PubMed Health⌕ Search

Biomedical subjects

Robert P Rapp

Publications and source records attributed to Robert P Rapp.

18 recordsLinked to original sources
PubMed2005

Trimethoprim-sulfamethoxazole as a viable treatment option for infections caused by methicillin-resistant Staphylococcus aureus.

OBJECTIVE: To review available data regarding the efficacy of trimethoprim-sulfamethoxazole (TMP-SMX) for the treatment of infections caused by methicillin-resistant Staphylococcus aureus (MRSA). DATA SOURCES: A MEDLINE search was performed (January 1966-December 2003) using the search terms Staphylococcus aureus , sulfamethoxazole, trimethoprim, co-trimoxazole, and methicillin resistance. Abstracts from infectious diseases meetings also were reviewed. DATA SYNTHESIS: The reported rate of TMP-SMX resistance in S. aureus is highly variable. From a mechanistic standpoint, TMP-SMX resistance among MRSA appears to be distinct from multidrug resistance, although some anecdotal reports suggest otherwise. Clonal outbreaks of MRSA resistant to TMP-SMX have been described; of these, the Brazilian clone has more often been resistant to TMP-SMX than the Iberian clone. Rates of TMP-SMX resistance are particularly high in institutions serving large numbers of patients infected by the human immunodeficiency virus, due to increased exposure for Pneumocystis prophylaxis. Limited studies and case reports have found TMP-SMX useful against infections caused by MRSA. CONCLUSIONS: A large body of anecdotal data, but only one randomized clinical trial, indicates the effectiveness of TMP-SMX as a treatment for MRSA infections. Double-blind, randomized controlled trials are needed to compare the two available oral agents-TMP-SMX and linezolid-against MRSA.

Anti-Infective Agents↗
PubMed2004

Use of macrolides and tetracyclines for chronic inflammatory diseases.

OBJECTIVE: To review the efficacy of macrolides and tetracyclines in several chronic inflammatory conditions. DATA SOURCES: Searches of MEDLINE (1966-March 2004) and an extensive bibliography search were undertaken. Key terms included acne, blepharitis, cardiovascular disease, cystic fibrosis, periodontitis, rosacea, and rheumatoid arthritis. STUDY SELECTION AND DATA EXTRACTION: Data were obtained primarily from randomized placebo-controlled trials upon which key recommendations are based. DATA SYNTHESIS: Antibiotics are often prescribed for months or even years for treatment of chronic inflammatory conditions such as acne, blepharitis, cardiovascular disease, cystic fibrosis, periodontitis, rosacea, and rheumatoid arthritis. Randomized controlled trials have shown that azithromycin is useful in the management of cystic fibrosis and the tetracyclines are beneficial in the management of rheumatoid arthritis, acne, blepharitis, and periodontitis. Several large, randomized controlled trials have failed to show any benefit of macrolides in the secondary prevention of cardiovascular disease. No randomized placebo-controlled clinical trials have been performed to assess the efficacy of macrolides or tetracyclines in patients with rosacea. CONCLUSIONS: The use of tetracyclines and macrolides for rosacea is based primarily on anecdotal reports or open-label trials. Limited clinical trials support the use of tetracyclines or macrolides in acne, blepharitis, periodontitis, rheumatoid arthritis, and cystic fibrosis. Trials to date do not support the use of antibiotics for secondary prevention of cardiovascular disease.

Acne Vulgaris↗
PubMed2004

Drug costs and bacterial susceptibility after implementing a single-fluoroquinolone use policy at a university hospital.

