Bruce K. Dixon

CHICAGO — Family physicians can close gaping holes in the safety net for individuals with bipolar disorder by following a few important guidelines, according to Dr. John R. Purvis.

“This is a very complicated illness with complicated treatment, and it's our job as family doctors to diagnose these patients,” Dr. Purvis said at the annual meeting of the American Academy of Family Physicians.

Research data suggest that two-thirds of bipolar patients are initially misdiagnosed. In addition, patients see a mean of four physicians before the correct diagnosis is made, and more than one-third wait 10 years or longer for the correct diagnosis (J. Clin. Psychiatry 2003;64:161–74).

“It's estimated that 3%–4% of the population has some sort of bipolar spectrum disorder, and roughly 20% of people who walk into your office with depression have bipolar disorder,” said Dr. Purvis, associated director of the family practice residency program at Tallahassee Memorial Healthcare in Florida.

Family physicians should use the Mood Disorder Questionnaire to screen all patients presenting with depression, panic disorder, or anxiety disorder, Dr. Purvis advised.

Because the questionnaire is designed for screening only, its results should be confirmed by the physician's evaluation, and “if you're unsure or uncomfortable managing the patient yourself, get a consultation with a psychiatrist,” he added.

A key question to ask patients is, “Do you have racing thoughts?” he said. “This is the most important question. In my experience, it is almost diagnostic, particularly when the racing thoughts keep the patient awake.”

Risk is increased in those with first-degree relatives who have bipolar illness or major depression. In addition, seasonal depression, postpartum depression, psychotic depression, and atypical depression should raise suspicion.

There's a common misconception that bipolar I (and II) disease involves regular intervals of mania (or hypomania) and depression separated by periods of euthymia, Dr. Purvis said.

“Even though the diagnosis rests with mania and hypomania, bipolar disease is primarily a disease of depression. Those who are bipolar I spend three times as much of their time depressed as they do manic, and for bipolar II illness the ratio is 1% of the time hypomanic and 50% of the time depressed,” he noted.

Comorbid conditions include attention-deficit/hyperactivity disorder, panic attacks, social phobia, and obsessive-compulsive phenomena.

“If you just make the diagnosis of bipolar disorder, you have done the patient a huge service,” Dr. Purvis said, explaining that bipolar patients often have chaotic lives, “so it's important to set boundaries, particularly regarding appointments and pain medications.”

The goals of treatment are to restore sleep, normalize mood, and maximize executive and cognitive functioning.

“The foundation of treatment of bipolar disorders is behavioral and medication therapy,” he said, adding that a good place for the treating physician to start is with the Texas Treatment Guidelines of 2005 (http://www.psycheducation.org/depression/APAguide.htm

Although some physicians believe that it's acceptable to use antidepressants with mood stabilizers, Dr. Purvis said he believes that mood stabilizers should be used to treat bipolar depression and that antidepressants should be used with caution and for only short periods of time.

“The one thing that is very clear is that antidepressant monotherapy in bipolar depressed patients is not acceptable,” he said in an interview.

Dr. Purvis noted that for some patients, bipolar illness can confer an advantage. “Bipolar illness is sort of like uranium, which can level a city or light a city. Some of the most creative people—including researchers, physicians, CEOs, and actors—are bipolar and can work on several levels at once when they're not in a depressed mood,” he said, adding that careful treatment is necessary to keep such patients from self-destructing.

CHICAGO — Family physicians can close gaping holes in the safety net for individuals with bipolar disorder by following a few important guidelines, according to Dr. John R. Purvis.

“This is a very complicated illness with complicated treatment, and it's our job as family doctors to diagnose these patients,” Dr. Purvis said at the annual meeting of the American Academy of Family Physicians.

Research data suggest that two-thirds of bipolar patients are initially misdiagnosed. In addition, patients see a mean of four physicians before the correct diagnosis is made, and more than one-third wait 10 years or longer for the correct diagnosis (J. Clin. Psychiatry 2003;64:161–74).

“It's estimated that 3%–4% of the population has some sort of bipolar spectrum disorder, and roughly 20% of people who walk into your office with depression have bipolar disorder,” said Dr. Purvis, associated director of the family practice residency program at Tallahassee Memorial Healthcare in Florida.

Family physicians should use the Mood Disorder Questionnaire to screen all patients presenting with depression, panic disorder, or anxiety disorder, Dr. Purvis advised.

Because the questionnaire is designed for screening only, its results should be confirmed by the physician's evaluation, and “if you're unsure or uncomfortable managing the patient yourself, get a consultation with a psychiatrist,” he added.

A key question to ask patients is, “Do you have racing thoughts?” he said. “This is the most important question. In my experience, it is almost diagnostic, particularly when the racing thoughts keep the patient awake.”

Risk is increased in those with first-degree relatives who have bipolar illness or major depression. In addition, seasonal depression, postpartum depression, psychotic depression, and atypical depression should raise suspicion.

There's a common misconception that bipolar I (and II) disease involves regular intervals of mania (or hypomania) and depression separated by periods of euthymia, Dr. Purvis said.

“Even though the diagnosis rests with mania and hypomania, bipolar disease is primarily a disease of depression. Those who are bipolar I spend three times as much of their time depressed as they do manic, and for bipolar II illness the ratio is 1% of the time hypomanic and 50% of the time depressed,” he noted.

Comorbid conditions include attention-deficit/hyperactivity disorder, panic attacks, social phobia, and obsessive-compulsive phenomena.

“If you just make the diagnosis of bipolar disorder, you have done the patient a huge service,” Dr. Purvis said, explaining that bipolar patients often have chaotic lives, “so it's important to set boundaries, particularly regarding appointments and pain medications.”

The goals of treatment are to restore sleep, normalize mood, and maximize executive and cognitive functioning.

“The foundation of treatment of bipolar disorders is behavioral and medication therapy,” he said, adding that a good place for the treating physician to start is with the Texas Treatment Guidelines of 2005 (http://www.psycheducation.org/depression/APAguide.htm

Although some physicians believe that it's acceptable to use antidepressants with mood stabilizers, Dr. Purvis said he believes that mood stabilizers should be used to treat bipolar depression and that antidepressants should be used with caution and for only short periods of time.

“The one thing that is very clear is that antidepressant monotherapy in bipolar depressed patients is not acceptable,” he said in an interview.

Dr. Purvis noted that for some patients, bipolar illness can confer an advantage. “Bipolar illness is sort of like uranium, which can level a city or light a city. Some of the most creative people—including researchers, physicians, CEOs, and actors—are bipolar and can work on several levels at once when they're not in a depressed mood,” he said, adding that careful treatment is necessary to keep such patients from self-destructing.

CHICAGO — Family physicians can close gaping holes in the safety net for individuals with bipolar disorder by following a few important guidelines, according to Dr. John R. Purvis.

“This is a very complicated illness with complicated treatment, and it's our job as family doctors to diagnose these patients,” Dr. Purvis said at the annual meeting of the American Academy of Family Physicians.

Research data suggest that two-thirds of bipolar patients are initially misdiagnosed. In addition, patients see a mean of four physicians before the correct diagnosis is made, and more than one-third wait 10 years or longer for the correct diagnosis (J. Clin. Psychiatry 2003;64:161–74).

“It's estimated that 3%–4% of the population has some sort of bipolar spectrum disorder, and roughly 20% of people who walk into your office with depression have bipolar disorder,” said Dr. Purvis, associated director of the family practice residency program at Tallahassee Memorial Healthcare in Florida.

Family physicians should use the Mood Disorder Questionnaire to screen all patients presenting with depression, panic disorder, or anxiety disorder, Dr. Purvis advised.

Because the questionnaire is designed for screening only, its results should be confirmed by the physician's evaluation, and “if you're unsure or uncomfortable managing the patient yourself, get a consultation with a psychiatrist,” he added.

A key question to ask patients is, “Do you have racing thoughts?” he said. “This is the most important question. In my experience, it is almost diagnostic, particularly when the racing thoughts keep the patient awake.”

Risk is increased in those with first-degree relatives who have bipolar illness or major depression. In addition, seasonal depression, postpartum depression, psychotic depression, and atypical depression should raise suspicion.

There's a common misconception that bipolar I (and II) disease involves regular intervals of mania (or hypomania) and depression separated by periods of euthymia, Dr. Purvis said.

“Even though the diagnosis rests with mania and hypomania, bipolar disease is primarily a disease of depression. Those who are bipolar I spend three times as much of their time depressed as they do manic, and for bipolar II illness the ratio is 1% of the time hypomanic and 50% of the time depressed,” he noted.

Comorbid conditions include attention-deficit/hyperactivity disorder, panic attacks, social phobia, and obsessive-compulsive phenomena.

“If you just make the diagnosis of bipolar disorder, you have done the patient a huge service,” Dr. Purvis said, explaining that bipolar patients often have chaotic lives, “so it's important to set boundaries, particularly regarding appointments and pain medications.”

The goals of treatment are to restore sleep, normalize mood, and maximize executive and cognitive functioning.

“The foundation of treatment of bipolar disorders is behavioral and medication therapy,” he said, adding that a good place for the treating physician to start is with the Texas Treatment Guidelines of 2005 (http://www.psycheducation.org/depression/APAguide.htm

Although some physicians believe that it's acceptable to use antidepressants with mood stabilizers, Dr. Purvis said he believes that mood stabilizers should be used to treat bipolar depression and that antidepressants should be used with caution and for only short periods of time.

“The one thing that is very clear is that antidepressant monotherapy in bipolar depressed patients is not acceptable,” he said in an interview.

Dr. Purvis noted that for some patients, bipolar illness can confer an advantage. “Bipolar illness is sort of like uranium, which can level a city or light a city. Some of the most creative people—including researchers, physicians, CEOs, and actors—are bipolar and can work on several levels at once when they're not in a depressed mood,” he said, adding that careful treatment is necessary to keep such patients from self-destructing.

CHICAGO — The multidrug-resistant Streptococcus pneumoniae serotype 19A continues to spread across the United States, according to Dr. David J. Farrell.

“We believe that that the emergence of this 19A clone has been driven by the 7-valent pneumococcal conjugate vaccine,” Dr. Farrell said in an interview during a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Dr. Farrell, director of clinical microbiology at G.R. Micro Ltd., a London-based company doing contract research for pharmaceutical firms, and his colleagues collected more than 21,000 S. pneumoniae samples from 103 U.S. centers during the 4 years of the global PROTEKT (Prospective Resistant Organism Tracking and Epidemi- ology for the Ketolide Telithromycin) study.

In all, 562 of the isolates were the multidrug resistant (MDR) 19A strain, Dr. Farrell said at the meeting, which was sponsored by the American Society for Microbiology. Sources of the isolates included blood, sputum, bronchoalveolar lavage fluid, middle-ear fluid, sinus aspirates, and nasopharyngeal swabs or aspirates.

Between 2002 and 2006, the proportion of isolates that were MDR 19A increased from 1% to 6%. The largest proportion was in the group aged 0–2 years (rising from 4% to 15%), followed by the group aged 3–14 years (1% to nearly 9%).

In the group of those aged at least 65 years, MDR 19A accounted for 3% of all isolates in 2005–2006, said Dr. Farrell in an interview. “So we've got this 19A serotype that's not in the vaccine, it's being driven by the vaccine, and it's becoming more prevalent and spilling over to older children and adults, including the elderly population.”

Although serotype data are incomplete for the group aged 15–64 years, genotype analysis suggested the same upward trend is occurring, and at the same rate, he said.

A second study of antimicrobial resistance patterns in S. pneumoniae isolated from children showed the experimental oral penem antibiotic faropenem was the most potent oral β-lactam based on in vitro activity.

During the 2005–2006 respiratory season, S. pneumoniae isolates were prospectively collected from 104 participating institutions distributed across the United States as part of the faropenem surveillance (FAMOUS) study. In total, 393 isolates were collected from children aged 6–14 years, 3–5 years, and younger than 2 years. The isolates were then tested for susceptibility to faropenem, meropenem, amoxicillin/clavulanate, cefdinir, cefuroxime, penicillin, azithromycin, levofloxacin, and trimethoprim/sulfamethoxazole.

Multidrug resistance was defined as resistance to either two or three of these agents, said Ian A. Critchley, Ph.D., director of microbiology at Replidyne Inc., Louisville, Colo., which is evaluating faropenem. Of the 393 S. pneumoniae isolates from children younger than age 14 years, half were penicillin susceptible, a quarter were penicillin intermediate, and another quarter were penicillin resistant.

Faropenem was the most active β-lactam against all pediatric isolates, with a minimum inhibitory concentration required to inhibit the growth of 90% of organisms (MIC90) of 1 mcg/mL. The MIC90 of both amoxicillin/clavulanate and cefdinir was 8 mcg/mL. The least effective agents were penicillin, azithromycin, and trimethoprim/sulfamethoxazole, with percent-susceptible rates of 49, 55, and 57, respectively.

Antimicrobial resistance was generally higher in isolates from children aged younger than 2 years, compared with isolates from those aged 6–14 years. Penicillin resistance ranged from 15% in isolates from children aged 6–14 years to 31% in isolates from children younger than 2 years.

“In children under 2 years, [in whom] there's been wide use of β-lactams and macrolides, the penem compound holds out favorably in our in vitro minimum inhibitory concentration profile, compared with amoxicillin/clavulanate and cefdinir,” said Dr. Critchley. In the S. pneumoniae resistant to three classes of agents, only 29% were susceptible to amoxicillin/clavulanate, and none of the isolates was susceptible to cefdinir, he added.

