Performance and clinical significance of direct antimicrobial susceptibility testing on urine from hospitalized patients

Item does not contain fulltextBACKGROUND: Urinary tract infections (UTIs) are common infections in the community and the hospital. With increasing antimicrobial resistance, specifically in the Gram-negative uropathogens, reliable, rapid antimicrobial susceptibility data would be useful to guide antimicrobial treatment. Direct antimicrobial susceptibility testing (DST) of urine with microscopic evidence of Gram-negative bacterial infection and its clinical significance was investigated in this study. METHODS: DST was performed by Kirby-Bauer disk diffusion method using undiluted urine as a non-standardized inoculum. Urine specimens with Gram-negative bacteria on microscopy were included. DST results from growth of Gram-negative bacteria were compared to routine antimicrobial susceptibility testing by Phoenix automated system (AST). Errors were scored as 'very major error' if susceptible by DST but resistant by AST and as 'major error' if resistant by DST but susceptible by AST. All other discrepancies were defined as 'minor error'. Discrepancies were resolved by determination of minimum inhibitory concentrations (MICs) using Etests. After discrepancy analysis, errors were scored as above using the Etest as the reference method. For analysis, specimens were divided into 3 categories: category A: 1 isolate found by DST as well as by routine culture; category B: 1 isolate detected by DST, but more than 1 isolate found on routine culture; category C: more than 1 isolate found by both DST and routine culture. The clinical significance of DST was determined prospectively by investigating the potential impact of DST on antimicrobial therapy. RESULTS: One hundred and sixteen urine specimens were included. For DST and AST there was agreement in 96% of 1152 comparisons in category A (n = 100), 88% of 41 comparisons in category B (n = 4), and 88% of 110 comparisons in category C (n = 12). The 64 discrepancies included 18 very major errors, 7 major errors, and 39 minor errors. Eight very major errors and 11 minor errors were not investigated because the isolates were not available. After Etest MIC determination for the 45 remaining discrepancies, DST showed 1 very major error, 1 major error, and 8 minor errors in category A, none in category B, and 5 major errors and 4 minor errors in category C. Antimicrobial therapy for UTI was prescribed for 53 patients. For 4 patients (8%) therapy was adjusted based on DST because of antimicrobial resistance and for 12 patients (23%) antimicrobial treatment could have been streamlined. CONCLUSIONS: DST on urine is reliable in monobacterial Gram-negative infections. With increasing antimicrobial resistance, DST can make an important contribution to patient management and reduce the use of broad-spectrum antimicrobials

Psychomotor Retardation and the prognosis of antidepressant treatment in patients with unipolar Psychotic Depression

Background: Psychomotor Retardation is a key symptom of Major Depressive Disorder. According to the literature its presence may affect the prognosis of treatment. Aim of the present study is to investigate the prognostic role of Psychomotor Retardation in patients with unipolar Psychotic Depression who are under antidepressant treatment. Methods: The Salpetriere Retardation Rating Scale was administered at baseline and after 6 weeks to 122 patients with unipolar Psychotic Depression who were randomly allocated to treatment with imipramine, venlafaxine or venlafaxine plus quetiapine. We studied the effects of Psychomotor Retardation on both depression and psychosis related outcome measures. Results: 73% of the patients had Psychomotor Retardation at baseline against 35% after six weeks of treatment. The presence of Psychomotor Retardation predicted lower depression remission rates in addition to a higher persistence of delusions. After six weeks of treatment, venlafaxine was associated with higher levels of Psychomotor Retardation compared to imipramine and venlafaxine plus quetiapine. Conclusions: Our data confirm that Psychomotor Retardation is a severity marker of unipolar Psychotic Depression. It is highly prevalent and predicts lower effectivity of antidepressant psychopharmacological treatment

Long-term response to successful acute pharmacological treatment of psychotic depression

Background: Data about follow-up after acute pharmacological treatment of psychotic depression are scarce. Methods: A 4 month open follow-up was done, preferentially with same medication as during acute treatment, of patients (n=59) with DSM-IV-TR major depressive disorder with psychotic features, aged 18 to 65 years, who had completed as responders an acute double-blind 7 week trial with imipramine, venlafaxine or venlafaxine plus quetiapine. Main outcome measures were Hamilton Rating Scale for Depression and Clinical Global Impression Scale. Results: Six patients dropped out during the 4 month follow-up. Almost all patients (86.4%; 51/59) remained responder while remission rate increased from 59.3% (35/59) to 86.8% (46/53), independent of treatment. Relapse rate was low (3.8%; 2/53). Tolerability was good. Weight increased with all treatments. Limitations: Limitations were the limited sample size and consequent limited statistical power. The treatment during follow-up was not double-blind. Conclusions: Continuation treatment with the same medication that was effective in the acute treatment trial, remained effective during the 4 month follow-up in many patients leading to further improvement, and was well tolerated. (C) 2009 Elsevier B.V. All rights reserved

Treatment of unipolar psychotic depression: a randomized, double-blind study comparing imipramine, venlafaxine, and venlafaxine plus quetiapine

Objective: It remains unclear whether unipolar psychotic depression should be treated with an antidepressant and an antipsychotic or with an antidepressant alone. Method: In a multi-center RCT, 122 patients (18-65 years) with DSM-IV-TR psychotic major depression and HAM-D-17 >= 18 were randomized to 7 weeks imipramine (plasma-levels 200-300 mu g/l), venlafaxine (375 mg/day) or venlafaxine-quetiapine (375 mg/day, 600 mg/day). Primary outcome was response on HAM-D-17. Secondary outcomes were response on CGI and remission (HAM-D-17). Results: Venlafaxine-quetiapine was more effective than venlafaxine with no significant differences between venlafaxine-quetiapine and imipramine, or between imipramine and venlafaxine. Secondary outcomes followed the same pattern. Conclusion: That unipolar psychotic depression should be treated with a combination of an antidepressant and an antipsychotic and not with an antidepressant alone, can be considered evidence based with regard to venlafaxine-quetiapine vs. venlafaxine monotherapy. Whether this is also the case for imipramine monotherapy is likely, but cannot be concluded from the data