The University of Kentucky Hospital investigated the feasibility of choosing a sole fluoroquinolone for its formulary in an effort to reduce costs without affecting clinical outcomes. A three-step process was used to plan, implement, and monitor the selection program. Based on the range of clinical indications, safety profile, local susceptibility, cost, and dosing convenience, levofloxacin was chosen over ciprofloxacin and gatifloxacin as the sole fluoroquinolone. Since the implementation of the program in May 2001, susceptibility to levofloxacin has been maintained or increased for the most common pathogens. In addition, University Hospital has saved nearly 100,000 dollars in antibiotic acquisition costs during the first 12 months after the switch. This assessment did not take into account effects in clinical outcomes, such as clinical failures (such as readmission rates), mortality, and adverse events, or measure changes in overall medical expenditures beyond drug acquisition costs. In the future, monitoring of overall patient care and medical care costs, in addition to susceptibility patterns and drug costs, will allow for a better understanding of the long-term benefits of this switch.

Anti-Bacterial Agents↗
PubMed2004

Methicillin-resistant staphylococcal infections: an important consideration for orthopedic surgeons.

Postoperative infections in joint prostheses and fracture-fixation devices commonly involve both MRSA and methicillin resistant coagulase-negative staphylococcus. In addition, community-acquired MRSA has also become an important consideration when infected patients are admitted to the hospital from the community. Preoperative colonization with MRSA and methicillin resistant coagulase-negative staphylococcus increases the risk of postoperative surgical site infections in orthopedic patients. Up to 5.3% of orthopedic patients are colonized with these organisms on hospital admission. Screening and decolonization of methicillin resistant staphylococci decrease the incidence of postoperative surgical site infections in the orthopedic patient. This may be particularly important in orthopedic implants given the difficulty encountered in treating infected prosthesis. Current US guidelines advocate screening for methicillin resistant staphylococci only when risk factors are present. Growing evidence suggests that screening and decolinization of all patients having elective orthopedic procedures, especially those including prosthetic implants, will decrease the incidence of postoperative infections. The infected prosthesis may be potentially salvaged if the clinical manifestations of infection have been present for < or = 10 days, the implant is stable, and the etiologic organisms are susceptible to oral antibiotics.

Anti-Bacterial Agents↗
PubMed2004

Changing strategies for the management of invasive fungal infections.

The frequency of invasive fungal infections (IFIs) has increased with the increase in number of high-risk patients. United States trends in mortality due to invasive mycoses showed a striking increase in the past 2 decades. Human immunodeficiency virus-associated opportunistic mycoses accounted for part of the increase, as did mycoses in other immunocompromised populations. Those at-risk populations include recipients of solid organ transplants or hematopoietic stem cell transplants, those with hematologic malignancies, and others receiving immunosuppressive treatment. Infections due to Candida sp are the most common fungal infections. The mortality rate due to invasive aspergillosis has risen steadily, with a 357% increase from 1980-1997. Depending on whether an IFI is possible, probable, or proved, three treatment strategies are available: prophylactic, empiric, and specific. Options for preventing and treating IFIs have increased, with four classes of antifungal agents available: polyenes, azoles, nucleoside analogs, and echinocandins. The effectiveness of the polyene amphotericin B deoxycholate (the standard for > 40 yrs) is limited by toxic effects, notably renal and infusion-related toxicity. Three lipid formulations are approved for the treatment of IFIs in patients refractory to or intolerant of amphotericin B: amphotericin lipid complex, amphotericin B colloidal dispersion, and liposomal amphotericin B. The nucleoside analog class contains only flucytosine--an antimetabolite targeting the nucleus of the fungal cell and generally not given as monotherapy because of frequent development of resistance. The azoles debuted with ketoconazole, followed by fluconazole, itraconazole, and voriconazole. Fluconazole is largely active against Candida sp and Cryptococcus neoformans; itraconazole's activity is largely against moulds, such as Aspergillus, and dimorphic fungi, such as Histoplasma and Blastomyces; and voriconazole is active against both yeasts and moulds. The echinocandin class has one drug approved for clinical use--caspofungin, which targets the fungal cell wall. Deciding which antifungal agent to use involves weighing such clinical factors as mycoses susceptibility and drug toxicity, as well as pharmacoeconomic considerations. Besides the price of the drug, the cost of antifungal therapy includes costs of mortality associated with failed treatment, prolonged hospitalization and treatment related to complications, and additional antifungal treatment to compensate for primary treatment failure.

