Bottom line: Communication between inpatient physicians and PCPs needs improvement to affect clinical outcomes, especially in high-risk patients.
Citation: Bell CM, Schnipper JL, Auerbach AD, et al. Association of communication between hospital-based physicians and primary care providers with patient outcomes. J Gen Intern Med. 2008;24(3):381-386.
Gentamicin Use in Staphylococcal Bacteremia or Endocarditis Causes Nephrotoxicity
Clinical question: Does gentamicin synergism in Staphylococcal bacteremia and endocarditis achieve faster eradication at the cost of nephrotoxicity?
Background: Gentamicin has been used to help with sterilization of blood or cardiac vegetations in patients with Staphylococcal bacteremia or infective endocarditis (IE). However, historic data negate its role in decreasing morbidity or mortality. If its potential nephrotoxicity were better characterized, it could help assess the overall utility of this practice.
Study design: Retrospective analysis of a cohort from a published randomized control trial.
Setting: 44 hospitals in the U.S. and Europe.
Synopsis: Two hundred thirty-six patients with Staphylococcal bacteremia or native-valve IE (mostly right-sided) were randomized to receive standard therapy (vancomycin or antistaphylococcal penicillin) or daptomycin. Patients receiving standard therapy and those with left-side IE in the daptomycin arm also received low-dose gentamicin. Sequential creatinine levels were used to determine primary outcomes of renal impairment events and a decrease in creatinine clearance.
Renal impairment events, elevation of mean serum creatinine, and decrease in creatinine clearance were more prevalent with standard therapy, especially in the elderly and those with diabetes. Combination of gentamicin with penicillin caused an earlier creatinine elevation compared with that with vancomycin.
Patients on gentamicin had a modest decrease in creatinine clearance (22% vs. 8%; P= 0.005), especially if their baseline was 50 to 80 mL/min. The decrease was early and sustained with gentamicin exposure. Multivariate analysis revealed age (≥65 years) and gentamicin use (not dose and duration) to be independent predictors of renal impairment. The analysis fails to address use of gentamicin in prosthetic-valve IE and left-side IE.
Bottom line: Initial low-dose gentamicin use in Staphylococcal bacteremia or endocarditis increases nephrotoxicity with no clear mortality benefit.
Citation: Cosgrove SE, Vigliani GA, Fowler VG, et al. Initial low-dose gentamicin for Staphylococcus aureus bacteremia and endocarditis is nephrotoxic. Clin Infect Dis. 2009;48(6):713-721.
Osteoporotic Fractures Increase Five-Year Mortality, Especially in the Elderly
Clinical question: What is the effect of initial osteoporotic fractures and subsequent fractures on mortality?
Background: With an aging population, osteoporotic fractures are poised to escalate into a national healthcare problem. Studies have outlined the increase in premature and long-term mortality associated with hip or vertebral fractures. However, other appendicular fractures have not been studied, and little is known about the mortality risk with subsequent fracturing.
Study design: Prospective cohort from the Dubbo Osteoporosis Epidemiology Study, a longitudinal, population-based study.
Setting: Stable population of men and women 60 and older in Dubbo, Australia.
Synopsis: 1,300 people with at least one minimal-trauma fracture were selected. Fractures were grouped as hip, vertebral, major (long bones and ribs), and minor (any remaining). Mortality data were extracted from local media, along with state and national registries. Age- and sex-specific mortality rates in each group were compared with population mortality rates to provide standardized mortality ratios (SMRs) over five-year periods.
Osteoporotic fractures increased five-year mortality with SMRs of 1.38 to 2.53 for women and 1.64 to 3.52 for men. An exception was minor fractures in patients 60 to 75 years old with no increase in mortality. Only hip fractures influenced mortality adversely for up to 10 years.
Interestingly, the nonhip, nonvertebral group included 50% of the fractures and contributed to 29% of overall mortality. Another five-year increase in mortality was evident in 364 people with a subsequent fracture.