In a separate comment, Dr. Stephen I. Pelton said MDR 19A should be suspected in children with persisting signs and symptoms of acute otitis media despite antimicrobial therapy. “Some of these isolates will be susceptible to high-dose Augmentin or a three-dose regimen of intramuscular ceftriaxone, but others may not,” said Dr. Pelton, chief of pediatric infectious disease at Boston Medical Center.

Tympanocentesis with or without tube insertion will offer symptomatic benefit for those with treatment failure or persistent earache, irritability, or other symptoms, Dr. Pelton said in an interview.

In addition, the PCV7 vaccine should not bear all the blame for the increase in the resistant 19A strain, he added. “The 19A strain was intermediate resistant in 2000, and it is both the vaccine's lack of cross-reactivity and the presence of resistance that has selected for the increase in 19A. So there are two processes: selection of 19A already [intermediate] resistant to penicillin, and the introduction of new 19A strains with even higher resistance. Switching to 19A may be the result of the vaccine, but continued use of antibiotics is the selection driving this clone increase,” he said.

This serotype is 'spilling over to older children and adults, including the elderly population.' DR. FARRELL

CHICAGO — The multidrug-resistant Streptococcus pneumoniae serotype 19A continues to spread across the United States, according to Dr. David J. Farrell.

“We believe that that the emergence of this 19A clone has been driven by the 7-valent pneumococcal conjugate vaccine,” Dr. Farrell said in an interview during a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Dr. Farrell, director of clinical microbiology at G.R. Micro Ltd., a London-based company doing contract research for pharmaceutical firms, and his colleagues collected more than 21,000 S. pneumoniae samples from 103 U.S. centers during the 4 years of the global PROTEKT (Prospective Resistant Organism Tracking and Epidemi- ology for the Ketolide Telithromycin) study.

In all, 562 of the isolates were the multidrug resistant (MDR) 19A strain, Dr. Farrell said at the meeting, which was sponsored by the American Society for Microbiology. Sources of the isolates included blood, sputum, bronchoalveolar lavage fluid, middle-ear fluid, sinus aspirates, and nasopharyngeal swabs or aspirates.

Between 2002 and 2006, the proportion of isolates that were MDR 19A increased from 1% to 6%. The largest proportion was in the group aged 0–2 years (rising from 4% to 15%), followed by the group aged 3–14 years (1% to nearly 9%).

In the group of those aged at least 65 years, MDR 19A accounted for 3% of all isolates in 2005–2006, said Dr. Farrell in an interview. “So we've got this 19A serotype that's not in the vaccine, it's being driven by the vaccine, and it's becoming more prevalent and spilling over to older children and adults, including the elderly population.”

Although serotype data are incomplete for the group aged 15–64 years, genotype analysis suggested the same upward trend is occurring, and at the same rate, he said.

A second study of antimicrobial resistance patterns in S. pneumoniae isolated from children showed the experimental oral penem antibiotic faropenem was the most potent oral β-lactam based on in vitro activity.

During the 2005–2006 respiratory season, S. pneumoniae isolates were prospectively collected from 104 participating institutions distributed across the United States as part of the faropenem surveillance (FAMOUS) study. In total, 393 isolates were collected from children aged 6–14 years, 3–5 years, and younger than 2 years. The isolates were then tested for susceptibility to faropenem, meropenem, amoxicillin/clavulanate, cefdinir, cefuroxime, penicillin, azithromycin, levofloxacin, and trimethoprim/sulfamethoxazole.

Multidrug resistance was defined as resistance to either two or three of these agents, said Ian A. Critchley, Ph.D., director of microbiology at Replidyne Inc., Louisville, Colo., which is evaluating faropenem. Of the 393 S. pneumoniae isolates from children younger than age 14 years, half were penicillin susceptible, a quarter were penicillin intermediate, and another quarter were penicillin resistant.

Faropenem was the most active β-lactam against all pediatric isolates, with a minimum inhibitory concentration required to inhibit the growth of 90% of organisms (MIC90) of 1 mcg/mL. The MIC90 of both amoxicillin/clavulanate and cefdinir was 8 mcg/mL. The least effective agents were penicillin, azithromycin, and trimethoprim/sulfamethoxazole, with percent-susceptible rates of 49, 55, and 57, respectively.

Antimicrobial resistance was generally higher in isolates from children aged younger than 2 years, compared with isolates from those aged 6–14 years. Penicillin resistance ranged from 15% in isolates from children aged 6–14 years to 31% in isolates from children younger than 2 years.

“In children under 2 years, [in whom] there's been wide use of β-lactams and macrolides, the penem compound holds out favorably in our in vitro minimum inhibitory concentration profile, compared with amoxicillin/clavulanate and cefdinir,” said Dr. Critchley. In the S. pneumoniae resistant to three classes of agents, only 29% were susceptible to amoxicillin/clavulanate, and none of the isolates was susceptible to cefdinir, he added.

In a separate comment, Dr. Stephen I. Pelton said MDR 19A should be suspected in children with persisting signs and symptoms of acute otitis media despite antimicrobial therapy. “Some of these isolates will be susceptible to high-dose Augmentin or a three-dose regimen of intramuscular ceftriaxone, but others may not,” said Dr. Pelton, chief of pediatric infectious disease at Boston Medical Center.

Tympanocentesis with or without tube insertion will offer symptomatic benefit for those with treatment failure or persistent earache, irritability, or other symptoms, Dr. Pelton said in an interview.

In addition, the PCV7 vaccine should not bear all the blame for the increase in the resistant 19A strain, he added. “The 19A strain was intermediate resistant in 2000, and it is both the vaccine's lack of cross-reactivity and the presence of resistance that has selected for the increase in 19A. So there are two processes: selection of 19A already [intermediate] resistant to penicillin, and the introduction of new 19A strains with even higher resistance. Switching to 19A may be the result of the vaccine, but continued use of antibiotics is the selection driving this clone increase,” he said.

This serotype is 'spilling over to older children and adults, including the elderly population.' DR. FARRELL

CHICAGO — The multidrug-resistant Streptococcus pneumoniae serotype 19A continues to spread across the United States, according to Dr. David J. Farrell.

“We believe that that the emergence of this 19A clone has been driven by the 7-valent pneumococcal conjugate vaccine,” Dr. Farrell said in an interview during a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Dr. Farrell, director of clinical microbiology at G.R. Micro Ltd., a London-based company doing contract research for pharmaceutical firms, and his colleagues collected more than 21,000 S. pneumoniae samples from 103 U.S. centers during the 4 years of the global PROTEKT (Prospective Resistant Organism Tracking and Epidemi- ology for the Ketolide Telithromycin) study.

In all, 562 of the isolates were the multidrug resistant (MDR) 19A strain, Dr. Farrell said at the meeting, which was sponsored by the American Society for Microbiology. Sources of the isolates included blood, sputum, bronchoalveolar lavage fluid, middle-ear fluid, sinus aspirates, and nasopharyngeal swabs or aspirates.

Between 2002 and 2006, the proportion of isolates that were MDR 19A increased from 1% to 6%. The largest proportion was in the group aged 0–2 years (rising from 4% to 15%), followed by the group aged 3–14 years (1% to nearly 9%).

In the group of those aged at least 65 years, MDR 19A accounted for 3% of all isolates in 2005–2006, said Dr. Farrell in an interview. “So we've got this 19A serotype that's not in the vaccine, it's being driven by the vaccine, and it's becoming more prevalent and spilling over to older children and adults, including the elderly population.”

Although serotype data are incomplete for the group aged 15–64 years, genotype analysis suggested the same upward trend is occurring, and at the same rate, he said.

A second study of antimicrobial resistance patterns in S. pneumoniae isolated from children showed the experimental oral penem antibiotic faropenem was the most potent oral β-lactam based on in vitro activity.

During the 2005–2006 respiratory season, S. pneumoniae isolates were prospectively collected from 104 participating institutions distributed across the United States as part of the faropenem surveillance (FAMOUS) study. In total, 393 isolates were collected from children aged 6–14 years, 3–5 years, and younger than 2 years. The isolates were then tested for susceptibility to faropenem, meropenem, amoxicillin/clavulanate, cefdinir, cefuroxime, penicillin, azithromycin, levofloxacin, and trimethoprim/sulfamethoxazole.

Multidrug resistance was defined as resistance to either two or three of these agents, said Ian A. Critchley, Ph.D., director of microbiology at Replidyne Inc., Louisville, Colo., which is evaluating faropenem. Of the 393 S. pneumoniae isolates from children younger than age 14 years, half were penicillin susceptible, a quarter were penicillin intermediate, and another quarter were penicillin resistant.

Faropenem was the most active β-lactam against all pediatric isolates, with a minimum inhibitory concentration required to inhibit the growth of 90% of organisms (MIC90) of 1 mcg/mL. The MIC90 of both amoxicillin/clavulanate and cefdinir was 8 mcg/mL. The least effective agents were penicillin, azithromycin, and trimethoprim/sulfamethoxazole, with percent-susceptible rates of 49, 55, and 57, respectively.

Antimicrobial resistance was generally higher in isolates from children aged younger than 2 years, compared with isolates from those aged 6–14 years. Penicillin resistance ranged from 15% in isolates from children aged 6–14 years to 31% in isolates from children younger than 2 years.

“In children under 2 years, [in whom] there's been wide use of β-lactams and macrolides, the penem compound holds out favorably in our in vitro minimum inhibitory concentration profile, compared with amoxicillin/clavulanate and cefdinir,” said Dr. Critchley. In the S. pneumoniae resistant to three classes of agents, only 29% were susceptible to amoxicillin/clavulanate, and none of the isolates was susceptible to cefdinir, he added.

In a separate comment, Dr. Stephen I. Pelton said MDR 19A should be suspected in children with persisting signs and symptoms of acute otitis media despite antimicrobial therapy. “Some of these isolates will be susceptible to high-dose Augmentin or a three-dose regimen of intramuscular ceftriaxone, but others may not,” said Dr. Pelton, chief of pediatric infectious disease at Boston Medical Center.

Tympanocentesis with or without tube insertion will offer symptomatic benefit for those with treatment failure or persistent earache, irritability, or other symptoms, Dr. Pelton said in an interview.

In addition, the PCV7 vaccine should not bear all the blame for the increase in the resistant 19A strain, he added. “The 19A strain was intermediate resistant in 2000, and it is both the vaccine's lack of cross-reactivity and the presence of resistance that has selected for the increase in 19A. So there are two processes: selection of 19A already [intermediate] resistant to penicillin, and the introduction of new 19A strains with even higher resistance. Switching to 19A may be the result of the vaccine, but continued use of antibiotics is the selection driving this clone increase,” he said.

This serotype is 'spilling over to older children and adults, including the elderly population.' DR. FARRELL

CHICAGO — The multidrug-resistant Streptococcus pneumoniae serotype 19A continues to spread across the United States, according to a study led by Dr. David J. Farrell.

“And we believe that that the emergence of this 19A clone has been driven by the 7-valent pneumococcal conjugate vaccine,” Dr. Farrell said in an interview during a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Dr. Farrell, director of clinical microbiology at G.R. Micro Ltd., a London-based company that does contract research for pharmaceutical companies, and his colleagues collected more than 21,000 S. pneumoniae samples from 103 U.S. centers within the 4 years of the global PROTEKT (Prospective Resistant Organism Tracking and Epidemiology for the Ketolide Telithromycin) study.

In all, 562 of the isolates were the multidrug-resistant (MDR) 19A strain, Dr. Farrell said at the meeting, which was sponsored by the American Society for Microbiology.

Between 2002 and 2006, the proportion of isolates that were MDR 19A increased from 1% to 6%. The largest proportion was in the group aged 0-2 years (rising from 4% to 15%), followed by the group aged 3-14 years (1% to nearly 9%). In the group of those aged at least 65 years, MDR 19A accounted for 3% of all isolates in 2005-2006, said Dr. Farrell in an interview.

“So we've got this 19A serotype that's not in the vaccine, it's being driven by the vaccine, and it's becoming more prevalent and spilling over to older children and adults, including the elderly population.”

A second study examining antimicrobial resistance patterns among S. pneumoniae isolated from children showed that the experimental oral penem antibiotic, faropenem, was the most potent oral β-lactam based on in vitro activity.

During the 2005-2006 respiratory season, S. pneumoniae isolates were prospectively collected from 104 participating institutions distributed across the United States as part of the faropenem surveillance (FAMOUS) study. In total, 393 isolates were collected from children aged 6-14 years, 3-5 years, and younger than 2 years.

The isolates were then tested for susceptibility to faropenem, meropenem, amoxicillin/clavulanate, cefdinir, cefuroxime, penicillin, azithromycin, levofloxacin, and trimethoprim/sulfamethoxazole.

Multidrug resistance was defined as resistance to either two or three of these agents, said Ian A. Critchley, Ph.D., the director of microbiology at Replidyne Inc., in Louisville, Colo., which is evaluating faropenem.

Of the 393 S. pneumoniae isolates from children younger than age 14 years, half were penicillin susceptible, one-fourth were penicillin intermediate, and another fourth were penicillin resistant, the authors stated.

Faropenem was the most active b-lactam against all pediatric isolates, with a minimum inhibitory concentration required to inhibit the growth of 90% of organisms (MIC90) of 1 mcg/mL. The MIC90 of both amoxicillin/clavulanate and cefdinir was 8 mcg/mL.

The least effective agents were penicillin, azithromycin, and trimethoprim/sulfamethoxazole, with percent-susceptible rates of 49, 55, and 57, respectively.

Antimicrobial resistance was generally higher among isolates from children aged younger than 2 years, compared with isolates from those aged 6-14 years, the authors reported.

Penicillin resistance ranged from 15% among isolates from children aged 6-14 years to 31% among isolates from children younger than 2 years.

