Surgery News - February 2009 - (Page 6) TRAUMA FEBRUARY 2009 • SURGERY NEWS Triage May Rescue Delayed Trauma Transfers BY DAMIAN MCNAMARA Else vier Global Medical Ne ws PA L M B E A C H , F L A . — Effective triage of critically ill trauma patients might ameliorate the higher mortality associated with delayed emergency department transfers, a retrospective study indicates. ED crowding and delayed transfers are “a major problem” at some institutions nationwide, said Dr. J. David Richardson, including the University of Louisville Hospital in Kentucky, where he is professor and vice chair of surgery. He and his associates retrospectively assessed 3,918 emergency patients transferred from the trauma/acute care surgery service to critical care or a hospital bed. Their facility is a level 1 trauma center with 325 beds, including 24 ED beds and 55 ICU beds. During the study period ( January 2005 to April 2007), ED capacity exceeded 90%. Despite the close cooperation between the ED and surgical teams in patient triage to ICU and floor beds, sometimes “there is poaching of general medicine beds or beds in the PACU [postanesthesia care unit]. We are not implying our situation is optimal care. We are planning greater capacity,” Dr. Richardson, an ACS Fellow, said at the annual meeting of the Southern Surgical Association. The mean age of the trauma patients studied was 43 years; 74% were male, BRIEF SUMMARY Please see package insert for full prescribing information. ® INDICATIONS AND USAGE: To reduce the development of drug-resistant bacteria and maintain the effectiveness of AZACTAM® (aztreonam for injection, USP) and other antibacterial drugs, AZACTAM should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. Before initiating treatment with AZACTAM, appropriate specimens should be obtained for isolation of the causative organism(s) and for determination of susceptibility to aztreonam. Treatment with AZACTAM may be started empirically before results of the susceptibility testing are available; subsequently, appropriate antibiotic therapy should be continued. AZACTAM is indicated for the treatment of the following infections caused by susceptible gramnegative microorganisms: Urinary Tract Infections (complicated and uncomplicated), including pyelonephritis and cystitis (initial and recurrent) caused by Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Enterobacter cloacae, Klebsiella oxytoca,* Citrobacter species * and Serratia marcescens.* Lower Respiratory Tract Infections, including pneumonia and bronchitis caused by Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Haemophilus influenzae, Proteus mirabilis, Enterobacter species and Serratia marcescens.* Septicemia caused by Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Proteus mirabilis,* Serratia marcescens * and Enterobacter species. Skin and Skin-Structure Infections, including those associated with postoperative wounds, ulcers and burns caused by Escherichia coli, Proteus mirabilis, Serratia marcescens, Enterobacter species, Pseudomonas aeruginosa, Klebsiella pneumoniae and Citrobacter species.* Intra-abdominal Infections, including peritonitis caused by Escherichia coli, Klebsiella species including K. pneumoniae, Enterobacter species including E. cloacae,* Pseudomonas aeruginosa, Citrobacter species* including C. freundii * and Serratia species* including S. marcescens.* Gynecologic Infections, including endometritis and pelvic cellulitis caused by Escherichia coli, Klebsiella pneumoniae,* Enterobacter species* including E. cloacae * and Proteus mirabilis.* AZACTAM is indicated for adjunctive therapy to surgery in the management of infections caused by susceptible organisms, including abscesses, infections complicating hollow viscus perforations, cutaneous infections and infections of serous surfaces. AZACTAM is effective against most of the commonly encountered gram-negative aerobic pathogens seen in general surgery. Concurrent Therapy: Concurrent initial therapy with other antimicrobial agents and AZACTAM is recommended before the causative organism(s) is known in seriously ill patients who are also at risk of having an infection due to gram-positive aerobic pathogens. If anaerobic organisms are also suspected as etiologic agents, therapy should be initiated using an anti-anaerobic agent concurrently with AZACTAM (see DOSAGE AND ADMINISTRATION). Certain antibiotics (e.g., cefoxitin, imipenem) may induce high levels of beta-lactamase in vitro in some gram-negative aerobes such as Enterobacter and Pseudomonas species, resulting in antagonism to many beta-lactam antibiotics including aztreonam. These in vitro findings suggest that such beta-lactamase inducing antibiotics not be used concurrently with aztreonam. Following identification and susceptibility testing of the causative organism(s), appropriate antibiotic therapy should be continued. CONTRAINDICATIONS: This preparation is contraindicated in patients with known hypersensitivity to aztreonam or any other component in the formulation. WARNINGS: Both animal and human data suggest that AZACTAM is rarely cross-reactive with other beta-lactam antibiotics and weakly immunogenic. Treatment with aztreonam can result in hypersensitivity reactions in patients with or without prior exposure. (See CONTRAINDICATIONS.) Careful inquiry should be made to determine whether the patient has any history of hypersensitivity