Bruce Lavin

Evaluation of the standardized disk diffusion and agar dilution antibiotic susceptibility test methods by using strains of Neisseria gonorrhoeae from the United States and Southeast Asia

Journal of Clinical Microbiology, Apr 1, 1992

Presently, most Neisseria gonorrhoeae testing is based on f-lactamase tests and agar dilution wit... more Presently, most Neisseria gonorrhoeae testing is based on f-lactamase tests and agar dilution with common therapeutic agents. The National Committee for Clinical Laboratory Standards (NCCLS) recently described a disk diffusion test that produced results similar to the reference agar dilution method for the antibiotic susceptibility of N. gonorrhoeae. We obtained 71 gonococcal isolates from active-duty males aboard a United States Navy vessel while deployed in the Western Pacific during 1989. In addition, 47 isolates ofN. gonorrhoeae were obtained from sexually transmitted disease clinics within the branch clinic operations of the Naval Hospital, San Diego (SD), and tested. Antibiotic susceptibility tests by using the NCCLS agar dilution and disk diffusion techniques were compared. Among the Southeast Asia (SEA) isolates, 47% were 1i-lactamase producers compared with 10.5% of the SD isolates. The mean MICs (SEA/SD) in micrograms per milliliter for both groups were as follows: penicillin, 88/15; tetracycline, 2.2/0.95; erythromycin, 1.2/0.49; ceftriaxone, 0.016/0.012; cefotaxime, 0.034/0.03; cefuroxime, 0.44/0.17; cefoxitin, 1.3/0.97; spectinomycin, 150/131; ciprofloxacin, 0.07/0.034; norfloxacin, 0.77/0.29; lomefloxacin, 0.15/0.056; and ofloxacin, 0.07/0.036. The established NCCLS interpretive criteria for both susceptibility methods appear applicable to domestic gonococcal strains. However, modifications may be necessary for the more antimicrobial agent-resistant SEA isolates on the basis of the clinical success and cure rates following the indicated single-dose regimens for the geographic region.

Emergence and Spread ofStreptococcus pneumoniaewitherm(B) andmef(A) Resistance

Emerging Infectious Diseases, Jun 1, 2005

Streptococcus pneumoniae isolates (N = 31,001) were collected from patients with community-acquir... more Streptococcus pneumoniae isolates (N = 31,001) were collected from patients with community-acquired respiratory tract infections during the PROTEKT US surveillance study (2000)(2001)(2002)(2003). While the macrolide (erythromycin) resistance rate remained stable at ≈29%, the prevalence of resistant isolates containing both erm(B) and mef(A) increased from 9.7% in year 1 to 16.4% in year 3, with substantial regional variability. Almost all (99.2%) dual erm(B)+mef(A) macrolide-resistant isolates exhibited multidrug resistance, whereas 98.6% and 99.0% were levofloxacin-and telithromycin-susceptible, respectively. These strains were most commonly isolated from the ear or middle-ear fluid of children. Of 152 representative erm(B)+mef(A) isolates, >90% were clonally related to the multidrug-resistant international Taiwan 19F -14 clonal complex 271 (CC271). Of 366 erm(B)+mef(A) isolates from the PROTEKT global study (1999)(2000)(2001)(2002)(2003), 83.3% were CC271, with the highest prevalence seen in South Africa, South Korea, and the United States. This study confirms the increasing global emergence and rapidly increasing US prevalence of this multidrug-resistant pneumococcal clone.

Detection of Chlamydia trachomatis in First Catch Urine Samples From Symptomatic and Asymptomatic Males

Sexually Transmitted Diseases, 1994

Non-invasive tests are needed to detect Chlamydia trachomatis in the genital tract. For men, urin... more Non-invasive tests are needed to detect Chlamydia trachomatis in the genital tract. For men, urine appears to be a useful specimen for chlamydial antigen or nucleic acid detection. To evaluate enzyme immunoassays (EIA) for chlamydial antigens in first catch urine (FCU) from symptomatic and asymptomatic men. We conducted five different studies; FCUs and urethral swabs were collected from 1,341 symptomatic and 816 asymptomatic males. Four EIAs (SureCell, Chlamydiazyme, MicroTrak and IDEIA) were tested on the FCU sediments. Prevalence of chlamydia by tissue culture isolation was 6% for asymptomatic and 14% for symptomatic men. With symptomatic males, the EIA sensitivities and specificities were: SureCell 85% and 97%, IDEIA 82% and 98%, MicroTrak 86% and 99%, and Chlamydiazyme 91% and 95%. For asymptomatic men, Chlamydiazyme sensitivity was 35% with frozen urine vs 77% with fresh urine. Overall, tissue culture sensitivity was about 90%. EIA results on FCU sediments are comparable to that of tissue culture isolation on urethral swabs. In many settings, FCU may be the specimen of choice for diagnosing chlamydial infections in men.

