Anti-Bacterial Agents ; therapeutic use ; Drug Resistance, Microbial ; Drug Resistance, Multiple ; Drug Utilization ; Humans ; World Health Organization

Intra-articular therapies, such as steroid injection, viscosupplement injection and acupuncture, are common non-surgical options for patients with osteoarthritis of the knee. With any intra-articular injection or acupuncture procedure, there is a potential for inoculation with bacteria leading to possible knee infection. The authors report a patient who incurred an acute infection found after a total knee arthroplasty attributed to prior acupuncture procedure done as part of conservative treatment.
Arthroplasty, Replacement, Knee

INTRODUCTIONPseudomonas aeruginosa (PA) bacteraemia is associated with high morbidity and mortality. We assessed clinical outcomes in patients with PA bacteraemia treated with piperacillin-tazobactam (TZP) versus other antibiotics, and monotherapy versus combination, all with proven activity by disc testing without minimum inhibitory concentration (MIC) data.

MATERIALS AND METHODSAll patients with PA bacteraemia in 2007 to 2008 were reviewed for demographic, comorbidity, clinical, laboratory, treatment and outcome data. Primary outcome was 30-day mortality. Secondary outcomes included microbiological clearance, clinical response and length of stay (LOS).

RESULTSMedian age for 91 patients was 65 years. Median Simplified Acute Physiology Score (SAPS) II score was 30. Monotherapy was used in 77 cases: 42 on ceftazidime, 17 on TZP, 10 on carbapenems, and 8 on other antipseudomonal antibiotics. The 30-day mortality was 20.9%, and similar between ceftazidime and TZP versus other antibiotics respectively. More patients in combination versus monotherapy group had cardiovascular diseases, diabetes mellitus and vascular access as source of bacteraemia. Patients on monotherapy had higher 30-day mortality (24.7% vs 0%, P = 0.037). Multivariate analysis identified SAPS II score (OR = 1.097, 95% CI, 1.032 to 1.166, P = 0.003) and cancer (OR = 4.873, 95% CI, 1.235 to 19.223, P = 0.024) as independent predictors of 30-day mortality.

CONCLUSIONTZP appeared to be an effective culture-guided antibiotic for PA bacteraemia. High 30-day mortality in monotherapy might be confounded by comorbidity, illness severity and sample size. Cancer patients and a high SAPS II score were independent predictors of 30-day mortality.

Aged ; Anti-Bacterial Agents ; therapeutic use ; Bacteremia ; drug therapy ; Ceftazidime ; therapeutic use ; Drug Therapy, Combination ; Female ; Humans ; Male ; Microbial Sensitivity Tests ; Middle Aged ; Penicillanic Acid ; analogs & derivatives ; therapeutic use ; Piperacillin ; therapeutic use ; Pseudomonas Infections ; drug therapy ; Pseudomonas aeruginosa ; Retrospective Studies ; Treatment Outcome

Adult ; Aged ; Antimalarials ; therapeutic use ; Female ; Humans ; Immune Reconstitution Inflammatory Syndrome ; drug therapy ; JC Virus ; immunology ; Leukoencephalopathy, Progressive Multifocal ; drug therapy ; Male ; Mefloquine ; therapeutic use ; Middle Aged ; Treatment Outcome

History, 20th Century ; History, 21st Century ; Rheumatology ; history ; Singapore

Adult ; Aged ; Aged, 80 and over ; Anti-Bacterial Agents ; therapeutic use ; Bacteremia ; drug therapy ; Cefazolin ; therapeutic use ; Drug Resistance, Bacterial ; Female ; Humans ; Klebsiella Infections ; drug therapy ; Klebsiella pneumoniae ; Male ; Microbial Sensitivity Tests ; Middle Aged ; Retrospective Studies ; Young Adult

INTRODUCTIONMultidrug-resistant (MDR) Gram-negative healthcare-associated infections are prevalent in Singaporean hospitals. An accurate assessment of the socioeconomic impact of these infections is necessary in order to facilitate appropriate resource allocation, and to judge the costeffectiveness of targeted interventions.

MATERIALS AND METHODSA retrospective cohort study involving inpatients with healthcare-associated Gram-negative bacteraemia at 2 large Singaporean hospitals was conducted to determine the hospitalisation costs attributed to multidrug resistance, and to elucidate factors affecting the financial impact of these infections. Data were obtained from hospital administrative, clinical and financial records, and analysed using a multivariate linear regression model.

RESULTSThere were 525 survivors of healthcare-associated Gram-negative bacteraemia in the study cohort, with 224 MDR cases. MDR bacteraemia, concomitant skin and soft tissue infection, higher APACHE II score, ICU stay, and appropriate definitive antibiotic therapy were independently associated with higher total hospitalisation costs, whereas higher Charlson comorbidity index and concomitant urinary tract infection were associated with lower costs. The excess hospitalisation costs attributed to MDR infection was $8638.58. In the study cohort, on average, 62.3% of the excess cost attributed to MDR infection was paid for by government subvention.

