They performed a prospective double-blind randomized trial comparing clindamycin against TMP-SMX in 524 ethnically diverse adults and children who presented as outpatients with uncomplicated skin infections during a 2-year period in Chicago, San Francisco, Los Angeles, and Nashville – areas in which community-associated MRSA is endemic. The mean patient age was 27 years, and approximately 30% were pediatric patients. All the participants had cellulitis without abscesses (including erysipelas), one or more abscesses larger than 5 cm in diameter, or both conditions. A total of 264 were randomized to clindamycin and 260 to TMP-SMX daily for 10 days.
Cure rates did not differ significantly between the two study groups. At 7-10 days after completing therapy, the rates of cure in the intention-to-treat population were 80% for clindamycin and 78% for TMP-SMX, and in the evaluable population the rates were nearly 90% and 88%, respectively.
At 1 month follow-up, the cure rates in the evaluable population were 84% for clindamycin and 78% for TMP-SMX, the investigators said (N. Engl. J. Med. 2015;372:1093-103 [doi:10.1056/NEJMoa1403789]). Rates of adverse events were nearly identical between the two study groups at about 19%, and most were mild and resolved without sequelae. There were no treatment-associated serious adverse events, and the rates of treatment discontinuation were similar at nearly 9% between patients receiving clindamycin and those receiving TMP-SMX.
Stroke ambulances speed treatment to U.S. patients
BY MITCHEL L. ZOLER
AT THE INTERNATIONAL STROKE CONFERENCE
Vitals Key clinical point: Dedicated stroke ambulances that bring a CT scanner and thrombolytic treatment to patients in the field speed thrombolytic therapy. Major finding: In Cleveland, stroke patients received thrombolysis an average of 38 minutes sooner from the CT-equipped ambulance, compared with standard protocols. Data source: Prospectively collected data on time-to-treatment from case series in Houston and in Cleveland. Disclosures: Dr. Hussain and Ms. Parker had no disclosures. |
NASHVILLE, TENN. – Bringing a CT scanner and thrombolytic treatment directly to stroke patients in the field sped the time to thrombolysis, compared with waiting for the patient to arrive at the hospital.
Some U.S. stroke centers now send out a team that can immediately assess and start treating stroke patients in the community. In 2014, the first two U.S. mobile stroke-treatment units began operating, one in Houston and the second in Cleveland.
Initial reports show both programs were successful in cutting the time to deliver thrombolytic treatment with intravenous tissue plasminogen activator (TPA) to appropriate patients.
In Houston, the active phase of the program started in May 2014, and by October 2014, 47 acute ischemic stroke patients had been treated with TPA. The mobile-unit crews started 43% of eligible patients on thrombolysis within 60 minutes of their symptom onset and another 31% were treated starting 61-80 minutes after symptom onset, said Stephanie A. Parker at the International Stroke Conference.
The unit also treats patients diagnosed with hemorrhagic stroke with intravenous nicardipine for rapid blood pressure reduction, said Ms. Parker, a critical care and emergency medicine–trained registered nurse who is project manager for the Houston mobile unit.
The Cleveland program began in July 2014; of the first 100 stroke patients seen by the mobile unit 16 of 19 eligible patients received tPA, with an average time of 56 minutes from symptom onset to treatment. This compared with an average 94 minutes to tPA onset in patients brought conventionally last year to a Cleveland-area hospital, Dr. M. Shazam Hussain said in a report at the meeting, sponsored by the American Heart Association.
The clinical impact and cost effectiveness of the pilot programs using the mobile units have not yet been assessed from the data, Dr. Hussain and Ms. Parker emphasized. Funding for the Cleveland and Houston vehicles came from local donors; the Houston program also received equipment donations from manufacturers.
The two mobile units are standard 12-foot, box-shaped ambulances outfitted with a CT scanner, a point-of-care lab, and telemedicine components as well as more standard emergency-vehicle equipment. The Houston vehicle contains “all the diagnostic equipment that is in our emergency room,” Ms. Parker said.
The concept behind both the Cleveland unit, operated by the Cleveland Clinic, and the Houston unit, operated by the University of Texas, Houston, is that the mobile stroke unit arrives to a patient with a suspected stroke, the unit is stationary while a CT scan and other diagnostic tests are run, diagnosis occurs with telemedicine assistance. If the patient is cleared for TPA treatment, the infusion starts and the vehicle carries the patient to an appropriate stroke center.
Currently, the Houston unit goes out with a vascular neurologist and a telemedicine physician on board, but plans are in place to test the feasibility of relying entirely on telemedicine when making diagnostic and treatment decisions. The Cleveland mobile unit already operates in this fashion, with no physician on board, and was the first mobile stroke unit in the world to depend completely on telemedicine, according to Dr. Hussain, a neurologist and head of the stroke program at the Cleveland Clinic.