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David A Talan

Publications and source records attributed to David A Talan.

At least 19 recordsLinked to original sources
PubMed2006

Methicillin-resistant S. aureus infections among patients in the emergency department.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly recognized in infections among persons in the community without established risk factors for MRSA. METHODS: We enrolled adult patients with acute, purulent skin and soft-tissue infections presenting to 11 university-affiliated emergency departments during the month of August 2004. Cultures were obtained, and clinical information was collected. Available S. aureus isolates were characterized by antimicrobial-susceptibility testing, pulsed-field gel electrophoresis, and detection of toxin genes. On MRSA isolates, we performed typing of the staphylococcal cassette chromosome mec (SCCmec), the genetic element that carries the mecA gene encoding methicillin resistance. RESULTS: S. aureus was isolated from 320 of 422 patients with skin and soft-tissue infections (76 percent). The prevalence of MRSA was 59 percent overall and ranged from 15 to 74 percent. Pulsed-field type USA300 isolates accounted for 97 percent of MRSA isolates; 74 percent of these were a single strain (USA300-0114). SCCmec type IV and the Panton-Valentine leukocidin toxin gene were detected in 98 percent of MRSA isolates. Other toxin genes were detected rarely. Among the MRSA isolates, 95 percent were susceptible to clindamycin, 6 percent to erythromycin, 60 percent to fluoroquinolones, 100 percent to rifampin and trimethoprim-sulfamethoxazole, and 92 percent to tetracycline. Antibiotic therapy was not concordant with the results of susceptibility testing in 100 of 175 patients with MRSA infection who received antibiotics (57 percent). Among methicillin-susceptible S. aureus isolates, 31 percent were USA300 and 42 percent contained pvl genes. CONCLUSIONS: MRSA is the most common identifiable cause of skin and soft-tissue infections among patients presenting to emergency departments in 11 U.S. cities. When antimicrobial therapy is indicated for the treatment of skin and soft-tissue infections, clinicians should consider obtaining cultures and modifying empirical therapy to provide MRSA coverage.

Acute Disease↗
PubMed2006

Severe sepsis and septic shock: review of the literature and emergency department management guidelines.

Severe sepsis and septic shock are as common and lethal as other acute life-threatening conditions that emergency physicians routinely confront such as acute myocardial infarction, stroke, and trauma. Recent studies have led to a better understanding of the pathogenic mechanisms and the development of new or newly applied therapies. These therapies place early and aggressive management of severe sepsis and septic shock as integral to improving outcome. This independent review of the literature examines the recent pathogenic, diagnostic, and therapeutic advances in severe sepsis and septic shock for adults, with particular relevance to emergency practice. Recommendations are provided for therapies that have been shown to improve outcomes, including early goal-directed therapy, early and appropriate antimicrobials, source control, recombinant human activated protein C, corticosteroids, and low tidal volume mechanical ventilation.

Adrenal Cortex Hormones↗
PubMed2005

Methicillin-resistant Staphylococcus aureus in community-acquired skin infections.

Community-associated methicillin-resistant Staphylococcus aureus (MRSA) is the most common pathogen among patients with skin and soft tissue infections seeking treatment at a Los Angeles (USA) area emergency department. The proportion caused by MRSA increased from 29% in 2001 to 2002 to 64% in 2003 to 2004. No clinical or historical features reliably predict MRSA etiology.

Adult↗
PubMed2004

Tetanus immunity and physician compliance with tetanus prophylaxis practices among emergency department patients presenting with wounds.

STUDY OBJECTIVE: We determine tetanus seroprotection rates and physician compliance with tetanus prophylaxis recommendations among patients presenting with wounds. METHODS: A prospective observational study of patients aged 18 years or older who presented to 5 university-affiliated emergency departments (EDs) because of wounds was conducted between March 1999 and August 2000. Serum antitoxin levels were measured by enzyme immunoassay with seroprotection defined as more than 0.15 IU/mL. Seroprotection rates, risk factors for lack of seroprotection, and rates of physician compliance with tetanus prophylaxis recommendations by the Advisory Committee on Immunization Practices were determined. RESULTS: The seroprotection rate among 1,988 patients was 90.2% (95% confidence interval 88.8% to 91.5%). Groups with significantly lower seroprotection rates were persons aged 70 years or older, 59.5% (risk ratio [RR] 5.2); immigrants from outside North America or Western Europe, 75.3% (RR 3.7); persons with a history of inadequate immunization, 86.3% (RR 2.9); and persons without education beyond grade school, 76.5% (RR 2.5). Despite a history of adequate immunization, 18% of immigrants lacked seroprotection. Overall, 60.9% of patients required tetanus immunization, of whom 57.6% did not receive indicated immunization. Among patients with tetanus-prone wounds, appropriate prophylaxis (ie, tetanus immunoglobulin and toxoid) was provided to none of 504 patients who gave a history of inadequate primary immunization (of whom 15.1% had nonprotective antibody titers) and to 218 (79%) of 276 patients who required only a toxoid booster. CONCLUSION: Although seroprotection rates are generally high in the United States, the risk of tetanus persists in the elderly, immigrants, and persons without education beyond grade school. There is substantial underimmunization in the ED (particularly with regard to use of tetanus immunoglobulin), leaving many patients, especially those from high-risk groups, unprotected. Better awareness of tetanus prophylaxis recommendations is necessary, and future tetanus prophylaxis recommendations may be more effective if they are also based on demographic risk factors.

