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Risk Factors for Infection: Community-Acquired Resistant Pathogens George H. Karam, MD Discussion Dr Linden: For Clostridium difficile, are there pending studies of alternatives to vancomycin and metronidazole that might be important? Dr Bartlett: I think it is going to be hard to beat vancomycin in patients who are seriously ill. There has never been a resistant strain and when given orally it goes right to the colon. You will be able to beat it in terms of relapse, but not for response to an acute infection. Tolevamer looks good for preventing relapse but does not look good for the acute disease. OPT-80 recently tied vancomycin for acute infection and was superior in the rate of relapses. Dr Linden: What about atypical C difficile in patients with ileus? Dr Bartlett: For the patient with ileus, we are going to need another approach. If you cannot get a drug to the colon through the mouth then it is going to have to be administered by another route, and that probably needs to be better understood. Dr Linden: We have all seen papers when new guidelines come out that show poor clinical practice penetration of the guidelines 2 years later. Often the guidelines do not really filter down to working physicians. Maybe one thing we need is guidelines on generating better guideline acceptance. Dr Bartlett: I could not agree more. The skin and soft tissue infection guideline is a good example. Many people know that it exists, but do not know what it says. New methicillin-resistant Staphylococcus aureus (MRSA) guidelines presented this year at the IDSA/ICAAC (Infectious Diseases Society of America/Interscience Conference on Antimicrobial Agents and Chemotherapy) meeting generated a great deal of interest. People are seeing so much MRSA now, they have so many questions, and they are looking for some guidance. Dr Napolitano: You also need to include your local antibiograms. You cannot just take a guideline and implement it. You have to look at your local antibiogram and determine what empiric antimicrobials might work best. Dr Owens: We have a send-out laboratory, and at one point, our reports indicated that we had very high number of Escherichia coli and MRSA isolates. When we asked the laboratory how our isolates compared with those of other hospitals, we learned that they did not break them down by individual hospital. We were one of 500 customers whose data were all being combined into antibiogram. So now we get one broken down every 6 months that is just for our hospital. But we also get the one that is generated from all 500 customers so that we can see what is happening in the community with E coli resistance to quinolones, for example.
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