they can spread to subcutaneous tissues, including muscle, joints, and bone. Many diabetic foot ulcers eventuate in an amputation; infection plays a role in approximately 60% of cases 2-4. Neuropathy is the main factor leading to skin breaks, while arterial perfusion largely affects infection outcome. Among the factors predisposing diabetic patients to foot infections are ill-defined immunological perturbations 56; foot anatomy may foster proximal spread of infection and ischemic necrosis 78.

Anti-Bacterial Agents↗
PubMedDate not supplied

What is the shelf life of physician-mixed antibiotic-impregnated calcium sulfate pellets?

This pilot study was undertaken to evaluate the short-term in vitro antimicrobial stability of both vancomycin- and tobramycin-impregnated calcium sulfate pellets mixed and stored in a clinical setting. Powdered tobramycin sulfate (500 mg) and vancomycin hydrochloride (500 mg) were blended into separate basins containing 25 g of surgical-grade calcium sulfate powder, then mixed with 8 mL of sterile saline. From this admixture, 6.0-mm pellets were produced. These were removed from the sterile container (stored at room temperature) at 1, 7, 30, 60, 90, and 120 days and tested against a variety of pathogenic bacterial isolates by using a modification of the standardized Kirby-Bauer test. Control pellets containing no antibiotic were also evaluated. There was no inhibition of bacterial growth by the non-antibiotic-impregnated (control) pellets. There was no appreciable difference in the zones of inhibition for any of the organisms with pellets stored for 1, 7, 30, 60, 90, or 120 days. Zones of inhibition for the various antibiotics to the strain of organism tested ranged from 17 mm to 30 mm, depending on the pathogenic isolate and the antibiotic evaluated. The zones of inhibition observed were similar to those designating antibiotic susceptibility in the Kirby-Bauer test. The results of this preliminary study suggest that clinician-mixed calcium sulfate pellets containing either vancomycin or tobramycin, when stored under normal room temperature and ambient humidity, appear to maintain their antimicrobial characteristics for at least 120 days.

Anti-Bacterial Agents↗