“Among children under age 2 years, [in whom] there's been wide use of b-lactams and macrolides, we saw that the penem compound holds out very favorably in our in vitro minimum inhibitory concentration (MIC) profile, when compared with amoxicillin/clavulanate and cefdinir,” said Dr. Critchley. Among the S. pneumoniae resistant to three classes of agents, only 29% were susceptible to amoxicillin/clavulanate, and none of the isolates was susceptible to cefdinir, he said.

In a separate comment, Dr. Stephen I. Pelton said MDR 19A should be suspected in children with persisting signs and symptoms of acute otitis media despite antimicrobial therapy.

“Some of these isolates will be susceptible to high-dose Augmentin or a three-dose regimen of intramuscular ceftriaxone, but others may not,” said Dr. Pelton, chief of pediatric infectious disease at Boston Medical Center.

Tympanocentesis with or without tube insertion will offer symptomatic benefit for those with treatment failure or persistent earache, irritability, or other symptoms, Dr. Pelton said in an interview. “The 19A strain was intermediate resistant in 2000, and it is both the [PCV7] vaccine's lack of cross-reactivity and the presence of resistance that has selected for the increase in 19A,” he said.

Between 2002 and 2006, the proportion of isolates that were MDR 19A increased from 1% to 6%. DR. FARRELL

CHICAGO — The multidrug-resistant Streptococcus pneumoniae serotype 19A continues to spread across the United States, according to a study led by Dr. David J. Farrell.

“And we believe that that the emergence of this 19A clone has been driven by the 7-valent pneumococcal conjugate vaccine,” Dr. Farrell said in an interview during a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Dr. Farrell, director of clinical microbiology at G.R. Micro Ltd., a London-based company that does contract research for pharmaceutical companies, and his colleagues collected more than 21,000 S. pneumoniae samples from 103 U.S. centers within the 4 years of the global PROTEKT (Prospective Resistant Organism Tracking and Epidemiology for the Ketolide Telithromycin) study.

In all, 562 of the isolates were the multidrug-resistant (MDR) 19A strain, Dr. Farrell said at the meeting, which was sponsored by the American Society for Microbiology.

Between 2002 and 2006, the proportion of isolates that were MDR 19A increased from 1% to 6%. The largest proportion was in the group aged 0-2 years (rising from 4% to 15%), followed by the group aged 3-14 years (1% to nearly 9%). In the group of those aged at least 65 years, MDR 19A accounted for 3% of all isolates in 2005-2006, said Dr. Farrell in an interview.

“So we've got this 19A serotype that's not in the vaccine, it's being driven by the vaccine, and it's becoming more prevalent and spilling over to older children and adults, including the elderly population.”

A second study examining antimicrobial resistance patterns among S. pneumoniae isolated from children showed that the experimental oral penem antibiotic, faropenem, was the most potent oral β-lactam based on in vitro activity.

During the 2005-2006 respiratory season, S. pneumoniae isolates were prospectively collected from 104 participating institutions distributed across the United States as part of the faropenem surveillance (FAMOUS) study. In total, 393 isolates were collected from children aged 6-14 years, 3-5 years, and younger than 2 years.

The isolates were then tested for susceptibility to faropenem, meropenem, amoxicillin/clavulanate, cefdinir, cefuroxime, penicillin, azithromycin, levofloxacin, and trimethoprim/sulfamethoxazole.

Multidrug resistance was defined as resistance to either two or three of these agents, said Ian A. Critchley, Ph.D., the director of microbiology at Replidyne Inc., in Louisville, Colo., which is evaluating faropenem.

Of the 393 S. pneumoniae isolates from children younger than age 14 years, half were penicillin susceptible, one-fourth were penicillin intermediate, and another fourth were penicillin resistant, the authors stated.

Faropenem was the most active b-lactam against all pediatric isolates, with a minimum inhibitory concentration required to inhibit the growth of 90% of organisms (MIC90) of 1 mcg/mL. The MIC90 of both amoxicillin/clavulanate and cefdinir was 8 mcg/mL.

The least effective agents were penicillin, azithromycin, and trimethoprim/sulfamethoxazole, with percent-susceptible rates of 49, 55, and 57, respectively.

Antimicrobial resistance was generally higher among isolates from children aged younger than 2 years, compared with isolates from those aged 6-14 years, the authors reported.

Penicillin resistance ranged from 15% among isolates from children aged 6-14 years to 31% among isolates from children younger than 2 years.

“Among children under age 2 years, [in whom] there's been wide use of b-lactams and macrolides, we saw that the penem compound holds out very favorably in our in vitro minimum inhibitory concentration (MIC) profile, when compared with amoxicillin/clavulanate and cefdinir,” said Dr. Critchley. Among the S. pneumoniae resistant to three classes of agents, only 29% were susceptible to amoxicillin/clavulanate, and none of the isolates was susceptible to cefdinir, he said.

In a separate comment, Dr. Stephen I. Pelton said MDR 19A should be suspected in children with persisting signs and symptoms of acute otitis media despite antimicrobial therapy.

“Some of these isolates will be susceptible to high-dose Augmentin or a three-dose regimen of intramuscular ceftriaxone, but others may not,” said Dr. Pelton, chief of pediatric infectious disease at Boston Medical Center.

Tympanocentesis with or without tube insertion will offer symptomatic benefit for those with treatment failure or persistent earache, irritability, or other symptoms, Dr. Pelton said in an interview. “The 19A strain was intermediate resistant in 2000, and it is both the [PCV7] vaccine's lack of cross-reactivity and the presence of resistance that has selected for the increase in 19A,” he said.

Between 2002 and 2006, the proportion of isolates that were MDR 19A increased from 1% to 6%. DR. FARRELL

CHICAGO — The multidrug-resistant Streptococcus pneumoniae serotype 19A continues to spread across the United States, according to a study led by Dr. David J. Farrell.

“And we believe that that the emergence of this 19A clone has been driven by the 7-valent pneumococcal conjugate vaccine,” Dr. Farrell said in an interview during a poster presentation at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Dr. Farrell, director of clinical microbiology at G.R. Micro Ltd., a London-based company that does contract research for pharmaceutical companies, and his colleagues collected more than 21,000 S. pneumoniae samples from 103 U.S. centers within the 4 years of the global PROTEKT (Prospective Resistant Organism Tracking and Epidemiology for the Ketolide Telithromycin) study.

In all, 562 of the isolates were the multidrug-resistant (MDR) 19A strain, Dr. Farrell said at the meeting, which was sponsored by the American Society for Microbiology.

Between 2002 and 2006, the proportion of isolates that were MDR 19A increased from 1% to 6%. The largest proportion was in the group aged 0-2 years (rising from 4% to 15%), followed by the group aged 3-14 years (1% to nearly 9%). In the group of those aged at least 65 years, MDR 19A accounted for 3% of all isolates in 2005-2006, said Dr. Farrell in an interview.

“So we've got this 19A serotype that's not in the vaccine, it's being driven by the vaccine, and it's becoming more prevalent and spilling over to older children and adults, including the elderly population.”

A second study examining antimicrobial resistance patterns among S. pneumoniae isolated from children showed that the experimental oral penem antibiotic, faropenem, was the most potent oral β-lactam based on in vitro activity.

During the 2005-2006 respiratory season, S. pneumoniae isolates were prospectively collected from 104 participating institutions distributed across the United States as part of the faropenem surveillance (FAMOUS) study. In total, 393 isolates were collected from children aged 6-14 years, 3-5 years, and younger than 2 years.

The isolates were then tested for susceptibility to faropenem, meropenem, amoxicillin/clavulanate, cefdinir, cefuroxime, penicillin, azithromycin, levofloxacin, and trimethoprim/sulfamethoxazole.

Multidrug resistance was defined as resistance to either two or three of these agents, said Ian A. Critchley, Ph.D., the director of microbiology at Replidyne Inc., in Louisville, Colo., which is evaluating faropenem.

Of the 393 S. pneumoniae isolates from children younger than age 14 years, half were penicillin susceptible, one-fourth were penicillin intermediate, and another fourth were penicillin resistant, the authors stated.

Faropenem was the most active b-lactam against all pediatric isolates, with a minimum inhibitory concentration required to inhibit the growth of 90% of organisms (MIC90) of 1 mcg/mL. The MIC90 of both amoxicillin/clavulanate and cefdinir was 8 mcg/mL.

The least effective agents were penicillin, azithromycin, and trimethoprim/sulfamethoxazole, with percent-susceptible rates of 49, 55, and 57, respectively.

Antimicrobial resistance was generally higher among isolates from children aged younger than 2 years, compared with isolates from those aged 6-14 years, the authors reported.

Penicillin resistance ranged from 15% among isolates from children aged 6-14 years to 31% among isolates from children younger than 2 years.

“Among children under age 2 years, [in whom] there's been wide use of b-lactams and macrolides, we saw that the penem compound holds out very favorably in our in vitro minimum inhibitory concentration (MIC) profile, when compared with amoxicillin/clavulanate and cefdinir,” said Dr. Critchley. Among the S. pneumoniae resistant to three classes of agents, only 29% were susceptible to amoxicillin/clavulanate, and none of the isolates was susceptible to cefdinir, he said.

In a separate comment, Dr. Stephen I. Pelton said MDR 19A should be suspected in children with persisting signs and symptoms of acute otitis media despite antimicrobial therapy.

“Some of these isolates will be susceptible to high-dose Augmentin or a three-dose regimen of intramuscular ceftriaxone, but others may not,” said Dr. Pelton, chief of pediatric infectious disease at Boston Medical Center.

Tympanocentesis with or without tube insertion will offer symptomatic benefit for those with treatment failure or persistent earache, irritability, or other symptoms, Dr. Pelton said in an interview. “The 19A strain was intermediate resistant in 2000, and it is both the [PCV7] vaccine's lack of cross-reactivity and the presence of resistance that has selected for the increase in 19A,” he said.

Between 2002 and 2006, the proportion of isolates that were MDR 19A increased from 1% to 6%. DR. FARRELL

CHICAGO — The trajectory of Streptococcus pneumoniae- related otitis media in the United States, which declined dramatically after the introduction of the pneumococcal conjugate vaccine in 2000, is now heading skyward, according to Dr. Michael E. Pichichero.

“Since the PCV vaccine came into play, we've seen a pathogen shift in which the percentage of S. pneumoniae bacteria causing ear infections in children, after dropping for the first 3 years, is now rising again,” Dr. Pichichero said in an interview.

Although Haemophilus influenzae continues to be the predominant pathogen, during the 2005–2006 season there was an upswing in S. pneumoniae isolates, with simultaneous increase in the proportion of strains that were penicillin resistant, Dr. Pichichero said.

There was a 20% increase in pneumococcal isolates obtained by tympanocentesis over 3 seasons between 2003 and 2006, according to a poster presented by Dr. Pichichero at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Virtually all the ear infections involved bacterial strains not covered by the vaccine, PCV7 (Prevnar, Wyeth Pharmaceuticals). Among those strains is the “superbug” multidrug resistant form of 19A, which is resistant to all antibacterials approved for pediatric use, said Dr. Pichichero, professor of microbiology and immunology at the University of Rochester Medical Center (URMC) in New York.

The investigators collected and analyzed 267 acute otitis media (AOM) isolates from tympanostomies conducted at URMC, Children's Hospital in Pittsburgh, and an Inova hospital in Fairfax, Va.

Most of the isolates were obtained from children under age 2 years who had been vaccinated with PCV7, and who had failed antibiotic treatment or had recurrent AOM.

The proportion of S. pneumoniae for the respiratory seasons 2003–2004, 2004–2005, and 2005–2006 was 30%, 34%, and 45%, respectively, the authors said, adding that for H. influenzae the proportions were 48%, 57%, and 39%; and for Moraxella catarrhalis, 6%, 8%, and 12%, respectively.

In 2003, 64% of S. pneumoniae isolates were penicillin susceptible, 14% were penicillin intermediate, and 23% were penicillin resistant. Three years later, those proportions were 50%, 23%, and 27%.

The authors explained that the increase in penicillin-resistant S. pneumoniae strains was largely due to increased isolation of non-PCV7 serotypes of the bacterium, especially serotypes 6A, 11, 15, 19A, and 35B.

Among the H. influenzae isolates, the proportions that produced β-lactamase, indicating resistance to amoxicillin, remained stable over time at about 50%.

In the first 3 years after PCV7 was approved, the incidence of S. pneumoniae- related AOM appeared to decline, while H. influenzae- related AOM increased. In the subsequent 3 years the reverse is occurring and the two incidence lines are intersecting, Dr. Pichichero explained, adding that physicians are faced with a treatment paradox.

“If a family physician sees a child with a difficult-to-treat ear infection tomorrow—the child with recent antibiotic treatment failure or recurrent ear infection—there's a 50% chance that it's S. pneumoniae and a 50% chance that its H. influenzae. If it's S. pneumoniae, there's a 50% chance it's resistant to penicillin and if it's H. influenzae there's a 50% chance it's resistant to amoxicillin,” he said. In addition, he noted that the treating physician's best option is to follow the American Academy of Family Physicians guidelines.

Only six antibiotic options are advised for empiric treatment, Dr. Pichichero said, including high-dose amoxicillin, high-dose Augmentin, the oral cephalosporins cefpodoxime, cefuroxime, and cefdinir, and injected ceftriaxone.

Levofloxacin, which is not Food and Drug Administration approved for pediatric use and whose safety in children remains unproven, is effective against resistant bacteria.

The AAFP has endorsed levofloxacin for pediatric use only when it's been proven that it's the only antibiotic that will work, according to lab test results, Dr. Pichichero said at the meeting, which was also sponsored by the American Society for Microbiology. The potential for a complication following off-label use of levofloxacin could leave the treating physician open to legal action, he warned.

