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O72 Implementation of guidelines for empiric antibiotic therapy
Abstracts 071 Cytomegalovirus radiculomyelitis P. Gil Martinez, Gorgolas (Madrid,
infection M. Molina, E)
in
HIV
J. Polo,
I European
patients:
two
J.F. Bayona,
Journal
cases
of
E. Malmierca,
of Internal
poly-
of guidelines for empiric antibiotic H. Edelstein, A. Darawsha, A. Markel
implement to prevent
14 (2003]
Sl-S159
these guidelines the development
521
in order to optimize antibiotic of resistant pathogens.
treatment
and
M.
Gastroenterology/Hepatology
We have reviewed two cases of patients with C3-HIV infection following HAART with progressive symptoms of loss of strength in lower limbs and fever. Neurological examination revealed flaccid palsy l-2/5 and abolition of osteotendinous reflexes in lower limbs and one of the two patients referred sensitive disturbances in lumbar and sacrum region as well as loss of sphincter control. CD4 count was 150 and 20 cells/mcl. Electromyographic study revealed polyradiculo-neuropathy. Lumbar RNM was normal. Lumbar punction showed clear cerebrospinal fluid with normal glucorraquia and rare cellularity, predominantly monocytes. Culture of CSF for cytomegalovirus (CMV) was negative in both cases. Serum detection of CMV (by shell-vial culture or by p65 antigenemia in peripheral leukocytes) was positive. Treatment with intravenous ganciclovir was started and both fever and neurological symptoms improved at days 7-10. In HIV patients, prevalence of CMV infection is about 100%. CMV viremia is a risk factor to develop CMV disease, that may be disseminated in patients with CD4 count below 100 cells/mcl. Usual CNS manifestations are encephalitis, ventriculitis and lumbosacral myeloradiculitis, which supposes 2% of neurological consultations of HIV patients. CSF study usually reveals neutrophilic pleocytosis, contrary to our patients’ CSF. Culture sensitivity is only 50% and CMV is then isolated in blood smear. Treatment with ganciclovir (induction therapy with 15 mg/kg/ 12 hours for 2-3 weeks) improves symptoms in 50% of patients, mostly when diagnosis is done early. These patients require indefinite prophylaxis with ganciclovir or cidofovir.
072 Implementation I. Kometiani,
Medicine
therapy (Afula, IL)
Objective; To evaluate the implementation of guidelines for empiric antimicrobial treatment in the E.R, regarding ambulatory and hospitalized patients. Material and methods: Patients who attended the ER and received antibiotic treatment were analyzed retrospectively, according to the hospital guidelines for antibiotic treatment in the E.R. and to the General (Clalit) Health Services guidelines for antibiotic treatment. Incorrect treatment was defined by type of antibiotics and dose. Results: A total of 200 patients between 14-96 years old (44.9IT21.3), were evaluated, including, 156 patients who were discharged from the ER and 44 who were hospitalized. The main diagnoses in the subgroup of patients who were discharged included, lower urinaty tract infections (UTI) - 38.50/c, acute tonsillitis - 14.1%, pneumonia - 12.8%. upper respiratory tract infection - 8.3%, and soft tissue infections - 7.7%. Leading antibiotics for this subgroup were: roxythromycin, amoxacyllin/ clavulanic acid, doxycycline, ofloxacin, and phenoxymethyl penicillin. In the subgroup of hospitalized patients, the main diagnoses were pneumonia - 36.4%, UT1 - 29.5%, and fever of unknown origin - 11.4%. Only 19/44 (43%) of the hospitalized patients started antibiotics at the ER. Leading antibiotics in the hospitalized patients that begun therapy at the ER were cefuroxime - 68.4% and ceftriaxon - 15.7%. For more than half of the diagnoses (59%) at the ER, the empiric antibiotic treatment given was incorrect, according to both mentioned guidelines. Wrong treatment was more frequent in the subgroup of patients who were discharged than in the patients who were hospitalized: 99/156 (63%) vs. 18/44 (410/o), respectively. Conclusions: Despite guidelines for the administration of empiric antibiotic therapy. a high proportion of patients still receive incorrect antibiotic therapy. Further, massive work, should be done in the ER to
073 Study of c-myc oncogene in hepatocellular N.A. Moustafa, A.F. Amer, M.F. El Moufty, Aziz, S.A. Zaki (Alexandria, EG)
carcinoma S.M. Abdel
Salam,
A. Abdel
Structural alterations in c-myc oncogene, copy number and expression have been implicated in the pathogenesis and progression of several human neoplastic diseases. However, the biologic significance of c-myc gene in human hepatocellular carcinoma (HCC) is unconfirmed. In the present study we correlated c-myc gene amplification and protein expression with the clinicopathologic features in 20 HCC cases c-myc amplification in tumour tissue was determined using a differential PCR, a procedure for the evaluation of gene amplification in comparison with a dopamine D2 receptor gene. The c-myc gene was amplified in 6 out of 20 tumour specimens (30%). Amplification of c-myc was more frequent in younger male patients with HBV infection and in less differentiated tumours. All cases demonstrated positive staining using anti-c-myc monoclonal antibody with increasing percentage of immunoreactive cells in less differentiated turnours. However, the high protein expression was not statistically correlated with c-myc amplification.
