Impact of prolonged treatment with high-dose ciprofloxacin on human gut flora: a case report

<p>Abstract</p> <p>Introduction</p> <p>Ciprofloxacin is a commonly marketed fluoroquinolone. It is not effective against obligate anaerobes, hence it is considered unlikely to have an impact on colonic microflora. We report the case of a patient who received prolonged treatment with high-dose ciprofloxacin for extensive pelvic osteomyelitis. We also report on the medication's effects on his bowel flora. To the best of our knowledge, this is the first report discussing the effects of prolonged administration of a quinolone on microbial flora.</p> <p>Case presentation</p> <p>A 62-year-old Caucasian man with diabetes presented with low back pain of four months' duration. A magnetic resonance imaging of his pelvis revealed sacroiliitis and extensive pelvic osteomyelitis. <it>Pseudomonas aeruginosa</it>, which is susceptible to ciprofloxacin, was noted as the offending pathogen. After seven weeks of intravenous treatment, he was prescribed with high-dose oral ciprofloxacin that he continued to take for the next 20 months. Quantitative stool cultures of our patient were obtained a month later as well as at the end of his treatment to record his corresponding sensitivities to the medication. The Gram-negative population of his bowel flora was restored fully upon the discontinuation of this medication. The Gram-negative population was shown to be fully sensitive to ciprofloxacin. His yeast levels were also found to be slightly increased, and no growth of resistant enterococci was noted.</p> <p>Conclusion</p> <p>The findings of this case report suggest that long term and high dose ciprofloxacin administration might be safe in preventing the risk of colonization with resistant Gram negative pathogens, overgrowth of anaerobes and the development of resistant enterococci.</p

Automated monitoring for the early detection of sepsis in critically ill patients

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To evaluate whether automated systems for the early detection of sepsis can reduce the time to appropriate treatment and improve clinical outcomes in critically ill patients in the ICU

Spinal infections: evolving concepts

Purpose of review Although rare, spinal infections are characterized by an indolent clinical course and delay in diagnosis. Physicians should be aware of current diagnostic and therapeutic developments. Recent findings The range of the pathogens causing spinal infections has expanded as a result of the increasing number of individuals at risk and enhanced diagnostics. The role of newer biological therapies in producing spinal infections has not been elucidated yet. Pyogenic bacteria still account for most of the cases; however, tuberculosis and brucellosis remain major causes in endemic countries and susceptible patients. Endoscopic techniques assist in sampling suspicious lesions and molecular microbiology has revolutionized diagnosis. Magnetic resonance imaging techniques remain the gold standard for diagnostic imaging; their role in follow-up is a matter of debate. Long-term antimicrobial treatment is currently the standard of care. The identification of individuals most likely to benefit from surgical intervention is crucial. Surgery may be required early to address any neurological deficits and later to treat infection refractory to conservative treatment. Summary Prompt diagnosis is essential in spinal infections. Early surgical intervention is required in patients with neurological deficits. Further research should clarify the appropriate duration of antimicrobial treatment and the overall role of surgery

Comparative Analysis of Mortality From Coronavirus Disease 2019 Across the European Union Countries and the Effects of Vaccine Coverage

Background Mortality is a critical measure of disease impact. The European Union (EU) countries share the same regulatory framework but different implementation policies. Methods We extracted cumulative COVID-19 mortality data across the EU countries. We evaluated the 27 member states using the location quotient (LQ) to adjust for the expected mortality in the whole EU region, where an LQ 1 a less favorable outcome. We categorized EU members into 3 distinct profiles based on their LQ estimates: favorable profile, LQ &lt;= 0.9; unfavorable profile, LQ &gt;1.10; and average profile, LQ between 0.9 and 1.10. We compared LQ estimates and profiles with the prevaccination era that ended in December 2020 with the COVID-19 vaccine rollout. Results Twelve member states had a favorable profile, 4 had an average profile, and 11 had an unfavorable profile. In quantitative analysis, an improvement (negative LQ difference) was noted across countries with higher vaccination coverage (median, 71% fully vaccinated vs 57% for countries with positive LQ differences). There was a significant negative association between the share of fully vaccinated and LQ changes (rho = -0.62, P &lt; .001) and a significant 4-month lag effect. After COVID-19 vaccines became available, 4 countries improved their profile and 5 moved to a worse profile. Conclusions There is significant variability in mortality and impact of COVID-19 between countries, even if they share the same regulatory framework. Extending immunization coverage may lead the transition to a more favorable profile, and alter the trajectory of COVID-19 mortality

Medicare part D prescribing for direct oral anticoagulants in the United States: Cost, use and the "rubber effect".