Dr. Pichichero cautioned that the results of this study may not be generalizable to children with uncomplicated or previously untreated AOM.

A separate analysis from the same study demonstrated that the multiresistant 19A serotype pneumococcal strain is able to evade all approved antibiotics.

In a second study, Dr. Pichichero and his colleagues reported tympanocentesis results from 162 children, three-quarters of whom were under age 2 years, experiencing recurrent AOM or AOM treatment failure. Isolates were obtained during 3 seasons between 2003 and 2006.

Among 34 S. pneumoniae with serotypes not included in PCV7, 9 were the multidrug resistant 19A strain.

Dr. Pichichero emphasized the urgent need for the expanded valency vaccine currently in a phase III clinical trial. The vaccine (PCV13), which contains the 19A strain, could become available in late 2009 or early 2010, according to a Wyeth spokesman.

Dr. Stephen I. Pelton commented that previous research has demonstrated that about 30% of children under 7 years of age harbor S. pneumoniae in their nasopharynx, and approximately 20% of S. pneumoniae are type 19A.

“The multidrug resistant [MDR] 19A is only a small fraction of the 19A isolates currently circulating in the community, and the risk for carriage of an MDR isolate is relatively low, involving about 1% or 2% of children,” explained Dr. Pelton, chief of pediatric infectious disease at Boston Medical Center.

The off-label use of levofloxacin may be necessary for children failing therapy.

“Documentation of the presence of MDR 19A in either pneumococcal pneumonia or middle ear disease probably is a good idea before initiating the use of levofloxacin,” Dr. Pelton added in an interview.

In fact, if MDR S. pneumoniae is suspected, then documentation by tympanocentesis or at a minimum nasopharyngeal culture is a good approach, he said.

After dropping for the first 3 years after the PCV vaccine, S. pneumoniae ear infections are now rising again. DR. PICHICHERO

CHICAGO — The trajectory of Streptococcus pneumoniae- related otitis media in the United States, which declined dramatically after the introduction of the pneumococcal conjugate vaccine in 2000, is now heading skyward, according to Dr. Michael E. Pichichero.

“Since the PCV vaccine came into play, we've seen a pathogen shift in which the percentage of S. pneumoniae bacteria causing ear infections in children, after dropping for the first 3 years, is now rising again,” Dr. Pichichero said in an interview.

Although Haemophilus influenzae continues to be the predominant pathogen, during the 2005–2006 season there was an upswing in S. pneumoniae isolates, with simultaneous increase in the proportion of strains that were penicillin resistant, Dr. Pichichero said.

There was a 20% increase in pneumococcal isolates obtained by tympanocentesis over 3 seasons between 2003 and 2006, according to a poster presented by Dr. Pichichero at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Virtually all the ear infections involved bacterial strains not covered by the vaccine, PCV7 (Prevnar, Wyeth Pharmaceuticals). Among those strains is the “superbug” multidrug resistant form of 19A, which is resistant to all antibacterials approved for pediatric use, said Dr. Pichichero, professor of microbiology and immunology at the University of Rochester Medical Center (URMC) in New York.

The investigators collected and analyzed 267 acute otitis media (AOM) isolates from tympanostomies conducted at URMC, Children's Hospital in Pittsburgh, and an Inova hospital in Fairfax, Va.

Most of the isolates were obtained from children under age 2 years who had been vaccinated with PCV7, and who had failed antibiotic treatment or had recurrent AOM.

The proportion of S. pneumoniae for the respiratory seasons 2003–2004, 2004–2005, and 2005–2006 was 30%, 34%, and 45%, respectively, the authors said, adding that for H. influenzae the proportions were 48%, 57%, and 39%; and for Moraxella catarrhalis, 6%, 8%, and 12%, respectively.

In 2003, 64% of S. pneumoniae isolates were penicillin susceptible, 14% were penicillin intermediate, and 23% were penicillin resistant. Three years later, those proportions were 50%, 23%, and 27%.

The authors explained that the increase in penicillin-resistant S. pneumoniae strains was largely due to increased isolation of non-PCV7 serotypes of the bacterium, especially serotypes 6A, 11, 15, 19A, and 35B.

Among the H. influenzae isolates, the proportions that produced β-lactamase, indicating resistance to amoxicillin, remained stable over time at about 50%.

In the first 3 years after PCV7 was approved, the incidence of S. pneumoniae- related AOM appeared to decline, while H. influenzae- related AOM increased. In the subsequent 3 years the reverse is occurring and the two incidence lines are intersecting, Dr. Pichichero explained, adding that physicians are faced with a treatment paradox.

“If a family physician sees a child with a difficult-to-treat ear infection tomorrow—the child with recent antibiotic treatment failure or recurrent ear infection—there's a 50% chance that it's S. pneumoniae and a 50% chance that its H. influenzae. If it's S. pneumoniae, there's a 50% chance it's resistant to penicillin and if it's H. influenzae there's a 50% chance it's resistant to amoxicillin,” he said. In addition, he noted that the treating physician's best option is to follow the American Academy of Family Physicians guidelines.

Only six antibiotic options are advised for empiric treatment, Dr. Pichichero said, including high-dose amoxicillin, high-dose Augmentin, the oral cephalosporins cefpodoxime, cefuroxime, and cefdinir, and injected ceftriaxone.

Levofloxacin, which is not Food and Drug Administration approved for pediatric use and whose safety in children remains unproven, is effective against resistant bacteria.

The AAFP has endorsed levofloxacin for pediatric use only when it's been proven that it's the only antibiotic that will work, according to lab test results, Dr. Pichichero said at the meeting, which was also sponsored by the American Society for Microbiology. The potential for a complication following off-label use of levofloxacin could leave the treating physician open to legal action, he warned.

Dr. Pichichero cautioned that the results of this study may not be generalizable to children with uncomplicated or previously untreated AOM.

A separate analysis from the same study demonstrated that the multiresistant 19A serotype pneumococcal strain is able to evade all approved antibiotics.

In a second study, Dr. Pichichero and his colleagues reported tympanocentesis results from 162 children, three-quarters of whom were under age 2 years, experiencing recurrent AOM or AOM treatment failure. Isolates were obtained during 3 seasons between 2003 and 2006.

Among 34 S. pneumoniae with serotypes not included in PCV7, 9 were the multidrug resistant 19A strain.

Dr. Pichichero emphasized the urgent need for the expanded valency vaccine currently in a phase III clinical trial. The vaccine (PCV13), which contains the 19A strain, could become available in late 2009 or early 2010, according to a Wyeth spokesman.

Dr. Stephen I. Pelton commented that previous research has demonstrated that about 30% of children under 7 years of age harbor S. pneumoniae in their nasopharynx, and approximately 20% of S. pneumoniae are type 19A.

“The multidrug resistant [MDR] 19A is only a small fraction of the 19A isolates currently circulating in the community, and the risk for carriage of an MDR isolate is relatively low, involving about 1% or 2% of children,” explained Dr. Pelton, chief of pediatric infectious disease at Boston Medical Center.

The off-label use of levofloxacin may be necessary for children failing therapy.

“Documentation of the presence of MDR 19A in either pneumococcal pneumonia or middle ear disease probably is a good idea before initiating the use of levofloxacin,” Dr. Pelton added in an interview.

In fact, if MDR S. pneumoniae is suspected, then documentation by tympanocentesis or at a minimum nasopharyngeal culture is a good approach, he said.

After dropping for the first 3 years after the PCV vaccine, S. pneumoniae ear infections are now rising again. DR. PICHICHERO

CHICAGO — The trajectory of Streptococcus pneumoniae- related otitis media in the United States, which declined dramatically after the introduction of the pneumococcal conjugate vaccine in 2000, is now heading skyward, according to Dr. Michael E. Pichichero.

“Since the PCV vaccine came into play, we've seen a pathogen shift in which the percentage of S. pneumoniae bacteria causing ear infections in children, after dropping for the first 3 years, is now rising again,” Dr. Pichichero said in an interview.

Although Haemophilus influenzae continues to be the predominant pathogen, during the 2005–2006 season there was an upswing in S. pneumoniae isolates, with simultaneous increase in the proportion of strains that were penicillin resistant, Dr. Pichichero said.

There was a 20% increase in pneumococcal isolates obtained by tympanocentesis over 3 seasons between 2003 and 2006, according to a poster presented by Dr. Pichichero at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Virtually all the ear infections involved bacterial strains not covered by the vaccine, PCV7 (Prevnar, Wyeth Pharmaceuticals). Among those strains is the “superbug” multidrug resistant form of 19A, which is resistant to all antibacterials approved for pediatric use, said Dr. Pichichero, professor of microbiology and immunology at the University of Rochester Medical Center (URMC) in New York.

The investigators collected and analyzed 267 acute otitis media (AOM) isolates from tympanostomies conducted at URMC, Children's Hospital in Pittsburgh, and an Inova hospital in Fairfax, Va.

Most of the isolates were obtained from children under age 2 years who had been vaccinated with PCV7, and who had failed antibiotic treatment or had recurrent AOM.

The proportion of S. pneumoniae for the respiratory seasons 2003–2004, 2004–2005, and 2005–2006 was 30%, 34%, and 45%, respectively, the authors said, adding that for H. influenzae the proportions were 48%, 57%, and 39%; and for Moraxella catarrhalis, 6%, 8%, and 12%, respectively.

In 2003, 64% of S. pneumoniae isolates were penicillin susceptible, 14% were penicillin intermediate, and 23% were penicillin resistant. Three years later, those proportions were 50%, 23%, and 27%.

The authors explained that the increase in penicillin-resistant S. pneumoniae strains was largely due to increased isolation of non-PCV7 serotypes of the bacterium, especially serotypes 6A, 11, 15, 19A, and 35B.

Among the H. influenzae isolates, the proportions that produced β-lactamase, indicating resistance to amoxicillin, remained stable over time at about 50%.

In the first 3 years after PCV7 was approved, the incidence of S. pneumoniae- related AOM appeared to decline, while H. influenzae- related AOM increased. In the subsequent 3 years the reverse is occurring and the two incidence lines are intersecting, Dr. Pichichero explained, adding that physicians are faced with a treatment paradox.

“If a family physician sees a child with a difficult-to-treat ear infection tomorrow—the child with recent antibiotic treatment failure or recurrent ear infection—there's a 50% chance that it's S. pneumoniae and a 50% chance that its H. influenzae. If it's S. pneumoniae, there's a 50% chance it's resistant to penicillin and if it's H. influenzae there's a 50% chance it's resistant to amoxicillin,” he said. In addition, he noted that the treating physician's best option is to follow the American Academy of Family Physicians guidelines.

Only six antibiotic options are advised for empiric treatment, Dr. Pichichero said, including high-dose amoxicillin, high-dose Augmentin, the oral cephalosporins cefpodoxime, cefuroxime, and cefdinir, and injected ceftriaxone.

Levofloxacin, which is not Food and Drug Administration approved for pediatric use and whose safety in children remains unproven, is effective against resistant bacteria.

The AAFP has endorsed levofloxacin for pediatric use only when it's been proven that it's the only antibiotic that will work, according to lab test results, Dr. Pichichero said at the meeting, which was also sponsored by the American Society for Microbiology. The potential for a complication following off-label use of levofloxacin could leave the treating physician open to legal action, he warned.

Dr. Pichichero cautioned that the results of this study may not be generalizable to children with uncomplicated or previously untreated AOM.

A separate analysis from the same study demonstrated that the multiresistant 19A serotype pneumococcal strain is able to evade all approved antibiotics.

In a second study, Dr. Pichichero and his colleagues reported tympanocentesis results from 162 children, three-quarters of whom were under age 2 years, experiencing recurrent AOM or AOM treatment failure. Isolates were obtained during 3 seasons between 2003 and 2006.

Among 34 S. pneumoniae with serotypes not included in PCV7, 9 were the multidrug resistant 19A strain.

Dr. Pichichero emphasized the urgent need for the expanded valency vaccine currently in a phase III clinical trial. The vaccine (PCV13), which contains the 19A strain, could become available in late 2009 or early 2010, according to a Wyeth spokesman.

Dr. Stephen I. Pelton commented that previous research has demonstrated that about 30% of children under 7 years of age harbor S. pneumoniae in their nasopharynx, and approximately 20% of S. pneumoniae are type 19A.

“The multidrug resistant [MDR] 19A is only a small fraction of the 19A isolates currently circulating in the community, and the risk for carriage of an MDR isolate is relatively low, involving about 1% or 2% of children,” explained Dr. Pelton, chief of pediatric infectious disease at Boston Medical Center.

The off-label use of levofloxacin may be necessary for children failing therapy.

“Documentation of the presence of MDR 19A in either pneumococcal pneumonia or middle ear disease probably is a good idea before initiating the use of levofloxacin,” Dr. Pelton added in an interview.

In fact, if MDR S. pneumoniae is suspected, then documentation by tympanocentesis or at a minimum nasopharyngeal culture is a good approach, he said.

After dropping for the first 3 years after the PCV vaccine, S. pneumoniae ear infections are now rising again. DR. PICHICHERO

CHICAGO — Physicians in the emergency department and cardiologists may be underestimating the risks faced by patients whose previous angiography results were considered “normal,” according to a study presented at the annual meeting of the Society for Academic Emergency Medicine.

“In an unselected population, history of a normal coronary angiogram within 5 years does not identify a low-risk population,” said Dr. Jason McMullan.

“Patients with risk factors for coronary artery disease will develop coronary artery disease regardless of whether or not they had a previously normal catheterization, and we cannot say with any certainty that a previously normal angiogram is protective up to 5 years,” Dr. McMullan said.

