Scabies_Repository_final

Scabies infestation status of human participants from a remote Aboriginal community in Northern Australia

Pharm-Assist: Using Personal Digital Assistants (PDAs) to Assist in Pharmacy Decisions

Pharm-Assist: Using Personal Digital Assistants (PDAs) to Assist in Pharmacy Decision

Intravenous Therapy Duration and Outcomes in Melioidosis: A New Treatment Paradigm

<div><p>Background</p><p>International melioidosis treatment guidelines recommend a minimum 10 to 14 days’ intravenous antibiotic therapy (intensive phase), followed by 3 to 6 months’ oral therapy (eradication phase). This approach is associated with rates of relapse, defined as recurrence following the eradication phase, that can exceed 5%. Rates of recrudescence, defined as recurrence during the eradication phase, have not previously been reported. In response to low eradication phase completion rates in Australia, a local guideline has evolved over the last ten years recommending a longer minimum intensive phase duration for many cases of melioidosis.</p><p>Methodology/ Principal Findings</p><p>This retrospective cohort study reviews antibiotic duration for the first episode of care for all patients diagnosed with melioidosis and surviving the intensive phase during a recent three year period in the tropical north of Australia’s Northern Territory; we also review adherence to the current local guideline and treatment outcomes. Of 215 first episodes of melioidosis surviving the intensive phase, the median (interquartile range) intensive phase duration was 26 (14-34) days. One hundred and eight (50.2%) patients completed eradication therapy; 58 (27.0%) patients took no eradication therapy. At 28 months’ follow-up, one (0.5%) relapse and eleven (5.1%) recrudescences had occurred. On exact logistic regression analysis, the only independent risk factors for recrudescence were self-discharge during the intensive phase (odds ratio 6.2 [95% confidence interval 1.2-30.0]) and septic shock (odds ratio 5.3 [95% confidence interval 1.1-25.7]).</p><p>Conclusions/ Significance</p><p>Relapsed melioidosis is rare in patients who receive a minimum intensive phase duration specified by our guideline and extended according to clinical progress. Recrudescence rates may improve with reductions in rates of self-discharge. Given the low relapse rate despite a high rate of eradication therapy non-adherence, the duration and necessity of eradication therapy for different patients after guideline-concordant intensive therapy should be evaluated further.</p></div

Clinician adherence to guideline-specified minimum intensive phase duration excluding patients who self-discharged.

<p>Clinician adherence to guideline-specified minimum intensive phase duration excluding patients who self-discharged.</p

Bivariate analysis of categorical risk factors for recrudescence.

<p>a. The denominator for all percentage calculations is 209 except where stated; there were no missing values.</p><p>b. Numerator and denominator for percentage calculation represent number of patients with doxycycline and either doxycycline or cotrimoxazole as the predominant eradication therapy respectively.</p><p>c. Numerator and denominator for percentage calculation represent number of patients with no eradication therapy and either no eradication therapy or cotrimoxazole as the predominant eradication therapy respectively.</p><p>Bivariate analysis of categorical risk factors for recrudescence.</p

Baseline characteristics.

<p>a. The denominator for all percentage calculations is 215; there were no missing values.</p><p>b. Median (interquartile range).</p><p>Baseline characteristics.</p

Median number of foci of infection ± interquartile range according to antibiotic duration-determining focus.

<p>Median number of foci of infection ± interquartile range according to antibiotic duration-determining focus.</p

Median treatment duration from last drainage ± interquartile range in comparison to minimum guideline duration.

<p>Median treatment duration from last drainage ± interquartile range in comparison to minimum guideline duration.</p

Darwin melioidosis guideline.

<p>a. Clinical judgement to guide prolongation of intensive phase if improvement is slow or if blood cultures remain positive at 7 days.</p><p>b. Defined as enlargement of any hilar or mediastinal lymph node to greater than 10mm diameter.</p><p>c. Defined as abscess anywhere other than skin, lungs, bone, CNS or vasculature; septic arthritis is considered a deep-seated collection.</p><p>d. Intensive phase duration is timed from date of most recent drainage or resection where culture of the drainage specimen or resected material grew <i>B</i>. <i>pseudomallei</i> or where no specimen was sent for culture; clock is not reset if specimen is culture-negative. On 1^st October 2010, the minimum duration for deep-seated collection changed from 2 to 4 weeks from last such drainage/resection.</p><p>e. Most commonly presenting as mycotic aneurysm.</p><p>Darwin melioidosis guideline.</p

Duration of intensive therapy.

<p>a. Excludes 118 patients who did not receive any meropenem.</p><p>b. Excludes 11 patients who did not receive any ceftazidime.</p><p>Duration of intensive therapy.</p