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Biomedical subjects

D A Goldmann

Publications and source records attributed to D A Goldmann.

134 records · Page 8Linked to original sources
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Rifampin alone and in combination with trimethoprim in chemoprophylaxis for infections due to Haemophilus influenzae type b.

The efficacy of rifampin in eradicating Haemophilus influenzae type b from the pharynx of colonized individuals was assessed for 1,467 close contacts of 291 children hospitalized with invasive infections due to H. influenzae type b. Twenty-six percent of all contacts were carrying H. influenzae type b in the pharynx, and 52% of contacts younger than age five had throat cultures positive for this organism. Four different regimens of rifampin were studied and compared with placebo for efficacy in eradication of carriage of H. influenzae type b. The most effective dosage was 20 mg of rifampin/kg given once daily for four days. This schedule was associated with eradication of carriage in 96.2% of 52 colonized, compliant contacts. Carriage of H. influenzae type b was eradicated in 90.9% of the 22 colonized contacts who were younger than age five. Significantly lower rates of carriage eradication were seen with other regimens of rifampin. Potential problems associated with widespread rifampin usage are reviewed.

Carrier State↗
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In vitro activity of penicillin and rifampin against group B streptococci.

Eighty-eight strains of group B streptococci were studied to determine their in vitro susceptibility to penicillin and rifampin alone and in combination. Minimal inhibitory concentrations (MICs) and minimal bactericidal concentrations (MBCs) were determined by broth microdilution; studies of synergy were performed by microdilution checkerboards and time-kill curves. The MIC90 and MBC90 for penicillin were both less than or equal to 0.06 microgram/ml. The MIC90 and MBC90 for rifampin were less than or equal to 0.25 microgram/ml and greater than 32.0 microgram/ml, respectively. Checkerboard MIC determinations revealed synergy for 46 strains (52%), an additive or indifferent effect for 42 strains (48%), and no antagonism. MBC checkerboards showed antagonism for 62 strains (70%); in 45 (73%) of these 62 strains, high concentrations of rifampin increased the MBC of penicillin, whereas low concentrations decreased the MBC of penicillin. Time-kill studies performed on selected strains supported the results of MBC checkerboards, although concentrations of antibiotics that were antagonistic in the checkerboards had an indifferent effect in time-kill experiments. When concentrations of antibiotics were used that are clinically achievable in cerebrospinal fluid, delayed killing was seen even though synergy had been observed in both MIC and MBC checkerboards.

Microbial Sensitivity Tests↗
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Imipenem/cilastatin in acute pulmonary exacerbations of cystic fibrosis.

Nineteen patients with pulmonary exacerbations of cystic fibrosis due to Pseudomonas aeruginosa were given imipenem/cilastatin for six to 10 days at dosages of 30-90 mg/kg per day. Mean Shwachman scores rose from 46.6 to 50.3 (P less than .001), clinical efficacy scores from 34.3 to 43.3 (P less than .001), vital capacity from 53.7% to 58.5% of the predicted value (P less than .01), forced expiratory volume in 1 sec from 39.5% to 42.6%, and partial pressure of oxygen in arterial blood from 68.2 mm Hg to 72.6 mm Hg. Treatment failed in only two instances. The concentration of P. aeruginosa in the sputum decreased to a modest extent (8.5 log10 cfu/ml on day 1, 8.1 log10 cfu/ml on day 10; P greater than .1). Four patients had imipenem-resistant strains of P. aeruginosa at the start of therapy, and 11 additional patients developed resistant strains during treatment; in eight patients greater than 90% of all Pseudomonas organisms in the sputum were resistant at the end of therapy. Six patients acquired Candida in their sputum. There was no correlation between bacteriologic improvement or the development of resistance to imipenem and either clinical outcome or improvement in pulmonary function. In summary, imipenem/cilastatin therapy is associated with a good clinical outcome in patients with cystic fibrosis, but resistance emerges rapidly.

Adolescent↗
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Epidemiology and prevention of pediatric viral respiratory infections in health-care institutions.

Nosocomial viral respiratory infections cause considerable illness and death on pediatric wards. Common causes of these infections include respiratory syncytial virus and influenza. Although primarily a community pathogen, rhinovirus also occasionally results in hospitalization and serious sequelae. This article reviews effective infection control interventions for these three pathogens, as well as ongoing controversies.