INTRODUCTION:Direct oral anticoagulants (DOAC) have gained an increased share over warfarin for prevention and treatment of thromboembolic disease. We studied DOAC adoption across providers and medical specialties. METHODS:Retrospective, cross-sectional analysis of Medicare Part D public use files (PUF), 2013 to 2015. We summarized prescription data for claims and drug payment, stratified by drug class, specialty and calendar year. We treated DOAC claims as a count outcome and explored patterns of expansion across prescribers via a truncated negative binomial regression. We described dispersion and spread in DOAC prescribing, across hospital referral regions (HRRs), including the p90/p10 ratios, and the median absolute deviation from the median. RESULTS:In 2015 part D PUF, oral anticoagulant claims have climbed to approximately 24.4 million with a payment cost of approximately $3.3 billion. DOAC claims comprised 31.0$367.4 (interquartile range 323.9 to 445.9), as opposed to $12.3 (interquartile range 9.2 to 16.5) for warfarin. The median cost per standardized (30-day supply) prescription was$317.0 (interquartile range 303.8 to 324.3) and $8.0 (6.7 to 9.8) for DOACs and warfarin, respectively. DOAC adoption differs by specialty. Cardiologists, cardiac electrophysiologists and orthopedics had the highest predicted DOAC share per 100 claims (53.8, 72.9 and 71.5, respectively in 2015); nephrologists, family practitioners and geriatricians the lowest (22.3, 21.5 and 20.7, respectively in 2015). The p90/p10 ratio and the median absolute deviation from the median varied across HRRs and correlated positively with the prevalence of stroke and atrial fibrillation in the Medicare population. CONCLUSIONS:DOACs have been increasing their share year-over-year, but adoption varies across specialties. In prevalent areas for stroke and atrial fibrillation, prescription dispersion magnifies, and this may signify a rapid adoption by top providers

Quantile analysis of p90/p10 percentile ratios for direct oral anticoagulant (DOAC) claims <i>vs</i>. stroke prevalence among hospital referral regions (HRRs).

<p>Each column in the graph marks a separate quintile of p90/p10 ratio in consecutive order, from the lowest (1^st) to the highest (5^th). The quintiles of stroke prevalence are marked with discrete colored bars, from the lowest (indicated with blue bar) to the highest (indicated with light blue bar) and the size of each color bar represents the percent share within each quintile of HRRs p90/p10 ratio. The differences in DOACs claims between high volume and low volume prescribers (measured by the p90/p10 ratio) were more pronounced in regions where stroke was more prevalent. For example, 4.8% of HRRs in the lowest quintile for p90/p10 ratio belonged to the highest quintile of stroke (light blue bar) in 2015 (panel A); 36.1% of HRRs in the highest quintile for p90/p10 ratio belonged to the highest quintile of stroke (light blue bar). These figures were 8.1% and 29.5%, respectively in 2014 (panel B) and 8.1% and 26.2%, respectively for 2013 (Panel C). Regional variation exists in DOAC prescribing, being more dispersed in areas with higher prevalence of stroke, as these regions are aligned towards higher p90/p10 ratios (the full set of conditional probabilities are in Tables E to G in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0198674#pone.0198674.s001" target="_blank">S1 Supplementary appendix</a>).</p

Medicare part D prescribing for direct oral anticoagulants in the United States: Cost, use and the “rubber effect” - Fig 1

<p><b>Panel A shows the cumulative part D claims (in millions) for direct oral anticoagulants, stratified by calendar year. Panel B shows the cumulative part D payments (in million dollars) for direct oral anticoagulants, stratified by calendar year</b>. The top 4 specialties are displayed. Cumulative claims and costs in part D prescriber PUF underestimate claims and costs, as records with 10 or fewer claims are suppressed by CMS policy. Cardiology and interventional cardiology are merged to compare across calendar years (since the new specialty code for interventional cardiology to distinguish from clinical cardiology became officially effective in 2015).</p

Share by drug per 100 standardized (30-day supply) prescriptions for direct oral anticoagulants (DOAC) in part D PUF, over 2013 to 2015 calendar years.

<p>The top 4 specialties by DOAC claims are displayed: (A) Cardiology, (B) Internal Medicine, (C) Family Practice, (D) Cardiac Electrophysiology. Cardiology and interventional cardiology are merged to compare across calendar years (since the new specialty code for interventional cardiology to distinguish from clinical cardiology became officially effective in 2015). Results are rounded to the first decimal. Edoxaban received FDA approval in 2015 and had no claims for 2013 and 2014 calendar years; it had fewer than <0.1% in 2015 part D PUF and does not appear in the figure.</p