Internship ratings as a validity outcome measure for an evaluation system to identify inadequate clerkship performance

Academic Medicine, Sep 1, 1998

To determine whether a third-year clerkship evaluation system validly predicted students&#39;... more To determine whether a third-year clerkship evaluation system validly predicted students&#39; later performance ratings during their internships. Adequacy of students&#39; clerkship performances and the need for remediation were determined during seven consecutive academic years at the Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine using a criterion-based process including formal evaluation sessions. Internship ratings of students who needed remediation (remediators) from 1986 to 1993 were compared with those of students who voluntarily chose fourth-year medicine (non-remediators). Using written questionnaires, internship directors rated the graduates on a five-point scale for fund of knowledge, attitude, and analytic ability, and also provided written comments. Responses to questionnaires were available for 75 of 97 remediators (78%) and 268 of 313 non-remediators (86%). The remediators were 12.9 times more likely to have low internship performance scores and 9.4 times more likely to receive unfavorable comments than were the non-remediators. However, the majority of the remediators (80%) received only favorable comments. The medicine clerkship grade was more sensitive than the non-medicine grade-point average in predicting problems during internship (75% vs 8%). The medicine clerkship evaluation process detected whether a student was likely to have problems during internship, and the internship ratings supported the predictive validity of the evaluation system. The majority of students who were successfully remediated had no identifiable problems during internship.

Endocarditis due to Vancomycin-resistant Enterococcus faecium in an Immunocompromised Patient: Cure by Administering Combination Therapy with Quinupristin/Dalfopristin and High-dose Ampicillin

Southern Medical Journal, Aug 1, 2003

A 56-year-old man with diabetes mellitus and cadaveric renal transplantation had vancomycin-resis... more A 56-year-old man with diabetes mellitus and cadaveric renal transplantation had vancomycin-resistant Enterococcus faecium tricuspid valve endocarditis. Relapse followed 6 weeks of treatment with intravenous gentamicin and high-dose ampicillin. On the basis of previous data suggesting the potential for synergistic activity of quinupristin/dalfopristin plus high-dose ampicillin, therapy with this combination was administered for 63 days. Cure was achieved and later confirmed at 2-year follow-up.

Clinical and bacteriologic efficacy of telithromycin in patients with acute bacterial sinusitis: A pooled analysis

The Journal of Allergy and Clinical Immunology, Feb 1, 2005

Changing the neurology policy landscape in the United States: Misconceptions and facts about epilepsy

Health policy, Jul 1, 2018

Epilepsy has a relatively high prevalence, and diagnosis and treatment are often challenging. Sei... more Epilepsy has a relatively high prevalence, and diagnosis and treatment are often challenging. Seizure freedom without significant side effects is the ultimate goal for both physicians and patients, but not always achievable. In those cases, the treatment goals of patients and providers may differ. In the United States, many clinicians continue to prescribe older AEDs, even though newer AEDs have a more desirable safety and tolerability profile, fewer drug-drug interactions, and are associated with lower epilepsy-related hospital visits. Newer AEDs are more commonly prescribed by neurologists and epilepsy center physicians, highlighting the importance of access to specialty care. We report that antiepileptic drugs are not the dominant cost driver for patients with epilepsy and costs are considerably higher in patients with uncontrolled epilepsy. Poor drug adherence is considered a main cause of unsuccessful epilepsy treatment and is associated with increases in inpatient and emergency department admissions and related costs. Interventions and educational programs are needed to address the reasons for nonadherence. Coverage policies placing a higher cost burden on patients with epilepsy lead to lower treatment adherence, which can result in higher future health care spending. Epilepsy is lagging behind other neurological conditions in terms of funding and treatment innovation. Increased investment in epilepsy research may be particularly beneficial given current funding levels and the high prevalence of epilepsy.

Iatrogenic Urinary Tract Infection with Pseudomonas Cepacia after Transrectal Ultrasound Guided Needle Biopsy of the Prostate

The Journal of Urology, Mar 1, 1993

In response to an unexplained development of Pseudomonas cepacia cystoprostatitis after transrect... more In response to an unexplained development of Pseudomonas cepacia cystoprostatitis after transrectal ultrasound guided prostate biopsy, a retrospective review of records and biopsy protocol was performed at our institution. Between June 5, 1990 and January 9, 1991 no documented infections occurred in 272 patients undergoing transrectal ultrasound and prostate biopsy. During the next 6 months, however, 9 of 110 patients (8.2%) presented again with infectious symptomatology after transrectal ultrasound guided needle biopsy of the prostate. Culture of a majority of the specimens (67%) yielded P. cepacia. Two additional asymptomatic patients became colonized with P. cepacia. Environmental investigations revealed the ultrasound transmission gel as the source of the contamination. The proposed mechanism of infection was direct prostate or bladder seeding of contaminated transmission gel used to prepare the ultrasound transducer probe. Infections developed in immunocompetent patients despite adequate antimicrobial prophylaxis most likely secondary to underlying bladder outlet obstruction and significant direct inoculum of organisms. We currently recommend use of individualized sterile packets of transmission gel in addition to appropriate antimicrobial prophylaxis and povidone-iodine cleansing enemas when performing transrectal sonographic guided biopsies of the prostate.

