508. Gentamicin Non-susceptibility is Associated with Persistence of Carbapenem-Resistant Klebsiella pneumoniae in the Urinary Tract.
NORTH Carolina; hospital admission; bacteriuria; urine; laboratory; antimicrobial susceptibility; Klebsiella pneumonia; bacteriuria; CENTERS for Disease Control & Prevention (U.S.); urinary tract infections; URINARY organs; urinary tract; health care systems; disclosure; CENTERS for Disease Control & Prevention (U.S.); amikacin; antibiotic overuse; carbapenem resistance; carbapenem-resistant enterobacteriaceae; GENTAMICIN; gentamicin sulfate (usp); gentamicins; health care safety; Klebsiella pneumonia; midwestern united states; persistence; persistence; rales; signs and symptoms; trimethoprim-sulfamethoxazole combination; urinary tract infections; urine culture
Background Urinary tract infection (UTI) is the most common clinical manifestation of carbapenem-resistant Klebsiella pneumoniae (CR Kp). Persistent CR Kp bacteriuria is associated with the spread of CR Kp and antibiotic overuse. Risk factors for persistent CR Kp bacteriuria are uncertain. Methods CRACKLE-1 was a multicenter, prospective study that included 960 patients with at least one carbapenem-resistant Enterobacteriaceae (CRE)-positive culture from December 2011 to June 2016 collected from 18 hospitals encompassing 8 healthcare systems in the Midwestern US and North Carolina. Patients with CR Kp bacteriuria who were discharged alive from index hospitalization were included in the current study, and sporadic (single positive CR Kp urine culture) and persistent (≥2 CR Kp urine cultures during independent hospital admissions occurring at least 2 days apart) cases were compared. Antibiotic susceptibility testing was performed by local laboratories. Amikacin, gentamicin (GENT), and trimethoprim/sulfamethoxazole were included in the analysis based on variance and frequency of testing. The CDC/National Healthcare Safety Network criteria for UTI were used. Results CR Kp was the most common CRE isolate (n = 869, prevalence 91%). In patients with CR Kp , 527 had CR Kp isolated from the urine (prevalence 61%, 95% CI 0.57, 0.64). Of these, 486 patients, of whom 129 (27%) were diagnosed with a UTI, were discharged alive. Notably, 135/486 (28%) patients with CR Kp bacteriuria were readmitted and yielded a second urine culture of CR Kp. Most patients with persistent bacteriuria, 99/135 (73%), were asymptomatic at initial admission. Of these patients, 20/99 (20%) were diagnosed with a UTI at second admission. In multivariable analysis, only GENT non-susceptibility was associated with an increased risk (adjusted OR 1.66, 95% CI 1.10–2.49) of persistent bacteriuria. Persistent bacteriuria was independent of GENT treatment during index hospitalization (GENT was used in 15% of patients). Conclusion Bacteriuria with GENT non-susceptible CR Kp strains was associated with persistent bacteriuria. As this was independent of GENT treatment, GENT resistance determinants may be co-transmitted along with traits that promote bacterial persistence in CR Kp. Disclosures All authors: No reported disclosures. [ABSTRACT FROM AUTHOR]
Luterbach Courtney L; Henderson Heather I; Cober Eric; Richter Sandra S; Salata Robert A; Kaye Keith S; Doi Yohei; Watkins Richard R; Bonomo Robert A; Duin David van
Open Forum Infectious Diseases
2019
2019-10-02
Journal Article
<a href="http://doi.org/10.1093/ofid/ofz360.577" target="_blank" rel="noreferrer noopener">10.1093/ofid/ofz360.577</a>
The rules of three in oliguria: how to use this technique for evaluation.
Adult; Female; Male; Aged; Algorithms; Clinical Assessment Tools; Diagnosis; Laboratory; Urologic; Kidney – Ultrasonography; Oliguria – Etiology
A systematic approach to the successful investigation and management of oliguria uses a reproducible method called the Rules of Three: consideration of three sources of olguria (postrenal, prerenal, and renal), three noninvasive tools for evaluation (history and physical examination, ultrasonography, and urinalysis with urinary electrolyte values), and three helpful clinical maxims. Constant application of this system provides clues to the presence of hidden but reversible postrenal and prerenal causes of oliguria. This approach also yields consistent and accurate results when used to evaluate azotemia and proteinuria
Rutecki G W; Whittier F C
Consultant (00107069)
1993
1993-01
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
Managing the patient with anaphylaxis, part 2: therapeutic strategies.
Adult; Child; Diagnosis; Laboratory; Emergency Care; Histamine Antagonists; Anaphylaxis – Drug Therapy; Epinephrine – Administration and Dosage; Hydrocortisone – Administration and Dosage; Anaphylaxis – Diagnosis; Glucagon – Administration and Dosage; Histamine H2 Antagonists – Administration and Dosage; Methylprednisolone – Administration and Dosage
Mackan MD
Emergency Medicine (00136654)
1995
1995-03
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
Magnesium disorders: what to do when homeostasis goes awry.
