Antimicrobial therapy in patients with acute variceal hemorrhage: DISCUSSION (2)

In: Antimicrobial therapy

27 Sep 2012

According to present clinical practice guidelines, gaps in antimicrobial therapy were observed in our patient population at risk of infection following variceal hemorrhage. Because many of the patients reviewed were hospitalized before most of the recommendations were published and widely disseminated, our results may not actually be an example of how clinical practice guidelines often have limited effect on changing physician behaviour . While it appears that adherence to guidelines may be greater when they are endorsed by a professional organization, the country of origin may have an impact on adherence . Canadian practice guidelines regarding antimicrobial prophylaxis pertain only to minimizing risk of endocarditis in high-risk patients undergoing endoscopy and who do not necessarily have cirrhosis . Successful integration of clinical guidelines into practice may also rely on how credible and compelling are the studies on which they are based . Clinical data demonstrate antibiotic prophylaxis decreases mortality in liver disease patients following GI bleeding. However, the strength of this evidence may still be in question by clinicians. A total of 864 patients were evaluated in the eight studies of antimicrobial prophylaxis in cirrhotic patients with GI bleeding. Methodology differed with respect to selection of intervention, timing and length of therapy. These variations make a specific antimicrobial recommendation and associated outcome difficult to identify. You will be glad to come across cialis professional 20 mg costing you very little money.

The limitations of our study hinge primarily on the retrospective design, and warrant further discussion. It is not possible to accurately ascertain clinical findings of infection in a medical record review due to incomplete or undocumented data. Microbiological and laboratory findings were employed to ascertain whether patients had developed site-specific infection, but we have no important information on patient symptoms (eg, urinary frequency, cough or abdominal pain); therefore, our values may actually underestimate the occurrence of clinically relevant infection. Unfortunately, we were also unable to consistently collect relevant investigative information (eg, urinalysis, chest radiograph or ascitic fluid). Because data were not collected prospectively, it cannot be determined with full certainty whether antimicrobial therapy was prescribed as prophylaxis against infection or treatment of infection suspected on admission; one-half of cirrhotic patients who received antibiotics did so within 24 h of admission or endoscopy before microbiological findings of infection were available. Length of antimicrobial therapy was not easily determined, because many patients received more than one agent to complete one course of therapy and some patients received repeat treatment during long hospital stays. Tolerability and adverse effects of administered antibiotics were not evaluated, but have not previously been demonstrated to be appreciable when used as prophylaxis . Finally, while different bleeding etiologies were identified in our initial search for cirrhotic patients hospitalized specifically with variceal hemorrhage, a review of antimicrobial therapy for cirrhotic patients with any source of GI bleeding would be valuable. Despite the methodological limitations, the overall proportion of patients prescribed antimicrobials in our population was consistent with low rates of antibiotic administration following acute variceal hemorrhage observed in other studies.


About this blog

Blog invites submissions of review articles, reports on clinical techniques, case reports, conference summaries, and articles of opinion pertinent to the control of pain and anxiety in dentistry.