Clinical Briefs By Louis Kuritzky, MD
Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is an advisor for Endo, Kowa, Pricara, and Takeda.
UTI in Long-Term Care Facilities Among Older Adults
Source: Genao L, Buhr GT. Ann Long-Term Care: Clin Care Aging 2012;20:33-38.
Unless a dramatic demographic shift occurs, approximately one in four of us will reside in a long-term care facility (LTCF) during our lifetime. Among LTCF residents, 30-50% of antibiotic utilization is for urinary tract infections (UTIs), resulting in substantial expense, adverse drug reactions, and ever-growing populations of resistant bacteria.
The first guidelines for managing UTI in LTCF were issued in 1991. The McGeer criteria included fever, chills, dysuria, frequency, urgency, flank pain, suprapubic pain, change in urine character, worsening of mental or functional status, and new or increased incontinence. Unfortunately, these criteria (and their subsequent modification, known as the Loeb guidelines) had a sensitivity of only 30%, a positive-predictive value of 57%, and negative-predictive value of 61%. Further modifications of the Loeb guidelines have evolved into an algorithm with major and minor symptoms that have been shown to reduce false-positive diagnoses by 30% and antibiotic use by 20%.
Genao and Buhr do not support treatment of asymptomatic bacteriuria in the LTCF setting for older adults. They remind us of the merit of urine dipstick testing because of its strong negative-predictive value: A dipstick urine test negative for leukocyte esterase and nitrate has an essentially 100% negative-predictive value for the presence of UTI. Although not yet in widespread use, other biomarkers of bacterial infection are gaining support. For instance, serum procalcitonin has been studied as a marker of bacterial infection (including UTI) in young adults, and might perform equally well in older adults.
Beyond Glucocentricity: Nonglycemic Effects of Incretin-Based Therapy
Source: Brown NJ. J Am Soc Hypertens 2012;6:163-168.
Although glucose control in diabetes has been consistently demonstrated to improve microvascular outcomes, no randomized clinical trial has shown favorable effects on macrovascular disease (stroke, MI, overall mortality). Whether the failure to achieve macrovascular risk reduction is secondary to adverse effects like weight gain, hypoglycemia, catecholamine activation, or other factors remains to be determined. In the mean time, clinicians would like to use agents that have favorable effects on glucose/A1c, but at worst neutral effects on cardiovascular risk factors.
The incretin class of agents is currently comprised of GLP-1 agonists (e.g., exenatide, liraglutide) and DPP4 inhibitors (e.g., linagliptin, saxagliptin, sitagliptin). Although both subgroups blunt glucagon and induce glucose-dependent insulin secretion, only the GLP-1 agonists have sufficient potency to also increase satiety and slow gastric emptying. Incretins are generally weight neutral (DPP4) or associated with weight loss (GLP-1). Accordingly, favorable lipid or blood pressure effects might be associated with incretins compared to other treatments that increase weight. The DPP4 enzyme has also been shown to be responsible for breakdown of some vasoactive peptides; hence, changes in blood pressure could be a direct effect of DPP4 inhibition. Because GLP-1 enhances endothelial function, any medication that augments GLP-1 would be anticipated to at least potentially favorably affect vascular function. We look forward to incretin clinical trials that will define the cardiovascular outcomes associated with this class of therapy.
Home BP Monitoring May Assist BP Goal Attainment in the Elderly
Source: Cushman WC, et al. J Am Soc Hypertens 2012;6:210-218.
Although clinic blood pressure (cbp) has been the primary standard by which the majority of major clinical hypertension (HTN) trials have been measured, home BP (hBP) and ambulatory blood pressure monitoring (ABPM) correlate more closely with outcomes and target organ damage. With the advent of reliable, inexpensive, validated devices for home oscillometric BP measurement, national and international agencies now recommend routine inclusion of home BP monitoring for patients with HTN.
Cushman et al report on a trial in elderly hypertensives (men and women > age 70) which compared hBP monitoring with cBP monitoring (n = 128) over 16 weeks. They determined that hBP measurements were consistent with cBP.
Adherence to HTN medications is suboptimal. Utilization of hBP monitoring enables early detection of hypotension, facilitates dose titration (up or down), and may uncover otherwise unidentified insufficient durability of pharmacotherapy (i.e., nighttime measurements showing a waning of antihypertensive effect). As has been demonstrated in other populations, elderly patients can effectively and reproducibly use hBP, which may enhance long-term adherence.
Unless a dramatic demographic shift occurs, approximately one in four of us will reside in a long-term care facility (LTCF) during our lifetime. Among LTCF residents, 30-50% of antibiotic utilization is for urinary tract infections (UTIs), resulting in substantial expense, adverse drug reactions, and ever-growing populations of resistant bacteria.Subscribe Now for Access
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