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Leonard Leibovici

Publications and source records attributed to Leonard Leibovici.

35 records · Page 2Linked to original sources
PubMed2004

Oral versus intravenous antibiotic treatment for febrile neutropenia in cancer patients: a systematic review and meta-analysis of randomized trials.

CONTEXT: Neutropenia is one of the grave consequences of cancer chemotherapy, and the treatment of neutropenic febrile patients with intravenous (iv) antibiotics has been shown to reduce mortality. Oral therapy could be an alternative approach for selected patients. OBJECTIVES: To compare the efficacy of oral antibiotics versus iv antibiotic therapy in febrile neutropenic cancer patients. DATA SOURCES: The Cochrane Library, the Cochrane Cancer Network Register of trials, EMBASE, LILACS and MEDLINE, databases for ongoing trials and the conference proceedings of the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC). STUDY SELECTION: Randomized controlled trials comparing oral antibiotic/s and iv antibiotic/s for the treatment of neutropenic cancer patients with fever. DATA COLLECTION: Two reviewers independently assessed trial eligibility, methodological quality and extracted all data. Data concerning mortality, treatment failures and adverse events were drawn from included studies assuming an 'intention-to-treat' and 'per-protocol' basis for the outcome measures whenever possible. Relative risks (RR) with their 95% confidence intervals (CI) for dichotomous data were estimated. MAIN RESULTS: Fifteen trials (median mortality 0, range 0%-8.8%) were included in the analyses. The mortality rate was similar comparing oral and iv antibiotic treatment (RR 0.83, 95% CI 0.49-1.41, 2224 patients). Treatment failure rates were also similar (RR 0.94, 95% CI 0.84-1.05, 15 trials). No significant heterogeneity was shown for the primary outcomes. This effect was stable in a wide range of patients. Quinolones alone or combined with other antibiotics were used with comparable results. Adverse reactions, mostly gastrointestinal, were more common with oral antibiotics. CONCLUSIONS: Oral antibiotics may be safely offered to neutropenic patients with fever who are at low risk for mortality.

Administration, Oral↗
PubMed2004

Beta lactam monotherapy versus beta lactam-aminoglycoside combination therapy for sepsis in immunocompetent patients: systematic review and meta-analysis of randomised trials.

OBJECTIVE: To compare beta lactam monotherapy with beta lactam-aminoglycoside combination therapy for severe infections. DATA SOURCES: Medline, Embase, Lilacs, Cochrane Library, and conference proceedings, to 2003; references of included studies; contact with all authors. No restrictions, such as language, year of publication, or publication status. STUDY SELECTION: All randomised trials of beta lactam monotherapy compared with beta lactam-aminoglycoside combination therapy for patients without neutropenia who fulfilled criteria for sepsis. DATA SELECTION: Two reviewers independently applied selection criteria, performed quality assessment, and extracted the data. The primary outcome assessed was all cause fatality by intention to treat. Relative risks were pooled with the random effect model (relative risk < 1 favours monotherapy). RESULTS: 64 trials with 7586 patients were included. There was no difference in all cause fatality (relative risk 0.90, 95% confidence interval 0.77 to 1.06). 12 studies compared the same beta lactam (1.02, 0.76 to 1.38), and 31 studies compared different beta lactams (0.85, 0.69 to 1.05). Clinical failure was more common with combination treatment overall (0.87, 0.78 to 0.97) and among studies comparing different beta lactams (0.76, 0.68 to 0.86). There was no advantage to combination therapy among patients with Gram negative infections (1835 patients) or Pseudomonas aeruginosa infections (426 patients). There was no difference in the rate of development of resistance. Nephrotoxicity was significantly more common with combination therapy (0.36, 0.28 to 0.47). Heterogeneity was not significant for these comparisons. CONCLUSIONS: In the treatment of sepsis the addition of an aminoglycoside to beta lactams should be discouraged. Fatality remains unchanged, while the risk for adverse events is increased.

Aminoglycosides↗
PubMed2004

Infective endocarditis in diabetic and non-diabetic patients.