Adult; Female; Male; Aged; Outpatients; Middle Age; Diagnosis; Laboratory; Magnesium; Hypermagnesemia; Hypomagnesemia; Hypermagnesemia – Diagnosis; Hypermagnesemia – Drug Therapy; Hypermagnesemia – Etiology; Hypomagnesemia – Diagnosis; Hypomagnesemia – Drug Therapy; Hypomagnesemia – Etiology; Magnesium – Analysis; Magnesium Sulfate – Administration and Dosage
Hypomagnesemia may be caused by renal losses (often related to drugs or diabetes), inadequate intake or inadequate intestinal absorption. Manifestations may include arrhythmias, particularly during myocardial ischemia or with digitalis use, and such neurologic findings tremors, seizures, and eventually coma. Measure magnesium levels in critically ill patients, those with diabetes or alcoholism, and those taking drugs associated with magnesium loss. Magnesium deficiency often coexists with hypokalemia and hypocalcemia: to correct the latter abnormalities, replete the magnesium deficit first. Base your decision to replace the magnesium orally or parenterally on symptom severity, rather than on absolute serum levels. Magnesium excess may lead to cardiac arrest, with symptoms resembling hyperkalemia. Treat as you would for hyperkalemia, with IV calcium gluconate, insulin, and dextrose.
Trehan S; Rutecki G W; Whittier F C
Consultant (00107069)
1996
1996-11
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
Hypokalemia: clinical implications, consequences, and corrective measures.
Adult; Female; Male; Aged; Muscle Weakness; Outpatients; Electrocardiography; Physical Examination; Diagnosis; Differential; Laboratory; Acid-Base Imbalance; Premature Ventricular Contractions; Hypokalemia – Diagnosis; Hypokalemia – Complications; Hypokalemia – Drug Therapy; Hypokalemia – Etiology; Hypokalemia – Physiopathology; Potassium – Administration and Dosage; Potassium – Drug Effects; Potassium – Metabolism
Rutecki G W; Whittier F C
Consultant (00107069)
1996
1996-01
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
Hyperkalemia: how to identify – and correct – the underlying cause... second of two articles.
Adult; Female; Dialysis; Male; Outpatients; Electrocardiography; Middle Age; Diagnosis; Differential; Laboratory; Insulin – Administration and Dosage; Adrenergic Beta-Agonists – Administration and Dosage; Calcium – Administration and Dosage; Cation Exchange Resins – Administration and Dosage; Diuretics – Administration and Dosage; Hyperkalemia – Diagnosis; Hyperkalemia – Drug Therapy; Hyperkalemia – Etiology; Potassium – Analysis; Sodium Bicarbonate – Administration and Dosage
Precipitants of hyperkalemia include diabetes, certain medications (eg, NSAIDs, ACE inhibitors), tissue injury, and hormonal abnormalities. Hyperkalemia alters the extracellular to intracellular potassium gradient, which decreases the resting membrane potential and may cause flaccid muscle paralysis and cardiac arrhythmias. Use the absolute serum potassium level and an ECG to measure the extent of end-organ dysfunction. ECG abnormalities include tall peaked T waves, decreased amplitude and/or absence of P waves, and QRS widening. To manage hyperkalemia, start with a membrane stabilizer (eg, IV calcium gluconate; also give agents (eg, insulin, sodium bicarbonate, or beta-agonists) that shift excess extracellular potassium into cells. To remove potassium altogether, consider diuretics, sodium polystyrene sulfonate, and/or dialysis.
Rutecki G W; Whittier F C
Consultant (00107069)
1996
1996-03
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
Case & comment: rheumatology. 'Is it the rheumatism, doc?'... polyarticular gout.
Male; Outpatients; Diagnostic Errors; Middle Age; Diagnosis; Laboratory; Gout – Diagnosis; Gout – Drug Therapy
Rothschild B M
Patient Care
1995
1995-10-30
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
Case & comment: rheumatology. Droopy eyes and pain all over... dermatomyositis.
Female; Outpatients; Physical Examination; Middle Age; Diagnosis; Laboratory; Dermatomyositis – Diagnosis; Prednisone – Administration and Dosage
Rothschild B M
Patient Care
1996
1996-09-15
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
Unexplained fever in infants and young children: when is it serious?
