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"Getting Serious About Vancomycin Selection and Dosing" by Steven P. LaRosa, M.D.

Introduction As an Infectious Disease physician and Antimicrobial Stewardship Director I encounter a large number of patients who have been empirically started on Vancomycin due to a concern for MRSA infections or Gram positive infection with a reported penicillin allergy. I often see patients being given 1gm IV q 12hours without any attention to seriousness of illness, body weight, kidney function or susceptibility of the infecting organism. This blog will address how to optimize the use and dosing of Vancomycin.

Is Vancomycin even necessary? Vancomycin is quite often given as part of empiric therapy for pneumonia and skin and soft tissue infections without much thought as to if it is necessary. A good starting point in the evaluation of the need for Vancomycin is to a "chart biopsy" on the patient. In the evaluation of the EMR I look for past cultures or MRSA screen results. This exercise may reveal that the patient has had in fact MSSA and not MRSA colonization/infections (s…

"Let's Increase the Use of Tetracyclines to Decrease C. difficile colitis" by Steven P. LaRosa, M.D.

Physicians are quite comfortable with the use of the tetracycline antibiotics Doxycycline and Minocycline in tickborne infections and acne. Short of these two indications this class of antibiotics is rarely reached for. A new study by Raseen Tariq and colleagues in Clinical Infectious Disease 2018;66(4):514-522 should change that. A meta-analysis of 6 studies demonstrated that tetracyclines were associated with a decreased risk of C diff Infection (CDI) (odds ratio 0.62, 95% CI , 0.40-0.81; p < .001. This decreased risk held when just Doxycycline was examined. There are at least 2 potential biologic explanations for this observed effect. The first is that tetracycyclines cause fewer and shorter lasting perturbations to the fecal microbiota than other classes of antibiotics. The second is that enteral delivery of tetracyclines has inhibitory effect on Clostridium difficile. In fact, Tigecycline, a glyclcycline relative of tetracyclines, has been used successfully as a salvage ther…

"Time to Reanimate Il-1ra for Sepsis" by Steven P. LaRosa, M.D.

My introduction to the world of clinical trials in sepsis occurred in the 1990’s while I was an Internal Medicine Resident in the MICU at the Cleveland Clinic. My attending physician and ICU director, Charles J. Fisher, Jr, was the lead investigator for the Phase III trial of Interleukin-1 receptor antagonist (IL-1 ra) in patients with sepsis. The basis of the strategy related to the discovery by Charles Dinarello, M.D. of IL-1 and the role it played in the pathophysiology of febrile vasodilatory shock. During this rotation I had the opportunity to enroll a patient of mine into this trial. He was a previously healthy 28 year old male who perforated his bowel as an initial presentation of inflammatory bowel disease. At the time of enrollment the patient was maxed out on vasopressors for septic shock, in ARDS, DIC and acute renal failure. Within 24 hours of beginning the study drug infusion the patient had a miraculous improvement and ultimately survived. When the study blind was broke…

C. diff Prevention "Tour de Force"

In the current issue of Clinical Infectious Disease Daniel Caroff and colleagues published an elegant article on the epidemiology and prevention of Clostridium difficile colitis. Many of the points that they make need to be emphasized in terms of how we operationalize C diff prevention efforts.
The most important points made in the paper are the following:
1) 10% of patients admitted to the hospital have asymptomatic C. diff colonization. This percentage is even higher in the following groups of patients:
a. Patients with recent hospitalizations b. Patients who have received recent antibiotics c. Patients who have recently had C. diff
2) Up to 30% of hospital -acquired C diff is likely acquired from those who are asymptomatically colonized and shedding C diff.
Based upon these 2 fundamental observations from the literature shouldn't we consider re-tooling our preventative efforts in the following ways?

1) Screening all admissions for asymptomatic C diff colonization or at least t…