reactions to any allergens. While cross-reactivity of aztreonam with other beta-lactam antibiotics is rare, this drug should be administered with caution to any patient with a history of hypersensitivity to beta-lactams (e.g., penicillins, cephalosporins, and/or carbapenems). Treatment with aztreonam can result in hypersensitivity reactions in patients with or without prior exposure to aztreonam. If an allergic reaction to aztreonam occurs, discontinue the drug and institute supportive treatment as appropriate (e.g., maintenance of ventilation, pressor amines, antihistamines, corticosteroids). Serious hypersensitivity reactions may require epinephrine and other emergency measures. (See ADVERSE REACTIONS.) Clostridium difficile associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including AZACTAM and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile. C. difficile produces toxins A and B, which contribute to the development of CDAD. Hypertoxin-producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibiotic use. Careful medical history is necessary since CDAD has been reported to occur over two months after the administration of antibacterial agents. If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated. Rare cases of toxic epidermal necrolysis have been reported in association with aztreonam in patients undergoing bone marrow transplant with multiple risk factors including sepsis, radiation therapy and other concomitantly administered drugs associated with toxic epidermal necrolysis. PRECAUTIONS: General: In patients with impaired hepatic or renal function, appropriate monitoring is recommended during therapy. If an aminoglycoside is used concurrently with aztreonam, especially if high dosages of the former are used or if therapy is prolonged, renal function should be monitored because of the potential nephrotoxicity and ototoxicity of aminoglycoside antibiotics. The use of antibiotics may promote the overgrowth of nonsusceptible organisms, including gram-positive organisms (Staphylococcus aureus and Streptococcus faecalis ) and fungi. Should superinfection occur during therapy, appropriate measures should be taken. Carcinogenesis, Mutagenesis, Impairment of Fertility: Carcinogenicity studies in animals have not been performed. Genetic toxicology studies performed in vivo and in vitro with aztreonam in several standard laboratory models revealed no evidence of mutagenic potential at the chromosomal or gene level. Two-generation reproduction studies in rats at daily doses up to 20 times the maximum recommended human dose, prior to and during gestation and lactation, revealed no evidence of impaired fertility. There was a slightly reduced survival rate during the lactation period in the offspring of rats that received the highest dosage, but not in offspring of rats that received five times the maximum recommended human dose. Pregnancy: Pregnancy Category B: Aztreonam crosses the placenta and enters the fetal circulation. Studies in pregnant rats and rabbits, with daily doses up to 15 and 5 times, respectively, the maximum recommended human dose, revealed no evidence of embryo- or fetotoxicity or teratogenicity. No drug induced changes were seen in any of the maternal, fetal, or neonatal parameters that were monitored in rats receiving 15 times the maximum recommended human dose of aztreonam during late gestation and lactation. There are no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, aztreonam should be used during pregnancy only if clearly needed. Nursing Mothers: Aztreonam is excreted in human milk in concentrations that are less than 1 percent of concentrations determined in simultaneously obtained maternal serum; consideration should be given to temporary discontinuation of nursing and use of formula feedings. Pediatric Use: The safety and
Table of Contents Feed for the Digital Edition of Surgery News - February 2009 Surgery News - February 2009 Contents The 20/20 Vision ICD-10 Looms News From the College: MedPAC Flak Oncology: Best for Breast General Surgery: Weighty Problem Surgery News - February 2009 Surgery News - February 2009 - Contents (Page 1) Surgery News - February 2009 - Contents (Page 2) Surgery News - February 2009 - Contents (Page 3) Surgery News - February 2009 - Contents (Page 4) Surgery News - February 2009 - The 20/20 Vision ICD-10 Looms (Page 5) Surgery News - February 2009 - The 20/20 Vision ICD-10 Looms (Page 6) Surgery News - February 2009 - The 20/20 Vision ICD-10 Looms (Page 7) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 8) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 9) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 10) Surgery News - February 2009 - News From the College: MedPAC Flak (Page 11) Surgery News - February 2009 - Oncology: Best for Breast (Page 12) Surgery News - February 2009 - Oncology: Best for Breast (Page 13) Surgery News - February 2009 - Oncology: Best for Breast (Page 14) Surgery News - February 2009 - Oncology: Best for Breast (Page 15) Surgery News - February 2009 - Oncology: Best for Breast (Page 16) Surgery News - February 2009 - Oncology: Best for Breast (Page 17) Surgery News - February 2009 - Oncology: Best for Breast (Page 18) Surgery News - February 2009 - General Surgery: Weighty Problem (Page 19) Surgery News - February 2009 - General Surgery: Weighty Problem (Page 20)
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