Adolescent↗
PubMed2004

Extended-release ciprofloxacin (Cipro XR) for treatment of urinary tract infections.

Symptomatic urinary tract infections (UTIs) constitute a major health problem throughout the Western world. In the USA, UTIs are responsible for 7-8 million outpatient visits each year and for over one-third of all hospital-acquired infections. Empiric antimicrobial therapy for UTIs, which are primarily caused by Escherichia coli, is increasingly being complicated by the emergence of resistance to the most widely used agents. Recent studies indicate that the prevalence of E. coli resistance to trimethoprim/sulphamethoxazole (TMP/SMX), the current first-line therapy for UTIs, exceeds 20% in many North American regions. Importantly, antibiotic resistance often translates into clinical failure. The use of antibiotics with favourable pharmacokinetic/pharmacodynamic profiles and convenient dosing schedules, which effectively increase bacterial eradication and patient compliance, can help to curb the current epidemic of resistance and reduce the rate of clinical failure associated with resistance. Fluoroquinolones have well-established efficacy in the treatment of multiple bacterial infections and, over the years, the rates of resistance to these antibiotics have remained very low. Fluoroquinolones are currently recommended for therapy of uncomplicated UTIs when the local incidence of TMP/SMX resistance is >or=10-20%, as well as for the treatment of complicated UTIs and acute pyelonephritis. Ciprofloxacin, one of the most widely used fluoroquinolones, has a potent bactericidal effect across the full spectrum of uropathogens, as well as a long and excellent efficacy and safety record in the management of UTI and other infections. A recently developed extended (modified)-release formulation of ciprofloxacin (Cipro XR or Cipro XL) provides higher maximum plasma concentrations with lower inter-patient variability than the conventional, immediate-release, twice-daily formulation. Additionally, therapeutic drug levels with extended-release ciprofloxacin are achieved rapidly and maintained over the course of 24 h, allowing once-daily dosing. Clinical trials in patients with cystitis and those with complicated UTIs or acute uncomplicated pyelonephritis indicate that extended-release ciprofloxacin is at least as effective as the immediate-release formulation. These studies have also confirmed good tolerability and safety of extended-release ciprofloxacin, similar to the immediate-release formulation. Therefore, extended-release ciprofloxacin is a convenient, well-tolerated and effective therapy for UTIs that may improve patients' compliance with treatment and thus decrease the risk of treatment failure and the spread of antibiotic resistance.

Bacterial Infections↗
PubMed2004

Once daily, extended release ciprofloxacin for complicated urinary tract infections and acute uncomplicated pyelonephritis.

PURPOSE: We assessed the efficacy and safety of 1,000 mg extended release ciprofloxacin orally once daily vs conventional 500 mg ciprofloxacin orally twice daily, each for 7 to 14 days, in patients with a complicated urinary tract infection (cUTI) or acute uncomplicated pyelonephritis (AUP). MATERIALS AND METHODS: In this prospective, randomized, double-blind, North American multicenter clinical trial adults were stratified based on clinical presentation of cUTI or AUP and randomized to extended release ciprofloxacin or ciprofloxacin twice daily. Efficacy valid patients had positive pretherapy urine cultures (105 or greater cFU/ml) and pyuria within 48 hours of study entry. Bacteriological and clinical outcomes were assessed at the test of cure visit (5 to 11 days after therapy) and the late followup visit (28 to 42 days after therapy). RESULTS: The intent to treat population comprised 1,035 patients (extended release ciprofloxacin in 517 and twice daily in 518), of whom 435 were efficacy valid (cUTI in 343 and AUP in 92). For efficacy valid patients (cUTI and AUP combined) bacteriological eradication rates at test of cure were 89% (183 of 206) vs 85% (195 of 229) (95% CI -2.4%, 10.3%) and clinical cure rates were 97% (198 of 205) vs 94% (211 of 225) (95% CI -1.2%, 6.9%) for extended release vs twice daily ciprofloxacin. Late followup outcomes were consistent with test of cure findings. Eradication rates for Escherichia coli, which accounted for 58% of pathogens, were 97% or greater per group. Drug related adverse event rates were similar for extended release and twice daily ciprofloxacin (13% and 14%, respectively). CONCLUSIONS: Extended release ciprofloxacin at a dose of 1,000 mg once daily was as safe and effective as conventional treatment with 500 mg ciprofloxacin twice daily, each given orally for 7 to 14 days in adults with cUTI or AUP. It provides a convenient, once daily, empirical treatment option.