Report on Electroencephalographic Findings in Critically Ill Patients with COVID‐19

Annals of Neurology, 2020

In March 2020, we treated a cohort of 26 critically ill hospitalized SARS‐CoV‐2–infected patients... more In March 2020, we treated a cohort of 26 critically ill hospitalized SARS‐CoV‐2–infected patients who underwent electroencephalography to assess unexplained altered mental status, loss of consciousness, or poor arousal and responsiveness. Of the 26 patients studied, 5 patients had electroencephalograms that showed periodic discharges consisting of high‐amplitude frontal monomorphic delta waves with absence of epileptic activity. These findings may suggest central nervous system injury potentially related to COVID‐19 in these patients. ANN NEUROL 2020;88:626–630

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Comments on Comparison of hospitalization rates in patients with community-acquired pneumonia treated with 10 days of telithromycin or clarithromycin and Comparison of hospitalization rates in patients with community-acquired pneumonia treated with telithromycin for 5 or 7 days or clarithromycin ...

Current Medical Research and Opinion, Nov 9, 2004

Meta-analysis of bacterial resistance to macrolides

Journal of Antimicrobial Chemotherapy, May 1, 2005

Objectives: Understanding changing resistance patterns is important in determining appropriate an... more Objectives: Understanding changing resistance patterns is important in determining appropriate antibiotic treatments. This meta-analysis systematically evaluated resistance of Streptococcus pneumoniae and Streptococcus pyogenes to macrolide antibiotics among patients with community-acquired respiratory tract infections. Methods: MEDLINE and EMBASE databases were searched and experts were consulted to identify published and unpublished literature reporting macrolide resistance rates. Identified studies were evaluated by two independent reviewers; those meeting a priori specified criteria (resistance by patient condition and strain, resistance thresholds, 1997-2003 isolates) were included. Data from included studies were abstracted by two independent reviewers using a standard review form. Discrepancies in abstracted data were resolved by the study investigator. Results: Random-effects meta-analysis was performed for outcomes present in at least four studies overall and for specified subgroups. We identified 3849 studies and performed detailed review on 407; of these 29, published between 1998-2003, met the inclusion criteria. Mean resistance of S. pneumoniae isolates to azithromycin was 27.2% [95% confidence interval (CI) 24.6 -29.7]; mean resistance to erythromycin was statistically equivalent (30.4%; 95% CI 28.1-32.7). Resistance of S. pyogenes to erythromycin (30.0%; CI 18.6-41.5) was similar to that of S. pneumoniae. Too few studies of clarithromycin were included to allow evaluation of resistance. In subgroup analyses, substantial variation in resistance to erythromycin was seen by geographic area. Conclusions: Reported macrolide resistance of S. pneumoniae varies substantially and may be a significant issue in certain regions. Use of meta-analysis to aggregate individual studies enabled determination of robust values for macrolide resistance. This information is useful for clinical and policy decision makers in developing appropriate antibiotic strategies.

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The bioequivalence of oral administration of telithromycin tablets crushed versus swallowed whole in healthy adult subjects

Clinical Pharmacology & Therapeutics, Feb 1, 2005

Background/Aim: To establish bioequivalence of telithromycin (TEL) crushed versus whole tablet ad... more Background/Aim: To establish bioequivalence of telithromycin (TEL) crushed versus whole tablet administration.Methods: Open-label, single-dose, randomized, 2-period, crossover study with a 6-day washout between periods: Treatment A: TEL 800 mg (2× 400-mg tablets), swallowed whole with 240 mL water; Treatment B: TEL 800 mg (2× 400-mg tablets), crushed and mixed in 240 mL Ensure®, followed by 120 mL water. Blood samples were collected predose and at 0.5, 1, 1.5, 2, 3, 4, 6, 8, 10, 12, 16, and 24 hpostdose. Plasma was assayed for TEL concentration by LC/MS/MS. Exposure measures were computed by noncompartmental methods using WinNonlin® (Pharsight Corporation). Cmax and AUC (0–24) were determined from observed data. Average bioequivalence criteria was applied.Results: 32 subjects (16 M, 16 F) completed the study. 90% confidence intervals for the mean ratio of AUC (0–24) and Cmax were within the 0.80–1.25 range. Median Tmax was also similar between treatments (3.00 hours for each treatment). Both methods of administration were safe and generally well tolerated.Conclusions: Crushing telithromycin tablets administered with Ensure is bioequivalent to administration of whole tablets. Breaking or crushing telithromycin tablets can be a viable alternate method of administration for patients unable to swallow whole tablets. (see Table)

