Background Gram-negative bacteremia is a major cause of morbidity and mortality in hospitalized patients. Data to guide the duration of antibiotic therapy are limited. Methods This was a randomized, multicenter, open-label, noninferiority trial. Inpatients with gram-negative bacteremia, who were afebrile and hemodynamically stable for at least 48 hours, were randomized to receive 7 days (intervention) or 14 days (control) of covering antibiotic therapy. Patients with uncontrolled focus of infection were excluded. The primary outcome at 90 days was a composite of all-cause mortality; relapse, suppurative, or distant complications; and readmission or extended hospitalization (>14 days). The noninferiority margin was set at 10%. Results We included 604 patients (306 intervention, 298 control) between January 2013 and August 2017 in 3 centers in Israel and Italy. The source of the infection was urinary in 411 of 604 patients (68%); causative pathogens were mainly Enterobacteriaceae (543/604 [90%]). A 7-day difference in the median duration of covering antibiotics was achieved. The primary outcome occurred in 140 of 306 patients (45.8%) in the 7-day group vs 144 of 298 (48.3%) in the 14-day group (risk difference, –2.6% [95% confidence interval, –10.5% to 5.3%]). No significant differences were observed in all other outcomes and adverse events, except for a shorter time to return to baseline functional status in the short-course therapy arm. Conclusions In patients hospitalized with gram-negative bacteremia achieving clinical stability before day 7, an antibiotic course of 7 days was noninferior to 14 days. Reducing antibiotic treatment for uncomplicated gram-negative bacteremia to 7 days is an important antibiotic stewardship intervention. Clinical Trials Registration NCT01737320.

ObjeCtiveTo show non-inferiority of trimethoprimsulfamethoxazole compared with vancomycin for the treatment of severe infections due to meticillin resistant Staphylococcus aureus (MRSA). DesignParallel, open label, randomised controlled trial.setting Four acute care hospitals in Israel. PartiCiPantsAdults with severe infections caused by MRSA susceptible to trimethoprim-sulfamethoxazole and vancomycin. Patients with left sided endocarditis, meningitis, chronic haemodialysis, and prolonged neutropenia were excluded.interventiOns Trimethoprim-sulfamethoxazole 320 mg/1600 mg twice daily versus vancomycin 1 g twice daily for a minimum of seven days and then by indication.

To cite this article: Vardi M, Ghanem-Zoubi NO, Zidan R, Yurin V, Bitterman H. Venous thromboembolism and the utility of the Padua Prediction Score in patients with sepsis admitted to internal medicine departments. J Thromb Haemost 2013; 11: 467-73.Summary. Background: Sepsis is prevalent in internal medicine (IM) departments. Elderly patients with sepsis and chronic medical conditions are at an increased risk for venous thromboemolism (VTE). The objective of this study was to assess the rate of VTE and the accuracy of the Padua Prediction Score (PPS) to predict VTE in patient with sepsis admitted to IM departments. Methods: We prospectively collected data on septic patients admitted to IM departments in a community-based medical center. Additionally, we retrospectively collected VTE risk factors and events throughout a 1-year post hospitalization period. We computed the PPS for every patient, and analyzed the data accordingly. Results: In total, 1080 patients were included in the study. The mean age was 74.68 AE 16.1 years. The average PPS was 4.86 AE 2.26, and 71.2% of the patients had a positive PPS. Only 17.8% of the patients received anticoagulant prophylaxis during their hospital stay. Seven patients had VTE on admission, 14 (1.29%) acquired in-hospital VTE, and 7 (0.65%) had VTE post discharge throughout 1 year. In all, 21.9% patients died during hospitalization, and the overall survival rate was 64%. PPS was not correlated with anticoagulant administration (P = 0.36), in-hospital VTE (P = 0.23) or 1-year VTE (P = 0.40), but was significantly associated with in-hospital death and survival (P < 0.0001). Conclusion: The rate of VTE in medical patients with sepsis in IM departments is low, and PPS lacks granularity in detecting patients at risk of acquiring it. In this population, a positive PPS is highly associated with death, and may reflect a more general co-morbidity and disease severity index.

IntroductionDue to the increasing burden on hospital systems, most elderly patients with non-surgical sepsis are admitted to general internal medicine departments. Disease-severity scoring systems are used for stratification of patients for utilization management, performance assessment, and clinical research. Some widely used scoring systems for septic patients are inappropriate when rating non-surgical patients in a non-intensive care unit (ICU) environment mainly because their calculations require types of data that are frequently unavailable. This study aimed to assess the fitness of four scoring systems for septic patients hospitalized in general internal medicine departments: modified early warning score (MEWS), simple clinical score (SCS), mortality in emergency department sepsis (MEDS) score, and rapid emergency medicine score (REMS).MethodsWe prospectively collected computerized data of septic patients admitted to general internal medicine departments in our community-based university hospital. We followed 28-day in-hospital mortality, overall in-hospital mortality, and 30- and 60-day mortality. Using a logistic regression procedure we calculated the area under ROC curve (AUC) for every scoring system.ResultsBetween February 1st, 2008 and April 30th, 2009 we gathered data of 1,072 patients meeting sepsis criteria on admission to general internal medicine departments. The 28-day mortality was 19.4%. The AUC for the MEWS was 0.65-0.70, for the SCS 0.76-0.79, for the MEDS 0.73-0.75, and for the REMS, 0.74-0.79. Using Hosmer-Lemeshow statistics, a lack of fit was found for the MEDS model. All scoring systems performed better than calculations based on sepsis severity.ConclusionsThe SCS and REMS are the most appropriate clinical scores to predict the mortality of patients with sepsis in general internal medicine departments.