This conclusion contrasts with previous, smaller studies suggesting that a negative angiogram predicts low morbidity and mortality outcomes, said Dr. McMullan, a fourth-year resident in emergency medicine at the University of Cincinnati.

However, the small sample sizes and highly selected populations limited these prior investigations, he explained.

Dr. McMullan's retrospective cohort study followed all subjects with normal coronary angiograms between January and May of 2000 for 5 years, with the hypothesis that those with a repeat angiogram within 5 years would have no coronary artery disease (CAD).

All adult patients with a true normal angiography were included unless they died during index hospitalization. Patients with minimal luminal irregularities, diffuse tapering, or nonfocused stenoses were considered to have abnormal angiograms, regardless of the final conclusion, he said.

A total of 598 angiograms were performed, and those that were deemed “normal” made up the “normal” cohort of 182 patients. The group's mean age was 51 years. One-third of patients were black, nearly half were men, and 45 (25%) underwent repeat angiography within 5 years. Subjects who did and did not undergo a repeat procedure did not differ by demographics, diabetes status, hypertension, renal insufficiency, or prior arrhythmias, Dr. McMullan said.

Repeat angiography was a more likely prospect for smokers, those with hyperlipidemia, those with a prior angiography, and transplant patients.

Upon repeat angiography, 18 of the 45 patients, or 40%, had developed CAD, Dr. McMullan said, adding that of those 18 patients, 1 required coronary artery bypass graft surgery, a second required percutaneous intervention, and 3 died within 5 years.

In addition, three patients had developed minimal luminal irregularities, seven had mild disease (with the largest lesion being less than 50% obstructive), and six developed significant disease of greater than 50% obstruction.

Those who had developed CAD tended to be about a decade older (mean age 58 years) than those who had not (mean age 46 years), he said, adding that such traditional risk factors as cocaine and tobacco use and prior angiography were not predictive.

Looking at the larger cohort of 182 patients whose initial angiograms were normal, 18 (10%) developed CAD within 5 years.

“Not only did these patients develop disease, but they also had poor outcomes,” Dr. McMullan said, noting that of those who developed CAD, 3 had died, compared with 1 of 27 repeat normals. Of the entire cohort of 182 initially normal patients, the mortality rate was 15%, the same as the rate among those whose repeat tests were normal.

The two patients who underwent interventions did so at 2 and 3 years, while others did so outside of the 5-year window, Dr. McMullan explained in an interview.

“People were recathed and found to have bad disease as early as 0.4 years after previous catheterization. Arguably, there were false negatives, but it's not that people didn't develop disease … it's that it wasn't picked up,” he said.

'We cannot say with any certainty that a previously normal angiogram is protective up to 5 years.' DR. MCMULLAN

CHICAGO — Physicians in the emergency department and cardiologists may be underestimating the risks faced by patients whose previous angiography results were considered “normal,” according to a study presented at the annual meeting of the Society for Academic Emergency Medicine.

“In an unselected population, history of a normal coronary angiogram within 5 years does not identify a low-risk population,” said Dr. Jason McMullan.

“Patients with risk factors for coronary artery disease will develop coronary artery disease regardless of whether or not they had a previously normal catheterization, and we cannot say with any certainty that a previously normal angiogram is protective up to 5 years,” Dr. McMullan said.

This conclusion contrasts with previous, smaller studies suggesting that a negative angiogram predicts low morbidity and mortality outcomes, said Dr. McMullan, a fourth-year resident in emergency medicine at the University of Cincinnati.

However, the small sample sizes and highly selected populations limited these prior investigations, he explained.

Dr. McMullan's retrospective cohort study followed all subjects with normal coronary angiograms between January and May of 2000 for 5 years, with the hypothesis that those with a repeat angiogram within 5 years would have no coronary artery disease (CAD).

All adult patients with a true normal angiography were included unless they died during index hospitalization. Patients with minimal luminal irregularities, diffuse tapering, or nonfocused stenoses were considered to have abnormal angiograms, regardless of the final conclusion, he said.

A total of 598 angiograms were performed, and those that were deemed “normal” made up the “normal” cohort of 182 patients. The group's mean age was 51 years. One-third of patients were black, nearly half were men, and 45 (25%) underwent repeat angiography within 5 years. Subjects who did and did not undergo a repeat procedure did not differ by demographics, diabetes status, hypertension, renal insufficiency, or prior arrhythmias, Dr. McMullan said.

Repeat angiography was a more likely prospect for smokers, those with hyperlipidemia, those with a prior angiography, and transplant patients.

Upon repeat angiography, 18 of the 45 patients, or 40%, had developed CAD, Dr. McMullan said, adding that of those 18 patients, 1 required coronary artery bypass graft surgery, a second required percutaneous intervention, and 3 died within 5 years.

In addition, three patients had developed minimal luminal irregularities, seven had mild disease (with the largest lesion being less than 50% obstructive), and six developed significant disease of greater than 50% obstruction.

Those who had developed CAD tended to be about a decade older (mean age 58 years) than those who had not (mean age 46 years), he said, adding that such traditional risk factors as cocaine and tobacco use and prior angiography were not predictive.

Looking at the larger cohort of 182 patients whose initial angiograms were normal, 18 (10%) developed CAD within 5 years.

“Not only did these patients develop disease, but they also had poor outcomes,” Dr. McMullan said, noting that of those who developed CAD, 3 had died, compared with 1 of 27 repeat normals. Of the entire cohort of 182 initially normal patients, the mortality rate was 15%, the same as the rate among those whose repeat tests were normal.

The two patients who underwent interventions did so at 2 and 3 years, while others did so outside of the 5-year window, Dr. McMullan explained in an interview.

“People were recathed and found to have bad disease as early as 0.4 years after previous catheterization. Arguably, there were false negatives, but it's not that people didn't develop disease … it's that it wasn't picked up,” he said.

'We cannot say with any certainty that a previously normal angiogram is protective up to 5 years.' DR. MCMULLAN

CHICAGO — Physicians in the emergency department and cardiologists may be underestimating the risks faced by patients whose previous angiography results were considered “normal,” according to a study presented at the annual meeting of the Society for Academic Emergency Medicine.

“In an unselected population, history of a normal coronary angiogram within 5 years does not identify a low-risk population,” said Dr. Jason McMullan.

“Patients with risk factors for coronary artery disease will develop coronary artery disease regardless of whether or not they had a previously normal catheterization, and we cannot say with any certainty that a previously normal angiogram is protective up to 5 years,” Dr. McMullan said.

This conclusion contrasts with previous, smaller studies suggesting that a negative angiogram predicts low morbidity and mortality outcomes, said Dr. McMullan, a fourth-year resident in emergency medicine at the University of Cincinnati.

However, the small sample sizes and highly selected populations limited these prior investigations, he explained.

Dr. McMullan's retrospective cohort study followed all subjects with normal coronary angiograms between January and May of 2000 for 5 years, with the hypothesis that those with a repeat angiogram within 5 years would have no coronary artery disease (CAD).

All adult patients with a true normal angiography were included unless they died during index hospitalization. Patients with minimal luminal irregularities, diffuse tapering, or nonfocused stenoses were considered to have abnormal angiograms, regardless of the final conclusion, he said.

A total of 598 angiograms were performed, and those that were deemed “normal” made up the “normal” cohort of 182 patients. The group's mean age was 51 years. One-third of patients were black, nearly half were men, and 45 (25%) underwent repeat angiography within 5 years. Subjects who did and did not undergo a repeat procedure did not differ by demographics, diabetes status, hypertension, renal insufficiency, or prior arrhythmias, Dr. McMullan said.

Repeat angiography was a more likely prospect for smokers, those with hyperlipidemia, those with a prior angiography, and transplant patients.

Upon repeat angiography, 18 of the 45 patients, or 40%, had developed CAD, Dr. McMullan said, adding that of those 18 patients, 1 required coronary artery bypass graft surgery, a second required percutaneous intervention, and 3 died within 5 years.

In addition, three patients had developed minimal luminal irregularities, seven had mild disease (with the largest lesion being less than 50% obstructive), and six developed significant disease of greater than 50% obstruction.

Those who had developed CAD tended to be about a decade older (mean age 58 years) than those who had not (mean age 46 years), he said, adding that such traditional risk factors as cocaine and tobacco use and prior angiography were not predictive.

Looking at the larger cohort of 182 patients whose initial angiograms were normal, 18 (10%) developed CAD within 5 years.

“Not only did these patients develop disease, but they also had poor outcomes,” Dr. McMullan said, noting that of those who developed CAD, 3 had died, compared with 1 of 27 repeat normals. Of the entire cohort of 182 initially normal patients, the mortality rate was 15%, the same as the rate among those whose repeat tests were normal.

The two patients who underwent interventions did so at 2 and 3 years, while others did so outside of the 5-year window, Dr. McMullan explained in an interview.

“People were recathed and found to have bad disease as early as 0.4 years after previous catheterization. Arguably, there were false negatives, but it's not that people didn't develop disease … it's that it wasn't picked up,” he said.

'We cannot say with any certainty that a previously normal angiogram is protective up to 5 years.' DR. MCMULLAN

CHICAGO — The experimental drug canfosfamide failed to achieve survival end points in two phase III trials that enrolled patients with platinum-refractory or platinum-resistant ovarian cancer.

One study compared the combination of canfosfamide (TLK286, Telcyta) and carboplatin with pegylated liposomal doxorubicin (Doxil) as second-line treatment in 247 patients recruited at 66 sites. The data failed to meet primary and secondary end points demonstrating superiority in objective response rate and progression-free survival, according to a research team led by Dr. Peter G. Rose.

Progression-free survival was 3.5 months in both arms of the trial. A subgroup of 38 patients (19 in each arm) who were characterized by a drug-free period of 6 months or longer responded more favorably to the combination therapy, with an overall response rate of 31.6%. Drug-free period was defined as the date from last treatment with platinum-based chemotherapy to the date of initiation of first study treatment.

The second trial compared single-agent canfosfamide and topotecan (Hycamtin) or pegylated liposomal doxorubicin in 461 women with disease progression following second-line treatment with doxorubicin or topotecan.

Dr. Ignace Vergote reported median overall survival was actually worse in the canfosfamide group: 8.5 months versus 10.8 months with topotecan and 14.2 months with doxorubicin (median 13.5 months for the latter two). The difference was statistically significant, said Dr. Vergote, of University Leuven (Belgium).

Both studies were sponsored by Telik Inc., and were presented in posters at the annual meeting of the American Society of Clinical Oncology.

In the trial reported by Dr. Rose, 123 women were randomized to receive intravenous canfosfamide (750 mg/m

Hematologic toxicity was more frequent in the combination arm but was well managed with growth factor support or dose reductions, according to the investigators. Grade 3–4 thrombocytopenia occurred in 33% of the women taking both canfosfamide and carboplatin. About 20% of both arms experienced grade 3–4 neutropenia.

Failure of the canfosfamide-carboplatin regime to meet established end points in second-line treatment of metastatic ovarian cancer “may in part be due to the challenges of radiologic imaging interpretation in ovarian cancer as well as to the complex biology involved in platinum resistance and resensitization,” said Dr. Rose, a professor of reproductive biology and oncology at Case Western Reserve University, Cleveland.

According to the independent radiology review, approximately one-fourth of patients may have been prematurely discontinued from study involvement. This may have confounded the analysis of progress.

In a discussion, Dr. Carol Aghajanian of Memorial Sloan Kettering Cancer Center in New York said, “It's unfortunate that the response rate is not reported—the authors explaining that response rate varied too much between clinician assessments and radiology review assessments—and it's disappointing that the trial's final results could not be analyzed.”

In the trial presented by Dr. Vergote, 232 patients received canfosfamide at 1,000 mg/m

“This study showed us that, as a single agent, canfosfamide doesn't have a lot of cytostatic effects, but other studies suggest that we may get better results by using this drug in combination,” he said.

The most common grade 3–4 adverse events for canfosfamide were nausea (32%), vomiting (9%), fatigue (6%), and anemia (6%). For the traditional drugs, the primary grade 3–4 adverse events were nausea (55%); anemia (15%); fatigue (7%); neutropenia (23%); thrombocytopenia (12%); and febrile neutropenia, stomatitis, or palmar-plantar erythrodysesthesia (6%).

CHICAGO — The experimental drug canfosfamide failed to achieve survival end points in two phase III trials that enrolled patients with platinum-refractory or platinum-resistant ovarian cancer.

One study compared the combination of canfosfamide (TLK286, Telcyta) and carboplatin with pegylated liposomal doxorubicin (Doxil) as second-line treatment in 247 patients recruited at 66 sites. The data failed to meet primary and secondary end points demonstrating superiority in objective response rate and progression-free survival, according to a research team led by Dr. Peter G. Rose.

Progression-free survival was 3.5 months in both arms of the trial. A subgroup of 38 patients (19 in each arm) who were characterized by a drug-free period of 6 months or longer responded more favorably to the combination therapy, with an overall response rate of 31.6%. Drug-free period was defined as the date from last treatment with platinum-based chemotherapy to the date of initiation of first study treatment.

The second trial compared single-agent canfosfamide and topotecan (Hycamtin) or pegylated liposomal doxorubicin in 461 women with disease progression following second-line treatment with doxorubicin or topotecan.

Dr. Ignace Vergote reported median overall survival was actually worse in the canfosfamide group: 8.5 months versus 10.8 months with topotecan and 14.2 months with doxorubicin (median 13.5 months for the latter two). The difference was statistically significant, said Dr. Vergote, of University Leuven (Belgium).

Both studies were sponsored by Telik Inc., and were presented in posters at the annual meeting of the American Society of Clinical Oncology.