Infant; Body Temperature; Age Factors; Physical Examination; Clinical Assessment Tools; Diagnosis; Newborn; Laboratory; Patient History Taking; Bacterial Infections – Diagnosis – In Infancy and Childhood; Blood – Analysis – In Infancy and Childhood; Fever – Etiology – In Infancy and Childhood; Urinalysis – In Infancy and Childhood
When an infant or child younger than 36 months presents with fever that has no obvious source, the major concern is overlooking a serious bacterial infection. Ask about underlying medical problems, previous hospitalizations, recent infectious contacts, current or recent antibiotic therapy, previous infectious illnesses, and immunization status. Determine whether an infant younger than 60 days was premature, received perinatal antibiotics, or had unexplained hyperbilirubinemia. The cutoff temperature varies by age for fever that signals the need for further evaluation: 38 degrees C (100.4 degrees F) or greater for infants younger than 60 days, and 39 degrees C (102.2 degrees F) or greater for children 60 days to 36 months of age. A white blood cell (WBC) count between 5000/microL and 15,000/microL in infants younger than 60 days indicates a very low risk of serious bacterial infection. In older infants and children who have high fever, a WBC count greater than 15,000/microL raises the relative risk of bacteremia 5-fold.
Bower J R; Powell K R
Consultant (00107069)
2001
2001-04-15
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
Decision points in hypocalcemia: is emergent therapy required? Complications may include tetany, seizures, and arrhythmias.
Inpatients; Diagnosis; Laboratory; Hypocalcemia – Diagnosis; Hypocalcemia – Symptoms; Hypocalcemia – Therapy; Hypoparathyroidism – Complications; Magnesium – Administration and Dosage; Pancreatitis – Complications
When a patient's total serum calcium level drops below 8.9 mg/dL, first determine whether the hypocalcemia is real. Measure the serum level of ionized calcium or (because 40% of calcium is bound to protein) adjust the total serum calcium level for changes in serum protein concentrations. This helps determine whether the calcium imbalance is severe and whether emergent treatment (with infusions of elemental calcium) is required. Symptoms and signs of neuromuscular irritability, such as Chvostek's sign and Trousseau's sign, point to true hypocalcemia. Hypomagnesemia often accompanies–and even may cause–hypocalcemia; when the serum magnesium level falls below the normal limit, the ability of the parathyroid hormone to stimulate osteoclast growth and activity can be diminished.
Rutecki G W; Whittier F C
Journal of Critical Illness
1998
1998-02
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
Case & comment: rheumatology. All that glistens is not gout... calcium pyrophosphate deposition disease (CPDD)
Male; Physical Examination; Microscopy; Middle Age; Diagnosis; Differential; Laboratory; Paracentesis; Hyperparathyroidism – Complications; Hyperparathyroidism – Surgery; Calcium Metabolism Disorders – Diagnosis; Joint Diseases – Diagnosis; Metatarsophalangeal Joint – Pathology
Rothschild B M
Patient Care
1997
1997-06-15
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
Case & comment. The bloody tip of the iceberg... hemarthrosis.
Male; Outpatients; Physical Examination; Middle Age; Diagnosis; Differential; Laboratory; Hemorrhage – Diagnosis; Knee Injuries – Diagnosis; Knee Joint – Pathology; Liver Cirrhosis – Complications
Rothschild B M; Kubitz ER
Patient Care
1997
1997-09-15
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
Laboratory exercise using "virtual rats" to teach endocrine physiology.
*Rats; *Teaching Materials; Animal Welfare; Animals; Curriculum; Education; Endocrinology/*education; Humans; Laboratory; Medical; Undergraduate/*methods
Animal experimentation is limited in many curricula due to the expense, lack of adequate animal facilities and equipment, and limited experience of the teachers. There are also ethical concerns dealing with the comfort and safety of the animals. To overcome these obstacles, we developed a "dry laboratory" using "virtual rats." The "virtual rat" eliminates the obstacles inherent in animal experimentation, such as inadequate budgets, as well as avoiding important animal rights issues. Furthermore, no special materials are required for the completion of this exercise. Our goal in developing this dry laboratory was to create an experience that would provide students with an appreciation for the value of laboratory data collection and analysis. Students are exposed to the challenge of animal experimentation, experimental design, data collection, and analysis and interpretation without the issues surrounding the use of live animals.
Odenweller C M; Hsu C T; Sipe E; Layshock J P; Varyani S; Rosian R L; DiCarlo S E
The American journal of physiology
1997
1997-12
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1152/advances.1997.273.6.S24" target="_blank" rel="noreferrer noopener">10.1152/advances.1997.273.6.S24</a>
Justifying multiple survival surgeries. Approval is appropriate.
*Animal Use Alternatives; Animal Care Committees/*legislation & jurisprudence; Animal Welfare/*legislation & jurisprudence; Animals; Decision Making; Female; Jurisprudence; Laboratory; Organizational; Pain/prevention & control; Research Design; Surgery; Unnecessary Procedures/ethics/*veterinary; Veterinary/*legislation & jurisprudence; Xenopus/*physiology
Horne Walter I
Lab animal
2010
2010-07
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.1038/laban0710-202" target="_blank" rel="noreferrer noopener">10.1038/laban0710-202</a>