The Bioequivalence of Telithromycin Administered Orally as Crushed Tablets Versus Tablets Swallowed Whole

The Journal of Clinical Pharmacology, Sep 1, 2005

This open-label, randomized, crossover study was conducted to demonstrate bioequivalence for teli... more This open-label, randomized, crossover study was conducted to demonstrate bioequivalence for telithromycin administered as crushed or whole tablets. Single 800-mg telithromycin doses (2x400-mg tablets) were administered as crushed tablets mixed in 240 mL nutritional supplement drink followed by 120 mL water or as whole tablets swallowed with 240 mL water. Plasma telithromycin concentrations were measured by liquid chromatography/mass spectrometry; pharmacokinetic parameters were determined using noncompartmental methods. Average bioequivalence criteria were applied. Thirty-two subjects received telithromycin by both methods. The 90% confidence intervals for the geometric mean ratios of maximum plasma concentration and area under the plasma concentration-time curve to 24 hours were within the 0.80 to 1.25 range. Median tmax was 3.00 hours for both treatments. Both methods of administration were well tolerated. Crushing telithromycin tablets and administering them with a nutritional supplement drink is bioequivalent to ingesting whole tablets and could be a viable method of administration for patients unable to swallow tablets whole.

Telemedicine and Epilepsy Care

Neurologic Clinics, Nov 1, 2022

Telemedicine and Epilepsy Care

Neurologic Clinics

Trends in anti-bacterial resistance among isolated in the USA, 2000�2003: PROTEKT US years 1�3

J Infection, 2005

A Case Series of Macrolide Treatment Failures in Community Acquired Pneumonia

Journal of Chemotherapy, 2007

This was a retrospective, multi-center study of patients admitted to hospital with community-acqu... more This was a retrospective, multi-center study of patients admitted to hospital with community-acquired pneumonia, caused by Streptococcus pneumoniae, after failing to respond to &amp;amp;amp;amp;gt;2 days of outpatient macrolide therapy. 122 cases, treated between 2000-2004, were enrolled from 31 North American sites between January 2004 - March 2005. Non-susceptible isolates (predominately low-level resistance: erythromycin MICs of 1-16 mcg/ml) were recovered from 87 patients (71%). Bacteremia was present in 63 patients (52%). The in-hospital mortality rate was 5.7 %; all 7 patients who died were bacteremic, 6 had a non-susceptible isolate. We report here the largest series of macrolide failures published to date. The patients were notable for their high rates of macrolide resistance, bacteremia, and mortality. High-level macrolide resistance remains rare among US patients failing outpatient macrolides. The majority of cases and virtually all of the mortality occurred in patients with low-level resistant strains.

Clinical and bacteriologic efficacy of telithromycin in patients with acute bacterial sinusitis: A pooled analysis

Journal of Allergy and Clinical Immunology, 2005

Comments on Comparison of hospitalization rates in patients with community-acquired pneumonia treated with 10 days of telithromycin or clarithromycin and Comparison of hospitalization rates in patients with community-acquired pneumonia treated with telithromycin for 5 or 7 days or clarithromycin ...

Current Medical Research and Opinion, 2004

Internship ratings as a validity outcome measure for an evaluation system to identify inadequate clerkship performance

Academic Medicine, 1998

To determine whether a third-year clerkship evaluation system validly predicted students&#39;... more To determine whether a third-year clerkship evaluation system validly predicted students&#39; later performance ratings during their internships. Adequacy of students&#39; clerkship performances and the need for remediation were determined during seven consecutive academic years at the Uniformed Services University of the Health Sciences F. Edward Hébert School of Medicine using a criterion-based process including formal evaluation sessions. Internship ratings of students who needed remediation (remediators) from 1986 to 1993 were compared with those of students who voluntarily chose fourth-year medicine (non-remediators). Using written questionnaires, internship directors rated the graduates on a five-point scale for fund of knowledge, attitude, and analytic ability, and also provided written comments. Responses to questionnaires were available for 75 of 97 remediators (78%) and 268 of 313 non-remediators (86%). The remediators were 12.9 times more likely to have low internship performance scores and 9.4 times more likely to receive unfavorable comments than were the non-remediators. However, the majority of the remediators (80%) received only favorable comments. The medicine clerkship grade was more sensitive than the non-medicine grade-point average in predicting problems during internship (75% vs 8%). The medicine clerkship evaluation process detected whether a student was likely to have problems during internship, and the internship ratings supported the predictive validity of the evaluation system. The majority of students who were successfully remediated had no identifiable problems during internship.

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