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Biomedical subjects

Matthew Bidwell Goetz

Publications and source records attributed to Matthew Bidwell Goetz.

9 recordsLinked to original sources
PubMed2006

Utilization and access to antiretroviral genotypic resistance testing and results within the US Department of Veterans Affairs.

OBJECTIVE: We sought to characterize variation in the use of HIV genotypic resistance tests and how results were reported. METHODS: Clinicians and laboratory managers at all Veterans Affairs (VA) medical centers were asked to complete a survey in March 2003 regarding HIV resistance testing practices. RESULTS: Surveys from 131 of 150 sites were returned. Forty-eight percent of HIV clinicians indicated that US Department of Health and Human Services guidelines were the usual basis for ordering tests. Although between 12% and 31% of respondents indicated that they always, sometimes, seldom, or never ordered resistance tests in patients with acute or chronic HIV infection, >70% ordered tests in adherent patients with treatment failure. Among the 32 centers with >200 patients in care, 13 +/- 8 (mean +/- standard deviation) tests were performed per 100 patients in care during 2002. Forty-nine percent of clinicians said that tests were helpful, but only 33% expressed confidence in using test results. Only 40% of sites entered results in the VA electronic medical record. CONCLUSION: Ordering patterns for HIV resistance tests differed significantly among VA sites. A minority of clinicians indicated confidence in the use of test results. A consistent system to capture and present complete results was absent.

Acquired Immunodeficiency Syndrome↗
PubMed2005

Impact of clinical guidelines in the management of severe hospital-acquired pneumonia.

STUDY OBJECTIVES: To asses the impact of locally developed antimicrobial treatment guidelines in the initial empiric treatment of ICU patients with severe hospital-acquired pneumonia (HAP). DESIGN: Observational cohort study with pre-guideline and post-guideline data collection. PATIENTS: A total of 48 pre-guideline patients with 56 episodes of severe HAP defined by the National Nosocomial Infections Surveillance (NNIS) compared with 58 guideline-treated (GUIDE) patients with 61 episodes of severe HAP. RESULTS: The two groups were similar in terms of mean (+/- SD) age (NNIS group, 67.7 +/- 9.6 years; GUIDE group, 68.0 +/- 11.5 years) and simplified acute physiology score (NNIS group, 12.9 +/- 3.9; GUIDE group, 12.6 +/- 3.1) at the HAP diagnosis, and the proportion of the most frequent isolates (ie, Pseudomonas and methicillin-resistant Staphylococcus aureus). There was wide variation in initial antibiotic use in NNIS-treated patients, with cefotaxime, ceftazidime, and piperacillin being the most common agents compared with all of the GUIDE patients who received an imipenem-cilastin-based regimen. Vancomycin use was similar in both groups. The GUIDE patients had a higher percentage of adequately treated patients (81% vs 46%, respectively; p < 0.01) with a lower mortality rate at 14 days (8% vs 23%, respectively; p = 0.03). A lower mortality rate was also noted at the end of 30 days and the end of hospitalization but was not statistically significant. Appropriate imipenem use (as defined by the guidelines) occurred in 74% of the cases, and there was no increase in the number of imipenem-resistant organisms isolated during the course of the study. CONCLUSIONS: These guidelines represent a successful implementation of a "deescalation" approach, because the recommended empiric therapy with broad-spectrum antibiotics was switched to therapy with narrower spectrum agents after 3 days. Based on our experience, this approach improves the adequacy of antibiotic treatment, with improvement in short-term survival and without increasing the emergence of resistant organisms.

Aged↗
PubMed2004

Lipid screening in HIV-infected veterans.

BACKGROUND: Lipid screening is recommended for patients taking protease inhibitors (PIs). METHODS: We examined data from the Veterans Administration Immunology Case Registry to assess lipid screening among HIV-infected veterans who received PIs for at least 6 consecutive months during 1999 and 2001. We estimated crude and adjusted associations between lipid screening and patient characteristics (age, gender, HIV exposure, and race/ethnicity), comorbidities (AIDS, cardiovascular disease, diabetes, hypertension, smoking, and hyperlipidemia), and facility characteristics (urban location, case management, guidelines, and quality improvement programs). RESULTS: Among 4065 patients on PIs, clinicians screened 2395 (59%) for lipids within 6 months of initiating treatment. Adjusting for patient characteristics, comorbidities, facility traits, and clustering, lipid screening was more common among patients who were cared for in urban areas (relative risk [RR] = 1.3, confidence limits: 1.0-1.5), diabetic (RR = 1.2, confidence limits: 1.1-1.3), or previously hyperlipidemic (RR = 1.4, confidence limits: 1.3-1.5) and less common among patients with a history of intravenous drug use (IVDU) (RR = 0.90, confidence limits: 0.79-1.0) or unknown HIV risk (RR = 0.85, confidence limits: 0.75-0.95). CONCLUSIONS: Six in 10 patients taking PIs receive lipid screening within 6 months of PI use. Systemic interventions to improve overall HIV quality of care should also address lipid screening, particularly among patients with unknown or IVDU HIV risk and those cared for in nonurban areas.

Adolescent↗
PubMed2003

Association between protease inhibitor use and increased cardiovascular risk in patients infected with human immunodeficiency virus: a systematic review.