CONCLUSIONMultidrug resistance in healthcare-associated Gram-negative bacteraemia is associated with higher financial costs--a significant proportion of which are subsidised by public funding in the form of governmental subvention. More active interventions aimed at controlling antimicrobial resistance are warranted, and the results of our study also provide possible benchmarks against which the cost-effectiveness of such interventions can be assessed.

Aged ; Anti-Bacterial Agents ; economics ; therapeutic use ; Bacteremia ; drug therapy ; economics ; Cohort Studies ; Cost of Illness ; Cross Infection ; drug therapy ; economics ; Drug Resistance, Multiple, Bacterial ; Female ; Gram-Negative Bacterial Infections ; drug therapy ; economics ; Hospitalization ; economics ; Humans ; Intensive Care Units ; economics ; Linear Models ; Male ; Middle Aged ; Prevalence ; Retrospective Studies ; Severity of Illness Index ; Singapore

INTRODUCTIONImipenem and meropenem are treatment of choice for extended-spectrum betalactamase (ESBL)-positive gram-negative bacteraemia. They may select for carbapenemresistant Acinetobacter baumannii and Pseudomonas aeruginosa; ertapenem may not do so as it is inactive against these bacteria. Clinical efficacy of ertapenem in ESBL-producing gramnegative bacteraemia is limited.

MATERIALS AND METHODSRetrospective study of patients with ESBL-positive gram-negative bacteraemia treated with ertapenem was undertaken.

RESULTSForty-seven patients with multidrug-resistant gram-negative bacteraemia (79% produced ESBL) were treated with ertapenem for a median duration of 11 days. The median age was 70 years. Septic shock occurred in 19% and mechanical ventilation was needed in 17%. Klebsiella pneumoniae comprised 53% and Escherichia coli 26%. Urinary infection accounted for 61% and hepatobiliary 15%. Favourable clinical response occurred in 96%. Attributable mortality was 4%.

CONCLUSIONErtapenem is promising in culture-guided step-down therapy of ESBL-positive gram-negative bacteraemia.

Adult ; Aged ; Aged, 80 and over ; Anti-Bacterial Agents ; pharmacology ; therapeutic use ; Bacteremia ; drug therapy ; etiology ; Drug Resistance, Multiple, Bacterial ; Escherichia coli ; drug effects ; enzymology ; Escherichia coli Infections ; drug therapy ; microbiology ; Female ; Gram-Negative Bacteria ; drug effects ; enzymology ; Gram-Negative Bacterial Infections ; drug therapy ; microbiology ; Humans ; Klebsiella Infections ; drug therapy ; microbiology ; Klebsiella pneumoniae ; drug effects ; enzymology ; Male ; Microbial Sensitivity Tests ; Middle Aged ; Retrospective Studies ; Urinary Tract Infections ; complications ; drug therapy ; beta-Lactamases ; biosynthesis ; beta-Lactams ; pharmacology ; therapeutic use

Dengue fever (DF) has several hematological manifestations including thrombocytopenia and increased bleeding risk. Prophylactic platelet transfusion-in the absence of major bleeding-is utilized in DF with thrombocytopenia with the intention of preventing hemorrhagic complications. However, prophylactic platelet transfusion in DF is neither standardized nor supported by clinical evidence. We conclude that risks, costs and poor resource utilization associated with prophylactic platelet transfusion in DF far outweigh any potential hematological benefit, and as such, should not constitute routine clinical practice.
Dengue ; complications ; therapy ; Hemorrhage ; etiology ; prevention & control ; Humans ; Platelet Transfusion ; adverse effects ; economics ; Thrombocytopenia ; etiology ; prevention & control

INTRODUCTIONDengue fever remains a significant public health concern in Singapore. Appropriate, timely diagnosis and risk stratification for severe disease are crucial in the optimal management of this illness. In the outpatient setting, the primary care physician plays a key role in dengue diagnosis, management, and triage. We present a descriptive analysis of the variations in dengue knowledge, attitudes, and practices among primary care physicians (PCPs) in Singapore.

MATERIALS AND METHODSA survey of 25 multiple-choice questions was mailed to 2000 PCPs in Singapore. Responses were analysed by physician age group (21-40, 41-60, and >61) and practice setting (government subsidised polyclinic or private practice).

RESULTSOf the 3 questions assessing dengue knowledge, 89.9% chose 2 or 3 of the preferred responses. Half of the respondents utilised dengue diagnostic tests at least 50% of the time, and 75% used serology when doing so. Older respondents and those from private practices used diagnostic tests more often than their counterparts, and both groups favoured non-serology tests. About 85% of surveyed PCPs monitored confirmed or suspected cases daily, and one-third referred patients to a hospital always or often.

CONCLUSIONSWhile no major gaps in knowledge about dengue were identified in PCPs in Singapore, there were significant variations in clinical practice by physician age group and practice setting. The results of this survey provide a useful opportunity to identify strengths and areas in need of improved awareness in primary care management of dengue.

Adult ; Dengue ; Female ; Health Knowledge, Attitudes, Practice ; Humans ; Male ; Middle Aged ; Physicians, Primary Care ; Public Health ; Singapore ; Surveys and Questionnaires