An Increase in Severe Community Acquired MRSA Infections in Texas
Gonzales BE, Martinez-Aguilar G, Hulten KG, et al. Severe staphylococcal sepsis in adolescents in the era of community-acquired methicillin-resistant Staphylococcus aureus. Pediatrics. 2005;115:642-8.
Gonzales et al. describe data prospectively gathered since August 1, 2001, showing an increase in the number of severely ill patients with community acquired (CA) Staphylococcus aureus infections. Fourteen patients with a mean age of 12.9 years (range: 10–15 years) were admitted to the PICU with sepsis. Twelve patients had CA methicillin-resistant S. aureus (CAMRSA). Thirteen patients (93%) had bone and joint infections. Thirteen patients had pulmonary involvement. Acute prerenal failure and peripheral vascular thrombosis were present in 50% and 29% of patients, respectively. Thirteen patients were bacteremic. All CAMRSA isolates were resistant to erythromycin, without inducible resistance to clindamycin. The review is interesting in light of the other literature reviewed by the authors suggesting a trend toward more severe infections caused by CAMRSA.
TheoPhylline vs. Terubutaline in Critically III Asthmatics
Wheeler DS, Jacobs BR, Kenreigh CA, et al. Theophylline versus terbutaline in treating critically ill children with status asthmaticus: A prospective, randomized, controlled trial. Pediatr Crit Care Med. 2005;6:142-7.
Status asthmaticus is a common diagnosis on the pediatric inpatient unit and in the pediatric intensive care unit (PICU). Inhaled beta-2 agonists, systemic corticosteroids, and supplemental oxygen are accepted as the standard of care for children with status asthmaticus who require admission. For critically ill children who are poorly responsive to the aforementioned triad of therapy, both theophylline and terbutaline are considered possible adjunctive therapies. Wheeler et al. suggest that the many studies failing to demonstrate added benefit of theophylline in non–critically ill patients has decreased the use of theophylline in the critical care setting, but point out that recent studies involving critically ill populations with status asthmaticus treated with theophylline have suggested benefit with comparison to placebo. Therefore, these researchers present a randomized, prospective, controlled, double-blind trial comparing the efficacy of theophylline alone, terbutaline alone, and theophylline and terbutaline together in critically ill pediatric patients receiving continuous nebulized albuterol and intravenous steroids. Forty patients with impending respiratory failure between the ages of 3 and 15 years were randomized to 1 of 3 groups: theophylline plus placebo (group 1), terbutaline plus placebo (group 2), or theophylline and terbutaline together (group 3). Thirty-six patients completed the study; 3 patients from group 1 were withdrawn due to parental request secondary to agitation (2 patients) and being inadvertently placed on a terbutaline infusion (1 patient). One patient from group 3 was withdrawn by the treating physician due to lack of improvement. All study participants, with the exception of the study pharmacist, were blinded to group assignment. Adjunctive therapies, including magnesium, ipatropium bromide and ketamine, were utilized at the discretion of the treating physician and were not controlled for. The primary outcome variable was change in a clinical scoring tool. Secondary outcomes variables included time to a specific clinical score, length of stay in the PICU, progression to mechanical ventilation, and incidence of adverse events. In addition, a cost analysis was performed isolating the 3 groups based on fiscal year 2003 cost estimates for theophylline and terbutaline. Results demonstrated no difference in the primary or secondary clinical outcome measures, with the exception of a higher incidence of nausea in group 3. The hospital costs were significantly lower in group 1 compared with groups 2 and 3 ($280 vs. $3,908 vs. $4,045, respectively, p<.0001). Significant limitations to the study include the lack of control of adjunctive therapies, a small sample size that confounds the ability to conclude no clinical difference between groups, and a baseline Pediatric Risk of Mortality (PRISM) Score in group 3 compared with groups 1 and 2. Despite these limitations the researchers suggest that the addition of intravenous theophylline to continuous nebulized albuterol and corticosteroids in the management of critically ill children with status asthmaticus is as safe and effective as adding intravenous terbutaline while being more cost-effective. Subsequent larger, well-controlled studies are required to support this conclusion.