Some studies have shown that currently available protease inhibitors (PIs) are associated with an increased risk of cardiovascular disease. We have systematically reviewed the published literature and conference abstracts for studies evaluating cardiovascular risk factors and events in patients receiving highly active antiretroviral therapy, with and without PIs. The majority of studies showed that the use of PIs was associated with increased levels of total cholesterol (36 [75%] of 48 studies), triglycerides (35 [73%] of 48 studies), and low-density lipoprotein (12 [100%] of 12 studies). PI use was often associated with morphological signs of cardiovascular disease, such as increased carotid intima thickness or atherosclerotic lesions (7 [88%] of 8 studies). Finally, 2 (67%) of 3 long-term observational studies that met our inclusion criteria demonstrated an association between use of PIs and subsequent myocardial infarction. The benefits of the currently available PIs should be balanced against the long-term risk of cardiovascular disease.

Antiretroviral Therapy, Highly Active↗
PubMed2003

Azithromycin monotherapy for patients hospitalized with community-acquired pneumonia: a 31/2-year experience from a veterans affairs hospital.

BACKGROUND: Current American Thoracic Society (ATS) community-acquired pneumonia treatment guidelines recommend azithromycin monotherapy for a limited subset of hospitalized patients. We evaluated the effectiveness of azithromycin monotherapy in a more generalized population of patients hospitalized with mild-to-moderate community-acquired pneumonia. METHODS: We reviewed medical records from a Veterans Affairs facility for patients admitted with community-acquired pneumonia between December 1, 1997, and June 30, 2001, comparing those receiving azithromycin monotherapy, other ATS-recommended antibiotics, and non-ATS-recommended antibiotics. We excluded patients with immunosuppression, metastatic cancer, or hospital-acquired pneumonia. Outcome measures included times to stability, meeting criteria for change to oral therapy, and eligibility for discharge; length of stay; intensive care unit transfer; and mortality. Outcomes were adjusted for pneumonia severity, skilled nursing facility status, and processes of care. RESULTS: A total of 442 patients were eligible for the study (221 in the azithromycin monotherapy group, 129 in the ATS group, and 92 in the non-ATS group). Times to clinical stability and to fulfilling early switch criteria were not statistically significantly different among the 3 groups. Mean time to fulfilling early discharge criteria was 2.48 days for patients receiving azithromycin monotherapy vs 2.84 days for those receiving ATS antibiotics (P =.008) and 2.58 days for those receiving non-ATS antibiotics (P =.64). Overall mean length of stay was shorter in the azithromycin monotherapy group (4.35 days) vs the ATS (5.73 days) (P =.002) and non-ATS (6.21 days) (P<.001) groups. Mortality, intensive care unit transfer, and readmission rates were similar across the groups. CONCLUSION: Azithromycin monotherapy is equally as efficacious as other ATS-recommended regimens for treating hospitalized patients with mild-to-moderate community-acquired pneumonia.

Aged↗
PubMed2002

Viral load response to a pneumococcal conjugate vaccine, polysaccharide vaccine or placebo among HIV-infected patients.

We determined the HIV viral load in 66 adults randomly assigned to receive pneumococcal immunization with one or two doses of protein conjugate vaccine, one dose of polysaccharide vaccine, one dose of each, or placebo. Second doses were given 8 weeks after the first. Mean baseline viral load and CD4 cell count were 3.41 copies/ml (log10) and 457 cells/microl, respectively. We found no change in viral load during 24 weeks of follow-up for any vaccine or combination of vaccines or placebo.

AIDS-Related Opportunistic Infections↗
PubMed2002

Aerobic Gram-negative Bacillary Pneumonia.

Gram-negative bacilli (GNB) are a common cause of severe hospital-acquired pneumonia. Due to changes in the health care environment and selective antimicrobial pressure, these bacteria also are becoming a more common cause of pneumonia in venues outside of the traditional hospital setting and are increasingly resistant to antimicrobial agents. Risk factors for acquisition of GNB allow the clinician to efficiently identify patients who are likely to have pneumonia due to these pathogens. Available diagnostic techniques have a limited capacity to accurately detect GNB pulmonary infection. Yet, a pathogen specific diagnosis and knowledge of local resistance patterns are quintessential elements in formulating an effective treatment plan. This article reviews the epidemiologic characteristics, pathogenesis, and current management issues of GNB pneumonia.

Journal Article↗
PubMedDate not supplied

Early switch and early discharge opportunities in intravenous vancomycin treatment of suspected methicillin-resistant staphylococcal species infections.

BACKGROUND: Patients with methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant coagulase negative staphylococci (MR-CoNS) infections are usually treated with intravenous (IV) vancomycin and remain hospitalized for the duration of IV therapy. Oral linezolid has excellent bioavailability and activity against MRSA and MR-CoNS and offers the potential for outpatient treatment of MRSA and MR-CoNS infections. OBJECTIVE: To determine the potential for early switch (ES) from IV vancomycin to oral linezolid and subsequent early discharge (ED) in hospitalized, adult patients treated for an MRSA or MR-CoNS infection. METHODS: We conducted a retrospective cohort study at the Veterans Administration Greater Los Angeles Healthcare System from January 1 through December 31, 2000. Potential reductions in vancomycin use, hospital length of stay (LOS), and economic savings were determined. RESULTS: A total of 103 of 177 (58%) treatment courses for MRSA or MR-CoNS infections were potentially eligible for ES, with annual and mean decreases in vancomycin use of 535 defined daily doses and 5.2 days per event. Of the ES cohort, 55 of 103 (53%) courses were potentially eligible for ED, with an annual and mean reduction in LOS of 181 days and 3.3 days per event. The total potential savings was $220,181, at an average of $3,478 per event. CONCLUSION: Early switch to oral linezolid for treatment of MRSA or MR-CoNS infections could reduce vancomycin use, hospital length of stay, and economic costs.

Acetamides↗