We compared clinical, microbiological, and prognostic characteristics of infective endocarditis in patients with and without diabetes mellitus. In 1987--1996, 213 patients with definite or possible infective endocarditis were included, of which 39 (18%) had diabetes mellitus. Diabetic patients were older than non-diabetic (median age of 71 vs 65 y, respectively; p =0.04), had more aortic valve and less mitral valve involvement (71% vs 27%, and 21% vs 62%; p = 0.004). There was no significant difference in the frequency of Staphylococcus aureus involvement between the 2 groups (21% in diabetic vs 20% in non-diabetic group; p = ns). On multivariate analysis diabetes mellitus was not found to be an independent factor for mortality. Unlike other infections diabetes mellitus does not significantly affect clinical and microbiological features, and outcome of infective endocarditis.

Adult↗
PubMed2004

Applying an artificial neural network to warfarin maintenance dose prediction.

BACKGROUND: Oral anticoagulation with warfarin can lead to life-threatening events as a result of either over-anticoagulation or undertreatment. One of the main contributors to an undesirable warfarin effect is the need to adjust its daily dose for a specific patient. The dose is adjusted empirically based on the experience of the clinician, a method that is often imprecise. There is currently no other well-accepted method for predicting the maintenance dose of warfarin. OBJECTIVE: To describe the application of an artificial neural network to the problem of warfarin maintenance dose prediction. METHODS: We designed a neural network that predicts the maintenance dose of warfarin. Data on 148 patients attending a large anticoagulant clinic were collected by file review. Using correlational analysis of the patients' data we selected the best input variables. The network was trained by using the back-propagation algorithm on a subset of our data and the results were validated against the rest of the data. We used a multivariate linear regression to create a comparable model. RESULTS: The neural network generated reasonable predictions of the maintenance dose (r = 0.823). The results of the linear regression model were similar (r = 0.800). CONCLUSION: Neural networks can be applied successfully for warfarin maintenance dose prediction. The results are promising, but further investigation is needed.

Adolescent↗
PubMed2003

Considering resistance in systematic reviews of antibiotic treatment.

CONTEXT: Microorganisms resistant to antibiotic drugs are a threat to the health and chances of survival of patients. Systematic reviews on antibiotic drugs that ignore the topic of resistance present readers with a skewed view, emphasizing short-term efficacy or effectiveness while ignoring long-term consequences. OBJECTIVES: To examine whether systematic reviews of antibiotic treatment consider resistance; if not, to find out whether data on resistance were reported in the original trials; and based on that, to offer a framework for taking resistance into account in systematic reviews. DATA SOURCES: The Cochrane Database of Systematic Reviews (the Cochrane Library, 2001, issue 2); and MEDLINE, 1996-2000. STUDY SELECTION: (i) Systematic reviews or meta-analyses of antimicrobial therapy, published during 1996-2000. (ii) Randomized, controlled trials abstracted in systematic reviews that addressed a topic highly relevant to antibiotic resistance. DATA EXTRACTION: We examined each systematic review, and each article, to see whether the implications of resistance were discussed; and whether data on resistance were collected. RESULTS: Out of 111 systematic reviews, only 44 (40%) discussed resistance. Ten reviews (9%) planned or performed collection of data on the response of patients with susceptible or resistant isolates. In 22 systematic reviews (20%), collection of data on induction of resistance was planned or performed. The topic of 41 reviews was judged highly relevant to resistance, and these reviews extracted data from 337 articles, out of which we retrieved 279 articles (83%). In 201 (72%) articles, resistance was discussed or data pertaining to it were collected. Ninety-seven articles (35%) gave actual data on resistance of pathogens to the study drugs, 71 articles (25%) data on efficacy of antibiotic drugs in patients with susceptible and resistant pathogens, and 55 articles (20%) provided data on infection or colonization with resistant strains during treatment. CONCLUSIONS: Most systematic reviews on antibiotic treatment ignored the issue of resistance, although many of the original articles referred to it and some reported relevant data. Reviewers should collect data on resistance and discuss the implications in their discussion and sections concerned with policy implications.

Anti-Bacterial Agents↗
PubMed2003

Beta lactam monotherapy versus beta lactam-aminoglycoside combination therapy for fever with neutropenia: systematic review and meta-analysis.