In the trial reported by Dr. Rose, 123 women were randomized to receive intravenous canfosfamide (750 mg/m

Hematologic toxicity was more frequent in the combination arm but was well managed with growth factor support or dose reductions, according to the investigators. Grade 3–4 thrombocytopenia occurred in 33% of the women taking both canfosfamide and carboplatin. About 20% of both arms experienced grade 3–4 neutropenia.

Failure of the canfosfamide-carboplatin regime to meet established end points in second-line treatment of metastatic ovarian cancer “may in part be due to the challenges of radiologic imaging interpretation in ovarian cancer as well as to the complex biology involved in platinum resistance and resensitization,” said Dr. Rose, a professor of reproductive biology and oncology at Case Western Reserve University, Cleveland.

According to the independent radiology review, approximately one-fourth of patients may have been prematurely discontinued from study involvement. This may have confounded the analysis of progress.

In a discussion, Dr. Carol Aghajanian of Memorial Sloan Kettering Cancer Center in New York said, “It's unfortunate that the response rate is not reported—the authors explaining that response rate varied too much between clinician assessments and radiology review assessments—and it's disappointing that the trial's final results could not be analyzed.”

In the trial presented by Dr. Vergote, 232 patients received canfosfamide at 1,000 mg/m

“This study showed us that, as a single agent, canfosfamide doesn't have a lot of cytostatic effects, but other studies suggest that we may get better results by using this drug in combination,” he said.

The most common grade 3–4 adverse events for canfosfamide were nausea (32%), vomiting (9%), fatigue (6%), and anemia (6%). For the traditional drugs, the primary grade 3–4 adverse events were nausea (55%); anemia (15%); fatigue (7%); neutropenia (23%); thrombocytopenia (12%); and febrile neutropenia, stomatitis, or palmar-plantar erythrodysesthesia (6%).

CHICAGO — The experimental drug canfosfamide failed to achieve survival end points in two phase III trials that enrolled patients with platinum-refractory or platinum-resistant ovarian cancer.

One study compared the combination of canfosfamide (TLK286, Telcyta) and carboplatin with pegylated liposomal doxorubicin (Doxil) as second-line treatment in 247 patients recruited at 66 sites. The data failed to meet primary and secondary end points demonstrating superiority in objective response rate and progression-free survival, according to a research team led by Dr. Peter G. Rose.

Progression-free survival was 3.5 months in both arms of the trial. A subgroup of 38 patients (19 in each arm) who were characterized by a drug-free period of 6 months or longer responded more favorably to the combination therapy, with an overall response rate of 31.6%. Drug-free period was defined as the date from last treatment with platinum-based chemotherapy to the date of initiation of first study treatment.

The second trial compared single-agent canfosfamide and topotecan (Hycamtin) or pegylated liposomal doxorubicin in 461 women with disease progression following second-line treatment with doxorubicin or topotecan.

Dr. Ignace Vergote reported median overall survival was actually worse in the canfosfamide group: 8.5 months versus 10.8 months with topotecan and 14.2 months with doxorubicin (median 13.5 months for the latter two). The difference was statistically significant, said Dr. Vergote, of University Leuven (Belgium).

Both studies were sponsored by Telik Inc., and were presented in posters at the annual meeting of the American Society of Clinical Oncology.

In the trial reported by Dr. Rose, 123 women were randomized to receive intravenous canfosfamide (750 mg/m

Hematologic toxicity was more frequent in the combination arm but was well managed with growth factor support or dose reductions, according to the investigators. Grade 3–4 thrombocytopenia occurred in 33% of the women taking both canfosfamide and carboplatin. About 20% of both arms experienced grade 3–4 neutropenia.

Failure of the canfosfamide-carboplatin regime to meet established end points in second-line treatment of metastatic ovarian cancer “may in part be due to the challenges of radiologic imaging interpretation in ovarian cancer as well as to the complex biology involved in platinum resistance and resensitization,” said Dr. Rose, a professor of reproductive biology and oncology at Case Western Reserve University, Cleveland.

According to the independent radiology review, approximately one-fourth of patients may have been prematurely discontinued from study involvement. This may have confounded the analysis of progress.

In a discussion, Dr. Carol Aghajanian of Memorial Sloan Kettering Cancer Center in New York said, “It's unfortunate that the response rate is not reported—the authors explaining that response rate varied too much between clinician assessments and radiology review assessments—and it's disappointing that the trial's final results could not be analyzed.”

In the trial presented by Dr. Vergote, 232 patients received canfosfamide at 1,000 mg/m

“This study showed us that, as a single agent, canfosfamide doesn't have a lot of cytostatic effects, but other studies suggest that we may get better results by using this drug in combination,” he said.

The most common grade 3–4 adverse events for canfosfamide were nausea (32%), vomiting (9%), fatigue (6%), and anemia (6%). For the traditional drugs, the primary grade 3–4 adverse events were nausea (55%); anemia (15%); fatigue (7%); neutropenia (23%); thrombocytopenia (12%); and febrile neutropenia, stomatitis, or palmar-plantar erythrodysesthesia (6%).

CHICAGO – The fundamental cause of most lost workdays and lost jobs attributed to medical conditions is not really medical necessity. Instead, it's uncoordinated, nonmedical decision making that distorts the stay-at-work/return-to-work process employed by the disability benefits system, Dr. Jennifer Christian said at the annual conference of the Academy of Organizational and Occupational Psychiatry.

In addition to being disruptive to employers and wasteful for the economy, needless work disability is destructive to the employee, in that it threatens his or her career and self-esteem and leads to iatrogenic invalidism, Dr. Christian said.

By needless work disability, she meant run-of-the-mill medical conditions that should not prevent a return to work, as opposed to severely disabling injuries.

“We as a society should adopt a work disability prevention model that addresses those behavioral and circumstantial realities that prolong work disability,” said Dr. Christian, president and chief medical officer of Webility.md, which describes itself as preventing medically unnecessary disability through Internet-based training and collaboration.

The stay-at-work/return-to-work (SAW/RTW) process determines whether a worker stays at work despite a medical condition or whether, when, and how a worker returns to work during or after recovery, according to the American College of Occupational and Environmental Medicine (ACOEM), which cosponsored the conference.

A work disability prevention model developed late last year by the ACOEM's Stay-at-Work and Return-to-Work Process Improvement Committee points out that a large minority of workers on disability “fail to recover successfully, adopt a disabled self-concept, and experience either a needlessly prolonged absence or a permanent withdrawal from work.”

Dr. Christian, who chaired the ACOEM committee, said the SAW/RTW process is ill-suited to detect and effectively address the most important issues related to disability outcomes.

By “medicalizing” the SAW/RTW process and allowing it to function as a series of separate decisions made by several parties, and by failing to acknowledge the powerful contribution that motivation makes to outcomes, a class of invalids is being created, she said.

“The process often stalls and gets sidetracked by the tendency to focus on corroborating, justifying, or evaluating the disability rather than preventing it. The SAW/RTW process is a team sport and we haven't been playing it like one,” said Dr. Christian, who is an occupational medicine specialist in Wayland, Mass.

“If we're going to adopt a work disability prevention model, we first of all have to increase awareness among all stakeholders, including psychiatrists, of how rarely work disability is medically required and how often those days away from work are due to nonmedical things,” she said.

In addition, physicians should be paid for disability prevention work to increase their commitment to it, she added.

It is important to support appropriate patient advocacy by getting treating doctors out of their “loyalties binds,” Dr. Christian said. “We should be working with employers to accomplish a common goal.”

Psychiatrists, drawn into disability issues because of the increasing use of anxiety and depression as reasons not to go to work, often are not trained or prepared to deal with SAW/RTW issues the way they are able to deal with such issues as marriage and other relationships, she said.

Each year, 100 million to 200 million return-to-work information or benefits documents, telephone calls, and e-mails move back and forth between doctors offices, employers, and insurers, Dr. Christian said.

Because there is no standardization of content or format, she said, physicians often resort to improvisation.

It is important to support patient advocacy by getting doctorsout of their 'loyalties binds.' DR. CHRISTIAN

CHICAGO – The fundamental cause of most lost workdays and lost jobs attributed to medical conditions is not really medical necessity. Instead, it's uncoordinated, nonmedical decision making that distorts the stay-at-work/return-to-work process employed by the disability benefits system, Dr. Jennifer Christian said at the annual conference of the Academy of Organizational and Occupational Psychiatry.

In addition to being disruptive to employers and wasteful for the economy, needless work disability is destructive to the employee, in that it threatens his or her career and self-esteem and leads to iatrogenic invalidism, Dr. Christian said.

By needless work disability, she meant run-of-the-mill medical conditions that should not prevent a return to work, as opposed to severely disabling injuries.

“We as a society should adopt a work disability prevention model that addresses those behavioral and circumstantial realities that prolong work disability,” said Dr. Christian, president and chief medical officer of Webility.md, which describes itself as preventing medically unnecessary disability through Internet-based training and collaboration.

The stay-at-work/return-to-work (SAW/RTW) process determines whether a worker stays at work despite a medical condition or whether, when, and how a worker returns to work during or after recovery, according to the American College of Occupational and Environmental Medicine (ACOEM), which cosponsored the conference.

A work disability prevention model developed late last year by the ACOEM's Stay-at-Work and Return-to-Work Process Improvement Committee points out that a large minority of workers on disability “fail to recover successfully, adopt a disabled self-concept, and experience either a needlessly prolonged absence or a permanent withdrawal from work.”

Dr. Christian, who chaired the ACOEM committee, said the SAW/RTW process is ill-suited to detect and effectively address the most important issues related to disability outcomes.

By “medicalizing” the SAW/RTW process and allowing it to function as a series of separate decisions made by several parties, and by failing to acknowledge the powerful contribution that motivation makes to outcomes, a class of invalids is being created, she said.

“The process often stalls and gets sidetracked by the tendency to focus on corroborating, justifying, or evaluating the disability rather than preventing it. The SAW/RTW process is a team sport and we haven't been playing it like one,” said Dr. Christian, who is an occupational medicine specialist in Wayland, Mass.

“If we're going to adopt a work disability prevention model, we first of all have to increase awareness among all stakeholders, including psychiatrists, of how rarely work disability is medically required and how often those days away from work are due to nonmedical things,” she said.

In addition, physicians should be paid for disability prevention work to increase their commitment to it, she added.

It is important to support appropriate patient advocacy by getting treating doctors out of their “loyalties binds,” Dr. Christian said. “We should be working with employers to accomplish a common goal.”

Psychiatrists, drawn into disability issues because of the increasing use of anxiety and depression as reasons not to go to work, often are not trained or prepared to deal with SAW/RTW issues the way they are able to deal with such issues as marriage and other relationships, she said.

Each year, 100 million to 200 million return-to-work information or benefits documents, telephone calls, and e-mails move back and forth between doctors offices, employers, and insurers, Dr. Christian said.

Because there is no standardization of content or format, she said, physicians often resort to improvisation.

It is important to support patient advocacy by getting doctorsout of their 'loyalties binds.' DR. CHRISTIAN

CHICAGO – The fundamental cause of most lost workdays and lost jobs attributed to medical conditions is not really medical necessity. Instead, it's uncoordinated, nonmedical decision making that distorts the stay-at-work/return-to-work process employed by the disability benefits system, Dr. Jennifer Christian said at the annual conference of the Academy of Organizational and Occupational Psychiatry.

In addition to being disruptive to employers and wasteful for the economy, needless work disability is destructive to the employee, in that it threatens his or her career and self-esteem and leads to iatrogenic invalidism, Dr. Christian said.

By needless work disability, she meant run-of-the-mill medical conditions that should not prevent a return to work, as opposed to severely disabling injuries.

“We as a society should adopt a work disability prevention model that addresses those behavioral and circumstantial realities that prolong work disability,” said Dr. Christian, president and chief medical officer of Webility.md, which describes itself as preventing medically unnecessary disability through Internet-based training and collaboration.

The stay-at-work/return-to-work (SAW/RTW) process determines whether a worker stays at work despite a medical condition or whether, when, and how a worker returns to work during or after recovery, according to the American College of Occupational and Environmental Medicine (ACOEM), which cosponsored the conference.

A work disability prevention model developed late last year by the ACOEM's Stay-at-Work and Return-to-Work Process Improvement Committee points out that a large minority of workers on disability “fail to recover successfully, adopt a disabled self-concept, and experience either a needlessly prolonged absence or a permanent withdrawal from work.”

Dr. Christian, who chaired the ACOEM committee, said the SAW/RTW process is ill-suited to detect and effectively address the most important issues related to disability outcomes.

By “medicalizing” the SAW/RTW process and allowing it to function as a series of separate decisions made by several parties, and by failing to acknowledge the powerful contribution that motivation makes to outcomes, a class of invalids is being created, she said.

“The process often stalls and gets sidetracked by the tendency to focus on corroborating, justifying, or evaluating the disability rather than preventing it. The SAW/RTW process is a team sport and we haven't been playing it like one,” said Dr. Christian, who is an occupational medicine specialist in Wayland, Mass.

“If we're going to adopt a work disability prevention model, we first of all have to increase awareness among all stakeholders, including psychiatrists, of how rarely work disability is medically required and how often those days away from work are due to nonmedical things,” she said.

In addition, physicians should be paid for disability prevention work to increase their commitment to it, she added.

It is important to support appropriate patient advocacy by getting treating doctors out of their “loyalties binds,” Dr. Christian said. “We should be working with employers to accomplish a common goal.”

Psychiatrists, drawn into disability issues because of the increasing use of anxiety and depression as reasons not to go to work, often are not trained or prepared to deal with SAW/RTW issues the way they are able to deal with such issues as marriage and other relationships, she said.