074 Upper gastrointestinal bleeding of non-variceal ori@n (UGB): differences between conventional and early discharge management J. Marco, R. Rodriguez Rosado, C. Vicente, P Serrano, R. Mielgo, J.L. Moran, P. Rondon, J.L. Castro (Madrid, E) Objective: We run an early discharge unit (EDU) with an expected maximum hospital stay of 5 days at an urban hospital in Madrid caring for 400,000 people. Upper gastrointestinal bleeding of non-variceal origin (UGB) is one of the diagnoses admitted in our unit. Our aim was to identify differences in management and outcome of this diagnosis between our unit and other hospital units like internal medicine (IM) and gastro-enterology (GE). Methods: Retrospective analysis of clinical records from patients admitted with this diagnosis in the three units: EDU, IM and GE. Results: Between 12-l-99 and 9-30-2002 we identified 260 cases of HDA: 81 (31%) in EDU, 86 (33%) in IM and 79 (30%) in GE. Mean age was 54, 67 and 57 years respectively with no difference in sex distribution (68% male). Mean hospital stay was 4.9, 11.5 and 8.62 days in EDU, IM and GE respectively, although co-morbidity was clearly higher in IM. When cases of destabilisation of co-morbid conditions (45 in 245 patients; 18.4%) were discarded, there were still differences in hospital stay: 4 for EDHU, 8 for GI and 9 for IM. 17 (21%), 45 (52%) and 32 (40%) in EDU, IM and GE respectively required transfusion (p 0.00014) with a mean of 3 units and no differences between groups. No differences were found in rates of early or late re-bleeding episodes between groups. Early hospital re-admittance (in the 30 day period after discharge) occurred in 3 (350/o), 3 (3.8%) and 2 (2.5%) in IM, GE and EDU patients respectively. Peptic ulcer was the most frequent bleeding lesion in all groups with 22 (27%) in EDU, 23 (23%) in IM and 34 (43%) in GE for gastric ulcer and 35 (43%) in EDU, 23 (26%) in IM and 21 (26%) in GE for duodenal ulcer. Mortality was higher in MI (8 cases, 9.3%) vs. 1 case (1.2%) in EDU and 1 case (1.3%) in GE; p
infection M. Molina, E)
in
HIV
J. Polo,
I European
patients:
two
J.F. Bayona,
Journal
cases
of
E. Malmierca,
of Internal
poly-
of guidelines for empiric antibiotic H. Edelstein, A. Darawsha, A. Markel
implement to prevent
14 (2003]
Sl-S159
these guidelines the development
521
in order to optimize antibiotic of resistant pathogens.
treatment
and
M.
Gastroenterology/Hepatology
We have reviewed two cases of patients with C3-HIV infection following HAART with progressive symptoms of loss of strength in lower limbs and fever. Neurological examination revealed flaccid palsy l-2/5 and abolition of osteotendinous reflexes in lower limbs and one of the two patients referred sensitive disturbances in lumbar and sacrum region as well as loss of sphincter control. CD4 count was 150 and 20 cells/mcl. Electromyographic study revealed polyradiculo-neuropathy. Lumbar RNM was normal. Lumbar punction showed clear cerebrospinal fluid with normal glucorraquia and rare cellularity, predominantly monocytes. Culture of CSF for cytomegalovirus (CMV) was negative in both cases. Serum detection of CMV (by shell-vial culture or by p65 antigenemia in peripheral leukocytes) was positive. Treatment with intravenous ganciclovir was started and both fever and neurological symptoms improved at days 7-10. In HIV patients, prevalence of CMV infection is about 100%. CMV viremia is a risk factor to develop CMV disease, that may be disseminated in patients with CD4 count below 100 cells/mcl. Usual CNS manifestations are encephalitis, ventriculitis and lumbosacral myeloradiculitis, which supposes 2% of neurological consultations of HIV patients. CSF study usually reveals neutrophilic pleocytosis, contrary to our patients’ CSF. Culture sensitivity is only 50% and CMV is then isolated in blood smear. Treatment with ganciclovir (induction therapy with 15 mg/kg/ 12 hours for 2-3 weeks) improves symptoms in 50% of patients, mostly when diagnosis is done early. These patients require indefinite prophylaxis with ganciclovir or cidofovir.