OBJECTIVE: To compare the effectiveness of beta lactam monotherapy versus beta lactam-aminoglycoside combination therapy in the treatment of patients with fever and neutropenia. DATA SOURCES: Medline, Embase, Lilacs, the Cochrane Library, and conference proceedings to 2002. References of included studies and contact with authors. No restrictions on language, year of publication, or publication status. STUDY SELECTION: All randomised trials of beta lactam monotherapy compared with beta lactam-minoglycoside combination therapy as empirical treatment for patients with fever and neutropenia. DATA SELECTION: Two reviewers independently applied selection criteria, performed quality assessment, and extracted data. An intention to treat approach was used. Relative risks were pooled with the random effect model. MAIN OUTCOME MEASURE: All cause fatality. RESULTS: Forty seven trials with 7807 patients met inclusion criteria. Nine trials compared the same beta lactam. There was no significant difference in all cause fatality (relative risk 0.85, 95% confidence interval 0.72 to 1.02). For success of treatment there was a significant advantage with monotherapy (0.92, 0.85 to 0.99), though there was considerable heterogeneity among trials. There was no significant difference between monotherapy and combination treatment in trials that compared the same beta lactam, whereas there was major advantage with monotherapy in trials that compared different beta lactams (0.87, 0.80 to 0.93). Rates of superinfection were similar. Adverse events, including those associated with severe morbidity, were significantly more common in the combination treatment group. Detected flaws in methods did not affect results. CONCLUSIONS: For patients with fever and neutropenia there is no clinical advantage in treatment with beta lactam-aminoglycoside combination therapy. Broad spectrum beta lactams as monotherapy should be regarded as the standard of care for such patients.

Aminoglycosides↗
PubMed2003

Seven-year study of bacteremia in hospitalized patients on chronic hemodialysis in a single tertiary hospital.

Sixty-seven hospitalized bacteremic patients on chronic hemodialysis were matched with 134 bacteremic controls. Mortality (25% and 28% respectively) was unrelated to dialysis. Predictors of mortality were: advanced age, decreased functional capacity, and malignancies. Most common organisms recovered were Staphylococcus aureus (30%), coagulase negative Staphylococcus (15%), and polymicrobial agents (15%).

Adolescent↗
PubMed2003

Co-trimoxazole-sensitive, methicillin-resistant Staphylococcus aureus, Israel, 1988-1997.

Among bloodstream methicillin-resistant Staphylococcus aureus (MRSA) isolates from adult patients in a single hospital, susceptibility to co-trimoxazole increased progressively from 31% in 1988 to 92% in 1997 (p<0.0001). If also observed in other institutions, these findings should encourage the performance of a clinical trial of sufficient size to compare co-trimoxazole to vancomycin in treating MRSA infections.

Adult↗
PubMed1995

Risk factors and a clinical index for diagnosis of Pseudomonas aeruginosa bacteremia.

OBJECTIVE: To define risk factors significantly and independently associated with Pseudomonas aeruginosa bacteremia and to combine them in a diagnostic index which will define groups of septic patients at low or high risk of bloodstream infection caused by P. aeruginosa. METHODS: Logistic regression analysis was used to identify risk factors associated with pseudomonal bacteremia among all patients with bacteremia at St Thomas' Hospital, London, from 1969 to 1989. The coefficients of the final logistic model were used to compile a linear model for the diagnosis of pseudomonal bacteremia. The index was validated in another set of patients with bacteremia detected at Beilinson Medical Center, Petah Tiqva, Israel, from 1988 to 1991. RESULTS: Seven factors were significantly and independently predictive of pseudomonal bacteremia: 1) neutropenia; 2) previous or current treatment with antibiotics; 3) cytotoxic or corticosteroid treatment; 4) hospital acquisition of infection; 5) detection in the intensive care unit; 6) male gender; and 7) focus of infection. High-risk foci were the urinary tract with catheter or post-instrumentation, or unknown source. Low-risk foci were bone, joint, meninges, female genital tract and upper respiratory tract. The index score divided patients into three groups with increasing likelihood of P. aeruginosa bacteremia: 1%, 7% and 19%, respectively (p=0.0001). In the validation set, the percentage of P. aeruginosa bacteremia in the three respective groups defined by the index were 5%, 18% and 22% (p=0.0001). CONCLUSIONS: The use of simple clinical and laboratory data known within hours of detection of an infectious episode can define patients at high and low risk for P. aeruginosa bacteremia.

Journal Article↗