Each year, 100 million to 200 million return-to-work information or benefits documents, telephone calls, and e-mails move back and forth between doctors offices, employers, and insurers, Dr. Christian said.

Because there is no standardization of content or format, she said, physicians often resort to improvisation.

It is important to support patient advocacy by getting doctorsout of their 'loyalties binds.' DR. CHRISTIAN

CHICAGO – A concerted effort to take better care of the brain with more healthful behaviors is likely to reduce the future incidence of Alzheimer's disease and may even slow disease progression in those who already have the disease, Dr. Nancy Emerson Lombardo said.

Cardiovascular health and glucose metabolism contribute to brain health, and the rise in obesity and other chronic illnesses has a direct impact on brain health, Dr. Lombardo said at a conference on dementia sponsored by the Alzheimer's Association.

Dr. Lombardo of the Boston University Medical Center has developed a lifestyle program trademarked as “Be Well,” based on research into the effects of nutrition on brain health.

“Be Well” dovetails with the Alzheimer's Association's “Maintain Your Brain” campaign, as well as the Centers for Disease Control and Prevention's brain health planning effort that was recently funded by Congress (for more information, visit www.alz.org

Dr. Lombardo explains that healthy brain tissue is better able to withstand the ravages of age, genetic vulnerabilities, environmental stresses, accidents, toxins, and disease. Healthy lifestyles “help us enhance and strengthen neurons, dendrites, and other body and brain cells.”

In addition, said Dr. Lombardo, obesity increases inflammation which, in turn, increases oxidative stress, possibly resulting in diabetes, heart disease, stroke, arthritis, osteoporosis, some cancers, and Alzheimer's disease (AD). “What harms the heart also harms the brain. Obesity, high blood pressure, diabetes, and heart problems all increase the risk for dementia. The future of all our obese young people is really scary,” she remarked.

If lifestyle can delay the onset of AD by 5 years, the prevalence of the disease would be halved, said Dr. Lombardo, who placed nutritional deficiency and excessive calories at the top of the list of societal factors threatening brain health in the United States.

Dr. Lombardo's Memory Preservation Diet reflects a convergence of independent research findings that nutrition can protect against AD, as well as diabetes and vascular diseases, which themselves are thought to elevate risk for AD.

“The first human placebo-controlled randomized clinical trial to be reported using marine-derived omega-3 fatty acids with persons with AD both confirmed the indications of the epidemiological and lab studies but also [suggested] the limitations of a single nutrient” for affecting the course of AD, she said (Arch. Neurol. 2006;63:1402–8).

In this Swedish trial of 174 AD patients, consumption of a daily intake of 1.7 grams of docosahexaenoic acid (DHA) and 0.6 grams of eicosapentaenoic acid (EPA) significantly slowed disease progression, but only in those with very mild dementia (Mini-Mental State Examination [MMSE] scores above 27).

The only AD diet study to date, carried out in Japan, reported that a daily regimen of fish along with additional fruits and vegetables and consumption of fewer sweets slowed progression of AD (J. Nutr. Health Aging 2004;8:432).

This controlled clinical trial with 56 subjects compared standard medical care with a daily diet of 80–90 g of fish, two servings of green vegetables, one serving of fruit, 1.3 L of water, and reduced sweets. All participants were on cholinesterase inhibitors.

Those in the diet treatment group had stable MMSE scores, sustained over a 30-month period, but scores declined by 6 points during the same time in control participants.

When and how we eat is also important, said Dr. Lombardo, stressing that it's important to have breakfast and to eat sitting at a table, preferably with other people.

Other societal factors that adversely affect brain and body health include lack of exercise, increases in stress, insufficient sleep, social disconnections, and environmental toxins, Dr. Lombardo said.

CHICAGO – A concerted effort to take better care of the brain with more healthful behaviors is likely to reduce the future incidence of Alzheimer's disease and may even slow disease progression in those who already have the disease, Dr. Nancy Emerson Lombardo said.

Cardiovascular health and glucose metabolism contribute to brain health, and the rise in obesity and other chronic illnesses has a direct impact on brain health, Dr. Lombardo said at a conference on dementia sponsored by the Alzheimer's Association.

Dr. Lombardo of the Boston University Medical Center has developed a lifestyle program trademarked as “Be Well,” based on research into the effects of nutrition on brain health.

“Be Well” dovetails with the Alzheimer's Association's “Maintain Your Brain” campaign, as well as the Centers for Disease Control and Prevention's brain health planning effort that was recently funded by Congress (for more information, visit www.alz.org

Dr. Lombardo explains that healthy brain tissue is better able to withstand the ravages of age, genetic vulnerabilities, environmental stresses, accidents, toxins, and disease. Healthy lifestyles “help us enhance and strengthen neurons, dendrites, and other body and brain cells.”

In addition, said Dr. Lombardo, obesity increases inflammation which, in turn, increases oxidative stress, possibly resulting in diabetes, heart disease, stroke, arthritis, osteoporosis, some cancers, and Alzheimer's disease (AD). “What harms the heart also harms the brain. Obesity, high blood pressure, diabetes, and heart problems all increase the risk for dementia. The future of all our obese young people is really scary,” she remarked.

If lifestyle can delay the onset of AD by 5 years, the prevalence of the disease would be halved, said Dr. Lombardo, who placed nutritional deficiency and excessive calories at the top of the list of societal factors threatening brain health in the United States.

Dr. Lombardo's Memory Preservation Diet reflects a convergence of independent research findings that nutrition can protect against AD, as well as diabetes and vascular diseases, which themselves are thought to elevate risk for AD.

“The first human placebo-controlled randomized clinical trial to be reported using marine-derived omega-3 fatty acids with persons with AD both confirmed the indications of the epidemiological and lab studies but also [suggested] the limitations of a single nutrient” for affecting the course of AD, she said (Arch. Neurol. 2006;63:1402–8).

In this Swedish trial of 174 AD patients, consumption of a daily intake of 1.7 grams of docosahexaenoic acid (DHA) and 0.6 grams of eicosapentaenoic acid (EPA) significantly slowed disease progression, but only in those with very mild dementia (Mini-Mental State Examination [MMSE] scores above 27).

The only AD diet study to date, carried out in Japan, reported that a daily regimen of fish along with additional fruits and vegetables and consumption of fewer sweets slowed progression of AD (J. Nutr. Health Aging 2004;8:432).

This controlled clinical trial with 56 subjects compared standard medical care with a daily diet of 80–90 g of fish, two servings of green vegetables, one serving of fruit, 1.3 L of water, and reduced sweets. All participants were on cholinesterase inhibitors.

Those in the diet treatment group had stable MMSE scores, sustained over a 30-month period, but scores declined by 6 points during the same time in control participants.

When and how we eat is also important, said Dr. Lombardo, stressing that it's important to have breakfast and to eat sitting at a table, preferably with other people.

Other societal factors that adversely affect brain and body health include lack of exercise, increases in stress, insufficient sleep, social disconnections, and environmental toxins, Dr. Lombardo said.

CHICAGO – A concerted effort to take better care of the brain with more healthful behaviors is likely to reduce the future incidence of Alzheimer's disease and may even slow disease progression in those who already have the disease, Dr. Nancy Emerson Lombardo said.

Cardiovascular health and glucose metabolism contribute to brain health, and the rise in obesity and other chronic illnesses has a direct impact on brain health, Dr. Lombardo said at a conference on dementia sponsored by the Alzheimer's Association.

Dr. Lombardo of the Boston University Medical Center has developed a lifestyle program trademarked as “Be Well,” based on research into the effects of nutrition on brain health.

“Be Well” dovetails with the Alzheimer's Association's “Maintain Your Brain” campaign, as well as the Centers for Disease Control and Prevention's brain health planning effort that was recently funded by Congress (for more information, visit www.alz.org

Dr. Lombardo explains that healthy brain tissue is better able to withstand the ravages of age, genetic vulnerabilities, environmental stresses, accidents, toxins, and disease. Healthy lifestyles “help us enhance and strengthen neurons, dendrites, and other body and brain cells.”

In addition, said Dr. Lombardo, obesity increases inflammation which, in turn, increases oxidative stress, possibly resulting in diabetes, heart disease, stroke, arthritis, osteoporosis, some cancers, and Alzheimer's disease (AD). “What harms the heart also harms the brain. Obesity, high blood pressure, diabetes, and heart problems all increase the risk for dementia. The future of all our obese young people is really scary,” she remarked.

If lifestyle can delay the onset of AD by 5 years, the prevalence of the disease would be halved, said Dr. Lombardo, who placed nutritional deficiency and excessive calories at the top of the list of societal factors threatening brain health in the United States.

Dr. Lombardo's Memory Preservation Diet reflects a convergence of independent research findings that nutrition can protect against AD, as well as diabetes and vascular diseases, which themselves are thought to elevate risk for AD.

“The first human placebo-controlled randomized clinical trial to be reported using marine-derived omega-3 fatty acids with persons with AD both confirmed the indications of the epidemiological and lab studies but also [suggested] the limitations of a single nutrient” for affecting the course of AD, she said (Arch. Neurol. 2006;63:1402–8).

In this Swedish trial of 174 AD patients, consumption of a daily intake of 1.7 grams of docosahexaenoic acid (DHA) and 0.6 grams of eicosapentaenoic acid (EPA) significantly slowed disease progression, but only in those with very mild dementia (Mini-Mental State Examination [MMSE] scores above 27).

The only AD diet study to date, carried out in Japan, reported that a daily regimen of fish along with additional fruits and vegetables and consumption of fewer sweets slowed progression of AD (J. Nutr. Health Aging 2004;8:432).

This controlled clinical trial with 56 subjects compared standard medical care with a daily diet of 80–90 g of fish, two servings of green vegetables, one serving of fruit, 1.3 L of water, and reduced sweets. All participants were on cholinesterase inhibitors.

Those in the diet treatment group had stable MMSE scores, sustained over a 30-month period, but scores declined by 6 points during the same time in control participants.

When and how we eat is also important, said Dr. Lombardo, stressing that it's important to have breakfast and to eat sitting at a table, preferably with other people.

Other societal factors that adversely affect brain and body health include lack of exercise, increases in stress, insufficient sleep, social disconnections, and environmental toxins, Dr. Lombardo said.

CHICAGO — Early antibiotic therapy does not improve survival in emergency department patients with community-acquired pneumonia, suggesting that the reallocation of resources for that purpose is unnecessary, according to two studies presented at the annual meeting of the Society for Academic Emergency Medicine.

“Our results suggest that the time to antibiotics in the 0- to 24-hour range has little impact on survival from community-acquired pneumonia,” said Dr. Marie Elie and colleagues at the New Jersey Medical School, Newark.

Largely as a result of a 2004 study (Arch. Intern. Med. 2004;164:637–44), the Centers for Medicare and Medicaid Services and the Joint Commission recommend that patients with community-acquired pneumonia be given an appropriate antibiotic within 4 hours of their arrival in the emergency department.

CMS and the Joint Commission set the measure identification number for this 4-hour guideline as quality measure PN-5b.

The 2004 retrospective study had mined the medical records from a national random sample of 18,000 Medicare patients older than 65 years who were hospitalized with community-acquired pneumonia (CAP) between 1988 and 1999.

Consistent with CMS guidelines, CAP patients in the study were identified as those with a discharge diagnosis between ICD-9 (CAP) codes 480 and 486, and pneumonia diagnosed within 24 hours of ED presentation, in order to distinguish CAP from hospital-acquired pneumonia, said Dr. Elie, director of emergency critical care at New Jersey Medical School.

The study cohort, drawn from three urban New York hospitals, consisted of 4,300 patients given antibiotics within 48 hours of hospital arrival.

The overall mortality rate was 7.6%. For patients with systemic inflammatory response syndrome (SIRS) in the ED, the mortality rate was 12%; without SIRS, it was significantly lower, at 5%. In addition, there was a significant relationship between increasing Acute Physiology and Chronic Health Evaluation (APACHE) II scores and decreasing survival.

There was no statistically significant linear effect of time to antibiotics on mortality, whether time to antibiotics was examined as the only explanatory variable or after adjustment for initial APACHE II score and SIRS.

A second study determined mortality rates and geometric length of stay (GLOS) for adult ED patients admitted to Union Memorial Hospital in Baltimore with a diagnosis of pneumonia.

Mortality rates and GLOS were determined for 1,781 patients and compared annually over 3 years during 2003–2006 with expected mortality rates and expected GLOS calculated using the CareScience risk-adjustment methodology (Quovadx Inc.).

CareScience is an Internet-based risk-adjustment program in which about 150 U.S. hospitals participate; each submitted information about resource use, pharmacy, radiology, device, procedure, discharge diagnosis, and demographics, said Dr. William Frohna, chief of emergency medicine at Union Memorial Hospital.

The retrospective, observational study used patient selection criteria of the Joint Commission's National Hospital Quality Measures, hospital records, and the CareScience database to determine outcomes at a time when performance improvement efforts significantly cut the time to antibiotics in the ED.

In the first of the 3 years, 67% of about 600 patients discharged from the Union Memorial Hospital ED with a diagnosis of pneumonia received an antibiotic within 4 hours. In the second and third years, the percentage rose to 77% and 91%, respectively, Dr. Frohna said.

“Our mortality went from 6.8% in year 1 to 8.4% in year 2, then dropped back to 6.8% in year 3, and the mortality differences were not statistically significant,” he said. The expected mortality rates were 7.6%, 8.1%, and 5.9%.

Geometric length of stay remained below the comparative group and declined each year, from 4.1% to 3.7%.

“Over the 3 years, our performance measure improved as reported to the National Hospital Quality Measures Program. Our mortality rate remained unchanged and our geometric length of stay decreased,” Dr. Frohna said.