Acute Disease↗
PubMed2003

Clinical presentation and bacteriologic analysis of infected human bites in patients presenting to emergency departments.

Previous studies of infected human bites have been limited by small numbers of patients and suboptimal microbiologic methodology. We conducted a multicenter prospective study of 50 patients with infected human bites. Seventy percent of the patients and assailants were young adult men. Fifty-six percent of injuries were clenched-fist injuries and 44% were occlusional bites. Most injuries were to the hands. Fifty-four percent of patients were hospitalized. The median number of isolates per wound culture was 4 (3 aerobes and 1 anaerobe); aerobes and anaerobes were isolated from 54% of wounds, aerobes alone were isolated from 44%, and anaerobes alone were isolated from 2%. Isolates included Streptococcus anginosus (52%), Staphylococcus aureus (30%), Eikenella corrodens (30%), Fusobacterium nucleatum (32%), and Prevotella melaninogenica (22%). Candida species were found in 8%. Fusobacterium, Peptostreptococcus, and Candida species were isolated more frequently from occlusional bites than from clenched-fist injuries. Many strains of Prevotella and S. aureus were beta-lactamase producers. Amoxicillin-clavulanic acid and moxifloxacin demonstrated excellent in vitro activity against common isolates.

Adolescent↗
PubMed2003

Antibiotic use for emergency department patients with acute diarrhea: Prescribing practices, patient expectations, and patient satisfaction.

STUDY OBJECTIVE: Physicians commonly prescribe antibiotics to meet patient expectations, even when antimicrobials are unnecessary. We evaluated factors emergency physicians consider in prescribing antibiotics to patients with diarrhea and examined patient expectations, physician-perceived patient expectations, and patient satisfaction. METHODS: Adults and children presenting with acute diarrhea to 1 of 10 academic emergency departments (EDs) were enrolled in this prospective observational cohort study. Adult patients and guardians of enrolled children were asked about treatment expectations before their physician encounter and about satisfaction with their medical care at discharge. Physicians were asked about factors influencing management decisions and their perceptions of patients' expectations. RESULTS: Of 104 patients enrolled, 25% received antibiotics. Physicians were more likely to prescribe antibiotics when features suggestive of bacterial enteritis were present (unadjusted odds ratio [OR] 2.5; 95% confidence interval [CI] 1.1 to 3.9). Physicians were also more likely to prescribe antibiotics when they believed patients expected them (unadjusted OR 2.3; 95% CI 1.1 to 4.4) but correctly identified such expectations in only 33% of instances. Satisfaction with care was reported by 100% of patients receiving antibiotics and 90% of those not receiving antibiotics (95% CI for difference of 10%, 3% to 17%). CONCLUSION: Physicians in academic EDs prescribe antibiotics for acute diarrhea to about 1 patient in 4 and are more likely to do so if signs or symptoms compatible with bacterial enteritis are present. Physicians' assessments of patients' expectations for therapy were accurate in only 1 of 3 patients but were nevertheless associated with antibiotic prescription. Patient satisfaction was weakly associated with receipt of antibiotics.

Acute Disease↗
PubMed2002

Once-daily, high-dose levofloxacin versus ticarcillin-clavulanate alone or followed by amoxicillin-clavulanate for complicated skin and skin-structure infections: a randomized, open-label trial.

This study tested whether levofloxacin, at a new high dose of 750 mg, was effective for the treatment of complicated skin and skin-structure infections (SSSIs). Patients with complicated SSSIs (n=399) were randomly assigned in a ratio of 1:1 to 2 treatment arms: levofloxacin (750 mg given once per day intravenously [iv], orally, or iv/orally) or ticarcillin-clavulanate (TC; 3.1 g given iv every 4-6 hours) followed, at the investigator's discretion, by amoxicillin-clavulanate (AC; 875 mg given orally every 12 hours). In the clinically evaluable population, therapeutic equivalence was demonstrated between the levofloxacin and TC/AC regimens (success rates of 84.1% and 80.3%, respectively). In the microbiologically evaluable population, the overall rate of eradication was 83.7% in the levofloxacin treatment group and 71.4% in the TC/AC treatment group (95% confidence interval, -24.3 to -0.2). Both levofloxacin and TC/AC were well tolerated. These data demonstrate that levofloxacin (750 mg once per day) is safe and at least as effective as TC/AC for complicated SSSIs.

Amoxicillin-Potassium Clavulanate Combination↗