Animals↗
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Hospital-based continuous quality improvement: a realistic appraisal.

OBJECTIVE: To evaluate the impact of a continuous quality improvement (CQI) multidisciplinary team process on emergency department admission times. DESIGN: Prospective observational intervention study. SETTING: A 349-bed tertiary care, university-affiliated, pediatric teaching hospital. RESULTS: The time from triage to departure from the emergency department (T1-T3) was reduced by 71 minutes, and the time from the decision to admit to departure from the emergency department (T2-T3) by 38 minutes following the planned interventions. There was no correlation between admission times and hospital inpatient census, number of emergency department admissions on a given day, or work shift. Medical patients were transferred to the wards more slowly than patients admitted by the general surgery service and several specialty surgical services once the decision to admit had been reached. No major adverse clinical outcomes could be attributed to expedited admissions. Physicians and nurses in the emergency department expressed improved satisfaction with the admissions process, while houseofficers on the wards were less satisfied. Parental satisfaction with the speed of admissions remained suboptimal. Additional potential problems with the application of CQI principles in an academic setting were identified. CONCLUSIONS: Although CQI is a promising approach to certain quality problems, a number of issues remain to be explored before full-scale implementation in academic centers can be endorsed.

Consumer Behavior↗
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A clinical pathway for pelvic inflammatory disease for use on an inpatient service.

OBJECTIVE: (1) To create a guideline to improve care of adolescent patients diagnosed with pelvic inflammatory disease (PID); (2) to promote cost-effective, consistent care while minimizing delays and ensuring timely and appropriate use of laboratory tests and other interventions; and (3) to describe the process of the development and the implementation of a clinical pathway for PID. METHODS: The study involved the creation and piloting of a multidisciplinary, collaborative clinical pathway for uncomplicated PID on an inpatient service, and the development of a standardized form for analysis of demographics and variances from the pathway. The setting was an inpatient adolescent service at a children's hospital in an urban setting. All patients admitted with a clinical diagnosis of PID from April 1, 1993, to November 30, 1993, were followed up by means of the clinical pathway. All patients discharged with a diagnosis of uncomplicated PID in fiscal year 1992 (FY92: October 1, 1991, to September 30, 1992) were used as a comparison population. The main outcome measures included length of stay, charges per patient, timing of antibiotic administration, use of laboratory tests at admission and at 48 to 72 hours, and documentation of pathway variances. RESULTS: A clinical pathway was created by consensus during a period of several months. During implementation, 28 of 34 (82%) patients admitted by use of the pathway had a final diagnosis of PID; 23 of the 28 (82%) had uncomplicated PID. Variances from the pathway included missed rapid plasma reagins (RPRs) and laboratory tests that were not indicated. For uncomplicated PID, length of stay was reduced (p=.08) from a median of 4 days in FY92 (mean, 5.0 1 3.1 days; range, 2-15 days) to a median of 3 days in the study group (mean, 3.5 + 1.0 days; range, 2-4 days), with differences not reaching the level of significance. There were significantly more patients staying 5 days or longer in FY92 than in the study group (p<.03). Average charges per patient also decreased by 10% (median, $5,275 in FY92 to $4,919), although these results were not statistically significant. CONCLUSION: A clinical pathway for uncomplicated PID can be developed and implemented through a multidisciplinary, collaborative process, with ongoing use as a means of quality improvement and continuing education. Variances from the pathway highlight the need for ongoing education for health care providers. Downward trends in charges per patient and length of stay, although not significant, are encouraging; but they require longitudinal follow up with larger numbers of patients and analysis of outcomes.

Adolescent↗
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Resistance movement: the antibiotic crisis in hospitals.

The near-miraculous healing power of antibiotic is being undermined by the rapid evolution of drug-resistant bacteria. The costs, in human and economic terms, could be staggering for all caregivers and patients, but especially for institutional providers like hospitals. In an article adapted from the Journal of the American Medical Association, Dr. Goldmann explains why antibiotic resistance is a crisis and how the danger can be mitigated.

Anti-Bacterial Agents↗