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Preventive treatment with antibiotics appears
to be more effective for severely ill patients
The benefits of treating patients in intensive care units with
prophylactic antibiotics appear to increase with the patients'
severity of illness. This finding is from a meta-analysis
reported in Critical Care Medicine by Xiaolu Sun, M.D.,
colleagues Douglas P. Wagner, Ph.D. and William A. Knaus, M.D. of
the University of Virginia. The study was supported in part by a
grant from the Agency for Health Care Policy and Research
(HS07137), for which Dr. Knaus was Principal Investigator.
Dr. Knaus explains that these severely ill patients, especially
when they have long ICU stays or are on mechanical ventilation,
are extremely vulnerable to hospital-acquired (or nosocomial)
infections. These infections are a major cause of sepsis ("blood
poisoning") and subsequent failure of major organ systems.
The meta-analysis examined 23 studies involving a total of 4,142
adult ICU patients. Taken together, the studies showed that ICU
patients at high risk of death who were treated with prophylactic
antibiotics had a significantly lower mortality rate than
patients who did not receive prophylactic antibiotics. The degree
of antibiotic protection was related to the degree of mortality
risk of the ICU patients at the time of study entry.
Details are in "Does selective decontamination of the digestive
tract reduce mortality for severely ill patients?" by Drs. Sun,
Wagner, and Knaus, which appears in Critical Care Medicine
pp. 753-755, 1996.
Pregnant women exposed to chicken pox should
be tested for immune status before being given varicella-zoster
Currently, it is recommended that all pregnant women who are
exposed to chicken pox (varicella zoster virus, VZV) be given
varicella-zoster immune globulin to prevent infection. However, a
recent study found that this approach is neither cost effective
nor necessary. Rather, these women should first be tested for
immunity to VZV, since about 80 percent of women with no history
of chicken pox infection are in fact immune and would not benefit
from the treatment. Also, the immune globulin costs $400 per
treatment compared with the $25 immune status test.
Varicella-zoster immune globulin is thought to modify the
severity of or even prevent varicella infection if administered
within 96 hours of exposure. According to members of the Patient
Outcomes Research Team (PORT) on Low Birthweight in Minority and
High Risk Women supported by the Agency for Health Care Policy
and Research (contract 282-92-0055), it remains controversial
whether chicken pox infection has severe consequences in pregnant
women. The PORT researchers, led by Robert L. Goldenberg, M.D.,
of the University of Alabama, constructed a simple
decision-analytic model to compare three strategies for managing
pregnant women exposed to VZV using a hypothetical 25-year-old
pregnant woman with a 55-year life expectancy. The strategies
were: one, merely observe; two, test immune status and administer
varicella-zoster immune globulin to women who test nonimmune; and
three, administer varicella-zoster immune globulin to all exposed
and presumed susceptible women.
Under most assumptions, the universal administration strategy was
not cost effective when compared with the immune-testing
strategy. The PORT researchers recommend selectively
administering the varicella-zoster immune globulin based on the
results of immune testing. This would allow most pregnant women
who are actually at risk of contracting chicken pox to receive
prophylaxis, while avoiding needless and expensive prophylaxis in
the large number of women who are not at risk.
For more details, see "Management of the presumed susceptible
varicella (chickenpox)-exposed gravida: A
cost-effectiveness/cost-benefit analysis," by Dwight J. Rouse,
M.D., Michael Gardner, M.D., M.P.H., Stephen J. Allen, M.D., and
Dr. Goldenberg, in the June 1996 issue of Obstetrics &
87(6), pp. 932-936.
Nonclinical factors may influence use of
Routine performance of episiotomies during vaginal deliveries is
falling into increasing disfavor. Recent studies show that they
are necessary in only a few clinical situations and often prolong
hospital stays. Yet a new study shows that 69 percent of women
who give birth vaginally have episiotomies. Furthermore,
nonclinical factors—such as physician attitudes and the
socioeconomic status—often figure into the decision to
episiotomy. At this rate, extra hospital days for women who
undergo episiotomies would account for annual health care
expenditures of $351 million, according to the study supported in
part by the Agency for Health Care Policy and Research
It is difficult to change long-standing physician attitudes that
episiotomies are needed to minimize perineal tearing and protect
against excessive vaginal stretching, explains William J.
Hueston, M.D., of the University of Wisconsin-Madison, author of
the study. He analyzed the reasons for use of episiotomies during
nearly 6,500 vaginal deliveries at five medical centers during
1991 and 1992 by retrospectively reviewing the medical records.
He found that women without children were four times more likely
to have an episiotomy than women with children, and that women
whose babies were delivered with instruments (forceps or vacuum
extraction) were four to five times more likely to undergo the
procedure than other women. Delivery of a larger infant and use
of epidural anesthesia also were associated with an
But clinical factors alone did not drive the decision to perform
episiotomies. For example, white women and women with private
health insurance were at higher risk for episiotomy than nonwhite
women and those without private insurance. Providers may perceive
privately insured patients as having higher expectations of
perfect outcomes and as more apt to file malpractice suits,
suggests Dr. Hueston. Midwives and some care sites were low users
of episiotomies (39 percent of vaginal births). Obstetricians and
other care sites were high users (68-79 percent), and family
physicians and still other sites fell somewhere between the
More details are in "Factors associated with the use of
episiotomy during vaginal delivery," by Dr. Hueston, which
appears in the June 1996 issue of Obstetrics & Gynecology
87(6), pp. 1001-1005.
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