The discrepancy between the findings of the New Jersey Medical School and Union Memorial Hospital studies and the 2004 study may be attributable to the fact that the 2004 retrospective study included only Medicare patients older than 65 years, Dr. Frohna explained.

Dr. Frohna cautioned emergency physicians to “be on the front lines of making sure that performance measures actually link to improved outcomes,” and not look the other way while others dictate how they treat their patients.

CHICAGO — Early antibiotic therapy does not improve survival in emergency department patients with community-acquired pneumonia, suggesting that the reallocation of resources for that purpose is unnecessary, according to two studies presented at the annual meeting of the Society for Academic Emergency Medicine.

“Our results suggest that the time to antibiotics in the 0- to 24-hour range has little impact on survival from community-acquired pneumonia,” said Dr. Marie Elie and colleagues at the New Jersey Medical School, Newark.

Largely as a result of a 2004 study (Arch. Intern. Med. 2004;164:637–44), the Centers for Medicare and Medicaid Services and the Joint Commission recommend that patients with community-acquired pneumonia be given an appropriate antibiotic within 4 hours of their arrival in the emergency department.

CMS and the Joint Commission set the measure identification number for this 4-hour guideline as quality measure PN-5b.

The 2004 retrospective study had mined the medical records from a national random sample of 18,000 Medicare patients older than 65 years who were hospitalized with community-acquired pneumonia (CAP) between 1988 and 1999.

Consistent with CMS guidelines, CAP patients in the study were identified as those with a discharge diagnosis between ICD-9 (CAP) codes 480 and 486, and pneumonia diagnosed within 24 hours of ED presentation, in order to distinguish CAP from hospital-acquired pneumonia, said Dr. Elie, director of emergency critical care at New Jersey Medical School.

The study cohort, drawn from three urban New York hospitals, consisted of 4,300 patients given antibiotics within 48 hours of hospital arrival.

The overall mortality rate was 7.6%. For patients with systemic inflammatory response syndrome (SIRS) in the ED, the mortality rate was 12%; without SIRS, it was significantly lower, at 5%. In addition, there was a significant relationship between increasing Acute Physiology and Chronic Health Evaluation (APACHE) II scores and decreasing survival.

There was no statistically significant linear effect of time to antibiotics on mortality, whether time to antibiotics was examined as the only explanatory variable or after adjustment for initial APACHE II score and SIRS.

A second study determined mortality rates and geometric length of stay (GLOS) for adult ED patients admitted to Union Memorial Hospital in Baltimore with a diagnosis of pneumonia.

Mortality rates and GLOS were determined for 1,781 patients and compared annually over 3 years during 2003–2006 with expected mortality rates and expected GLOS calculated using the CareScience risk-adjustment methodology (Quovadx Inc.).

CareScience is an Internet-based risk-adjustment program in which about 150 U.S. hospitals participate; each submitted information about resource use, pharmacy, radiology, device, procedure, discharge diagnosis, and demographics, said Dr. William Frohna, chief of emergency medicine at Union Memorial Hospital.

The retrospective, observational study used patient selection criteria of the Joint Commission's National Hospital Quality Measures, hospital records, and the CareScience database to determine outcomes at a time when performance improvement efforts significantly cut the time to antibiotics in the ED.

In the first of the 3 years, 67% of about 600 patients discharged from the Union Memorial Hospital ED with a diagnosis of pneumonia received an antibiotic within 4 hours. In the second and third years, the percentage rose to 77% and 91%, respectively, Dr. Frohna said.

“Our mortality went from 6.8% in year 1 to 8.4% in year 2, then dropped back to 6.8% in year 3, and the mortality differences were not statistically significant,” he said. The expected mortality rates were 7.6%, 8.1%, and 5.9%.

Geometric length of stay remained below the comparative group and declined each year, from 4.1% to 3.7%.

“Over the 3 years, our performance measure improved as reported to the National Hospital Quality Measures Program. Our mortality rate remained unchanged and our geometric length of stay decreased,” Dr. Frohna said.

The discrepancy between the findings of the New Jersey Medical School and Union Memorial Hospital studies and the 2004 study may be attributable to the fact that the 2004 retrospective study included only Medicare patients older than 65 years, Dr. Frohna explained.

Dr. Frohna cautioned emergency physicians to “be on the front lines of making sure that performance measures actually link to improved outcomes,” and not look the other way while others dictate how they treat their patients.

CHICAGO — Early antibiotic therapy does not improve survival in emergency department patients with community-acquired pneumonia, suggesting that the reallocation of resources for that purpose is unnecessary, according to two studies presented at the annual meeting of the Society for Academic Emergency Medicine.

“Our results suggest that the time to antibiotics in the 0- to 24-hour range has little impact on survival from community-acquired pneumonia,” said Dr. Marie Elie and colleagues at the New Jersey Medical School, Newark.

Largely as a result of a 2004 study (Arch. Intern. Med. 2004;164:637–44), the Centers for Medicare and Medicaid Services and the Joint Commission recommend that patients with community-acquired pneumonia be given an appropriate antibiotic within 4 hours of their arrival in the emergency department.

CMS and the Joint Commission set the measure identification number for this 4-hour guideline as quality measure PN-5b.

The 2004 retrospective study had mined the medical records from a national random sample of 18,000 Medicare patients older than 65 years who were hospitalized with community-acquired pneumonia (CAP) between 1988 and 1999.

Consistent with CMS guidelines, CAP patients in the study were identified as those with a discharge diagnosis between ICD-9 (CAP) codes 480 and 486, and pneumonia diagnosed within 24 hours of ED presentation, in order to distinguish CAP from hospital-acquired pneumonia, said Dr. Elie, director of emergency critical care at New Jersey Medical School.

The study cohort, drawn from three urban New York hospitals, consisted of 4,300 patients given antibiotics within 48 hours of hospital arrival.

The overall mortality rate was 7.6%. For patients with systemic inflammatory response syndrome (SIRS) in the ED, the mortality rate was 12%; without SIRS, it was significantly lower, at 5%. In addition, there was a significant relationship between increasing Acute Physiology and Chronic Health Evaluation (APACHE) II scores and decreasing survival.

There was no statistically significant linear effect of time to antibiotics on mortality, whether time to antibiotics was examined as the only explanatory variable or after adjustment for initial APACHE II score and SIRS.

A second study determined mortality rates and geometric length of stay (GLOS) for adult ED patients admitted to Union Memorial Hospital in Baltimore with a diagnosis of pneumonia.

Mortality rates and GLOS were determined for 1,781 patients and compared annually over 3 years during 2003–2006 with expected mortality rates and expected GLOS calculated using the CareScience risk-adjustment methodology (Quovadx Inc.).

CareScience is an Internet-based risk-adjustment program in which about 150 U.S. hospitals participate; each submitted information about resource use, pharmacy, radiology, device, procedure, discharge diagnosis, and demographics, said Dr. William Frohna, chief of emergency medicine at Union Memorial Hospital.

The retrospective, observational study used patient selection criteria of the Joint Commission's National Hospital Quality Measures, hospital records, and the CareScience database to determine outcomes at a time when performance improvement efforts significantly cut the time to antibiotics in the ED.

In the first of the 3 years, 67% of about 600 patients discharged from the Union Memorial Hospital ED with a diagnosis of pneumonia received an antibiotic within 4 hours. In the second and third years, the percentage rose to 77% and 91%, respectively, Dr. Frohna said.

“Our mortality went from 6.8% in year 1 to 8.4% in year 2, then dropped back to 6.8% in year 3, and the mortality differences were not statistically significant,” he said. The expected mortality rates were 7.6%, 8.1%, and 5.9%.

Geometric length of stay remained below the comparative group and declined each year, from 4.1% to 3.7%.

“Over the 3 years, our performance measure improved as reported to the National Hospital Quality Measures Program. Our mortality rate remained unchanged and our geometric length of stay decreased,” Dr. Frohna said.

The discrepancy between the findings of the New Jersey Medical School and Union Memorial Hospital studies and the 2004 study may be attributable to the fact that the 2004 retrospective study included only Medicare patients older than 65 years, Dr. Frohna explained.

Dr. Frohna cautioned emergency physicians to “be on the front lines of making sure that performance measures actually link to improved outcomes,” and not look the other way while others dictate how they treat their patients.

CHICAGO — Extended emergency department waiting times significantly elevated hospital costs and, for the large subset of patients with congestive heart failure, extended hospital stays, according to a single-hospital study led by Dr. Bram Dolcourt.

“If a patient waits in our emergency room for 8 hours or longer, that person will end up with an additional $6,000 in total hospital charges,” said Dr. Dolcourt, of Henry Ford Hospital in Detroit.

Based on that finding, Dr. Dolcourt estimated that extended ED waits cost Henry Ford Hospital nearly $2 million annually.

Although length of stay for the top 20 admitting diagnoses combined was not significantly affected by ED waits of more than 8 hours, congestive heart failure (CHF) by itself stood out.

“Interestingly, for CHF—which is the No. 1 admitting diagnosis in our ED—patients who stayed longer than 8 hours stayed in the hospital 3 additional days,” Dr. Dolcourt said. Causation is unclear, he added, and may reflect other factors associated with long bed waits.

This retrospective study included 1,747 patients aged 18 years or older admitted through the ED with one of the top 20 admitting diagnoses to a general practice unit from July to December 2005. It was presented as a poster at the annual meeting of the Society for Academic Emergency Medicine. Patients were assessed for time spent waiting for a bed after a bed request was made, hospital length of stay, and total hospital charges.

Prolonged ED lengths of stay were based on an a priori cutoff of 4 hours; however, after data analysis, 8 hours represented 1 standard deviation above the mean (which was approximately 4 hours).

“Although our results may not apply to other hospitals, these findings underscore the importance of looking at our processes and finding areas where we can speed aspects of admission and discharge so that, hopefully, we can reduce costs and lengths of stay,” Dr. Dolcourt said. Waiting times most likely are more of a symptom than a cause, he concluded.

A patient who waits in our ED for 8 hours or longer will end up with an additional $6,000 in total hospital charges. DR. DOLCOURT

CHICAGO — Extended emergency department waiting times significantly elevated hospital costs and, for the large subset of patients with congestive heart failure, extended hospital stays, according to a single-hospital study led by Dr. Bram Dolcourt.

“If a patient waits in our emergency room for 8 hours or longer, that person will end up with an additional $6,000 in total hospital charges,” said Dr. Dolcourt, of Henry Ford Hospital in Detroit.

Based on that finding, Dr. Dolcourt estimated that extended ED waits cost Henry Ford Hospital nearly $2 million annually.

Although length of stay for the top 20 admitting diagnoses combined was not significantly affected by ED waits of more than 8 hours, congestive heart failure (CHF) by itself stood out.

“Interestingly, for CHF—which is the No. 1 admitting diagnosis in our ED—patients who stayed longer than 8 hours stayed in the hospital 3 additional days,” Dr. Dolcourt said. Causation is unclear, he added, and may reflect other factors associated with long bed waits.

This retrospective study included 1,747 patients aged 18 years or older admitted through the ED with one of the top 20 admitting diagnoses to a general practice unit from July to December 2005. It was presented as a poster at the annual meeting of the Society for Academic Emergency Medicine. Patients were assessed for time spent waiting for a bed after a bed request was made, hospital length of stay, and total hospital charges.

Prolonged ED lengths of stay were based on an a priori cutoff of 4 hours; however, after data analysis, 8 hours represented 1 standard deviation above the mean (which was approximately 4 hours).

“Although our results may not apply to other hospitals, these findings underscore the importance of looking at our processes and finding areas where we can speed aspects of admission and discharge so that, hopefully, we can reduce costs and lengths of stay,” Dr. Dolcourt said. Waiting times most likely are more of a symptom than a cause, he concluded.

A patient who waits in our ED for 8 hours or longer will end up with an additional $6,000 in total hospital charges. DR. DOLCOURT

CHICAGO — Extended emergency department waiting times significantly elevated hospital costs and, for the large subset of patients with congestive heart failure, extended hospital stays, according to a single-hospital study led by Dr. Bram Dolcourt.

“If a patient waits in our emergency room for 8 hours or longer, that person will end up with an additional $6,000 in total hospital charges,” said Dr. Dolcourt, of Henry Ford Hospital in Detroit.

Based on that finding, Dr. Dolcourt estimated that extended ED waits cost Henry Ford Hospital nearly $2 million annually.

Although length of stay for the top 20 admitting diagnoses combined was not significantly affected by ED waits of more than 8 hours, congestive heart failure (CHF) by itself stood out.

“Interestingly, for CHF—which is the No. 1 admitting diagnosis in our ED—patients who stayed longer than 8 hours stayed in the hospital 3 additional days,” Dr. Dolcourt said. Causation is unclear, he added, and may reflect other factors associated with long bed waits.

This retrospective study included 1,747 patients aged 18 years or older admitted through the ED with one of the top 20 admitting diagnoses to a general practice unit from July to December 2005. It was presented as a poster at the annual meeting of the Society for Academic Emergency Medicine. Patients were assessed for time spent waiting for a bed after a bed request was made, hospital length of stay, and total hospital charges.

Prolonged ED lengths of stay were based on an a priori cutoff of 4 hours; however, after data analysis, 8 hours represented 1 standard deviation above the mean (which was approximately 4 hours).

“Although our results may not apply to other hospitals, these findings underscore the importance of looking at our processes and finding areas where we can speed aspects of admission and discharge so that, hopefully, we can reduce costs and lengths of stay,” Dr. Dolcourt said. Waiting times most likely are more of a symptom than a cause, he concluded.

A patient who waits in our ED for 8 hours or longer will end up with an additional $6,000 in total hospital charges. DR. DOLCOURT