Antifungal Agents↗
PubMed2003

Growth of early continental crust by partial melting of eclogite.

The tectonic setting in which the first continental crust formed, and the extent to which modern processes of arc magmatism at convergent plate margins were operative on the early Earth, are matters of debate. Geochemical studies have shown that felsic rocks in both Archaean high-grade metamorphic ('grey gneiss') and low-grade granite-greenstone terranes are comprised dominantly of sodium-rich granitoids of the tonalite-trondhjemite-granodiorite (TTG) suite of rocks. Here we present direct experimental evidence showing that partial melting of hydrous basalt in the eclogite facies produces granitoid liquids with major- and trace-element compositions equivalent to Archaean TTG, including the low Nb/Ta and high Zr/Sm ratios of 'average' Archaean TTG, but from a source with initially subchondritic Nb/Ta. In modern environments, basalts with low Nb/Ta form by partial melting of subduction-modified depleted mantle, notably in intraoceanic arc settings in the forearc and back-arc regimes. These observations suggest that TTG magmatism may have taken place beneath granite-greenstone complexes developing along Archaean intraoceanic island arcs by imbricate thrust-stacking and tectonic accretion of a diversity of subduction-related terranes. Partial melting accompanying dehydration of these generally basaltic source materials at the base of thickened, 'arc-like' crust would produce compositionally appropriate TTG granitoids in equilibrium with eclogite residues.

Journal Article↗
PubMed2002

A decade of antimicrobial susceptibilities at the University of Kentucky Hospital.

OBJECTIVE: To determine the antimicrobial susceptibility rates for key antimicrobial agents and selective bacterial pathogens in the decade of the 1990s. METHODS: Data from 1990 to 2000 from the University of Kentucky Clinical Microbiology Laboratory were analyzed by linear regression analysis to identify agents and pathogens that show a decline in susceptibility. For selected pathogens and antimicrobial agents, predictions were made for further declines in susceptibility for 2005 and 2010. RESULTS: Significant declines in susceptibility to selected antimicrobial agents were found for Pseudomonas aeruginosa, Klebsiella pneumoniae, Enterobacter cloacae, Escherichia coli, Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus pneumoniae. Further declines were predicted for 2005 and 2010. CONCLUSIONS: Examination of susceptibility rates over time in a university hospital medical center provides useful data for future planning. In our institution, antimicrobial susceptibility rates have significantly declined during the 1990s for certain antimicrobial agents and bacterial pathogens. We are attempting to change our antimicrobial use patterns through formulary manipulation and clinician education, which may retard or prevent such declines in the future.

Anti-Bacterial Agents↗
PubMed2002

The effect of an antimicrobial formulary change on hospital resistance patterns.

A university hospital formulary change that was designed to reduce the use of the third-generation cephalosporins ceftazidime and cefotaxime and replace them with the so-called "fourth-generation" cephalosporin cefepime was evaluated. A retrospective review of antibiotic use and antimicrobial resistance during two 6-month periods before and after the formulary change was performed. All hospital patients with vancomycin-resistant Enterococcus (VRE), ceftazidime-resistant Klebsiella pneumoniae (CRKP), methicillin-resistant Staphylococcus aureus (MRSA), piperacillin-resistant Pseudomonas aeruginosa (PRPA), and ceftazidime-resistant P. aeruginosa (CRPA) infections were included in the study Ceftazidime use decreased from 9600 g to 99 g, and cefotaxime use decreased from 6314 g to 732 g, which represented a combined decrease of 89%. Use of cefepime increased from 0 g to 5396 g. Infections from CRKP decreased from 13% to 3%, PRPA infections decreased from 22% to 14%, and CRPA infections decreased from 25% to 15% (p<0.05 for all). Infections from MRSA dropped insignificantly, and VRE infections increased significantly. Substituting cefepime for ceftazidime and cefotaxime while reducing the overall use of cephalosporins appears to decrease rates of CRKP, PRPA, and CRPA.

Cephalosporin Resistance↗