072 Implementation I. Kometiani,
Medicine
therapy (Afula, IL)
Objective; To evaluate the implementation of guidelines for empiric antimicrobial treatment in the E.R, regarding ambulatory and hospitalized patients. Material and methods: Patients who attended the ER and received antibiotic treatment were analyzed retrospectively, according to the hospital guidelines for antibiotic treatment in the E.R. and to the General (Clalit) Health Services guidelines for antibiotic treatment. Incorrect treatment was defined by type of antibiotics and dose. Results: A total of 200 patients between 14-96 years old (44.9IT21.3), were evaluated, including, 156 patients who were discharged from the ER and 44 who were hospitalized. The main diagnoses in the subgroup of patients who were discharged included, lower urinaty tract infections (UTI) - 38.50/c, acute tonsillitis - 14.1%, pneumonia - 12.8%. upper respiratory tract infection - 8.3%, and soft tissue infections - 7.7%. Leading antibiotics for this subgroup were: roxythromycin, amoxacyllin/ clavulanic acid, doxycycline, ofloxacin, and phenoxymethyl penicillin. In the subgroup of hospitalized patients, the main diagnoses were pneumonia - 36.4%, UT1 - 29.5%, and fever of unknown origin - 11.4%. Only 19/44 (43%) of the hospitalized patients started antibiotics at the ER. Leading antibiotics in the hospitalized patients that begun therapy at the ER were cefuroxime - 68.4% and ceftriaxon - 15.7%. For more than half of the diagnoses (59%) at the ER, the empiric antibiotic treatment given was incorrect, according to both mentioned guidelines. Wrong treatment was more frequent in the subgroup of patients who were discharged than in the patients who were hospitalized: 99/156 (63%) vs. 18/44 (410/o), respectively. Conclusions: Despite guidelines for the administration of empiric antibiotic therapy. a high proportion of patients still receive incorrect antibiotic therapy. Further, massive work, should be done in the ER to
073 Study of c-myc oncogene in hepatocellular N.A. Moustafa, A.F. Amer, M.F. El Moufty, Aziz, S.A. Zaki (Alexandria, EG)
carcinoma S.M. Abdel
Salam,
A. Abdel
Structural alterations in c-myc oncogene, copy number and expression have been implicated in the pathogenesis and progression of several human neoplastic diseases. However, the biologic significance of c-myc gene in human hepatocellular carcinoma (HCC) is unconfirmed. In the present study we correlated c-myc gene amplification and protein expression with the clinicopathologic features in 20 HCC cases c-myc amplification in tumour tissue was determined using a differential PCR, a procedure for the evaluation of gene amplification in comparison with a dopamine D2 receptor gene. The c-myc gene was amplified in 6 out of 20 tumour specimens (30%). Amplification of c-myc was more frequent in younger male patients with HBV infection and in less differentiated tumours. All cases demonstrated positive staining using anti-c-myc monoclonal antibody with increasing percentage of immunoreactive cells in less differentiated turnours. However, the high protein expression was not statistically correlated with c-myc amplification.
074 Upper gastrointestinal bleeding of non-variceal ori@n (UGB): differences between conventional and early discharge management J. Marco, R. Rodriguez Rosado, C. Vicente, P Serrano, R. Mielgo, J.L. Moran, P. Rondon, J.L. Castro (Madrid, E) Objective: We run an early discharge unit (EDU) with an expected maximum hospital stay of 5 days at an urban hospital in Madrid caring for 400,000 people. Upper gastrointestinal bleeding of non-variceal origin (UGB) is one of the diagnoses admitted in our unit. Our aim was to identify differences in management and outcome of this diagnosis between our unit and other hospital units like internal medicine (IM) and gastro-enterology (GE). Methods: Retrospective analysis of clinical records from patients admitted with this diagnosis in the three units: EDU, IM and GE. Results: Between 12-l-99 and 9-30-2002 we identified 260 cases of HDA: 81 (31%) in EDU, 86 (33%) in IM and 79 (30%) in GE. Mean age was 54, 67 and 57 years respectively with no difference in sex distribution (68% male). Mean hospital stay was 4.9, 11.5 and 8.62 days in EDU, IM and GE respectively, although co-morbidity was clearly higher in IM. When cases of destabilisation of co-morbid conditions (45 in 245 patients; 18.4%) were discarded, there were still differences in hospital stay: 4 for EDHU, 8 for GI and 9 for IM. 17 (21%), 45 (52%) and 32 (40%) in EDU, IM and GE respectively required transfusion (p 0.00014) with a mean of 3 units and no differences between groups. No differences were found in rates of early or late re-bleeding episodes between groups. Early hospital re-admittance (in the 30 day period after discharge) occurred in 3 (350/o), 3 (3.8%) and 2 (2.5%) in IM, GE and EDU patients respectively. Peptic ulcer was the most frequent bleeding lesion in all groups with 22 (27%) in EDU, 23 (23%) in IM and 34 (43%) in GE for gastric ulcer and 35 (43%) in EDU, 23 (26%) in IM and 21 (26%) in GE for duodenal ulcer. Mortality was higher in MI (8 cases, 9.3%) vs. 1 case (1.2%) in EDU and 1 case (1.3%) in GE; p