Is antibiotic prophylaxis required for flexible cystoscopy? A truncated randomized double-blind controlled trial. Due to low infection rates no routine anti‐infective prophylaxis is required in younger patients with chronic lymphocytic leukaemia during fludarabine‐based first line therapy Oral ciprofloxacin or trimethoprim reduces bacteriuria after flexible cystoscopy Pediatricians’ Attitudes and Practices on ADHD Before and After the Development of ADHD Pediatric Practice Guidelines Urinary tract infection and patient satisfaction after flexible cystoscopy and urodynamic evaluation. Use of granulocyte colony-stimulating factor (G-CSF) in patients receiving myelosuppressive chemotherapy for the treatment of cancer. Provincial Systemic Treatment Disease Site Group. The Issue of Prophylactic Antibiotics prior to Flexible Cystoscopy Antibiotic prophylaxis for cardiac surgery in Australia. Canadian Thoracic Society 2012 guideline update: diagnosis and management of asthma in preschoolers, children and adults.
PURPOSE To examine the incidence of  urinary tract infection ( UTI ) after flexible cystoscopy ( FC ) and determine whether prophylactic norfloxacin reduces this incidence compared with placebo . PATIENTS AND METHODS A double-blind trial was performed , r and omizing 234 patients to either 400 mg of norfloxacin or placebo prior to FC . All patients provided a midstream urine specimen ( MSU ) before the procedure , as well as at day 3 and day 7 after FC . In addition , a telephone question naire was performed to correlate the nature and severity of any symptoms associated with UTI . RESULTS Interim analysis was performed because of the low recruitment rate , and a significantly lower infection rate than expected meant that the trial was discontinued . There was one symptomatic UTI in the placebo group ( 0.82 % ) and one in the norfloxacin group ( 0.89 % ) . The UTI in the placebo group was de novo , while the infection in the norfloxacin group was secondary to pre-FC bacteriuria . There was no difference in the infection rates in the two groups . The overall infection rate ( de novo and secondary to existing bacteruria ) after FC was 0.85 % . CONCLUSION Infection after flexible cystoscopy is rare and not associated with significant morbidity . A much larger study would be required to determine whether antibiotic prophylaxis significantly reduces the rate of postprocedure UTI The impact of the combination therapy fludarabine plus cyclophosphamide ( FC ) in comparison with fludarabine alone regarding the incidence and severity of infections among previously untreated patients with chronic lymphocytic leukaemia ( CLL ) was evaluated within a multicentre phase III study . A total of 375 patients , up to 65 years old , were r and omised between fludarabine or FC for first line therapy . No routine anti‐infective prophylaxis was provided . A total of 196 infectious episodes , including 33 severe infections , were documented . In the fludarabine arm , 32·9 % of the patients developed an infectious complication compared with 39·9 % in the FC arm ( P = 0·2 ) . No difference was observed in the rate of severe infections ( Common Toxicity Crtieria grade s III and IV ) between both treatment arms . Dose reductions were performed more frequently in FC‐treated patients  . Granulocyte colony‐stimulating factor ( G‐CSF ) was administered due to leucopenia in 5 % of all patients . A multivariate regression model identified only elevated thymidine kinase , but not the treatment arm , as a statistically independent risk factor for infections . In summary , FC was not associated with a higher rate of infections compared with fludarabine alone . No routine antibiotic or virostatic prophylaxis , or pre‐emptive treatment with G‐CSF , is necessary in first line therapy with fludarabine‐based regimens in younger patients with CLL , if adequate dose reduction is performed . The combination therapy FC is not associated with a higher rate of infections  compared with fludarabine alone . No routine antibiotic or virostatic prophylaxis as well as pre‐emptive treatment with G‐CSF is necessary in first line therapy with fludarabine‐based regimen in younger patients with CLL , if adequate dose reductions due to cytopenia or previous infections are performed To report a large prospect i ve , pragmatic , double‐blind r and omized controlled trial to determine whether oral prophylactic antibiotics reduce the risk of bacteriuria  after flexible cystoscopy ( FC ) , as up to 10 % of patients develop urinary infection afterwards , with significant morbidity and costs for health services Purpose : The study aims to assess the changes in attitudes and practice s about ADHD reported by AAP fellows between 1999 and 2005 during which AAP ADHD guidelines , training , and quality improvement initiatives occurred . Method : The study assesses AAP-initiated surveys  that were conducted between 1999 and 2005 and involving a r and om sample of 1,000 and 1,603 pediatricians , respectively . Results : The findings reveal that significant , although modest , increases occurred in pediatric practitioners ’ self-reported adherence to the guidelines . About 81 % of respondents reported routine use of formal diagnostic criteria ( up from 67 % ) , and 67 % of the respondents routinely use ADHD teacher rating scales ( compared to 49 % in the 1999 survey ) . Findings further reveal that treatment with stimulant medications was used extensively by pediatricians from both surveys ; more pediatricians in the 2005 survey reported use of a second stimulant if the first did not work , and still more reported almost always providing parent training , although the estimated number remained only about a quarter of the total ; and greater familiarity with the initiatives predicted better reported adherence to the guidelines . Conclusion : The reported behaviors of practitioners have moved in the direction of greater adherence with the recommended AAP ADHD guidelines , and there was a positive response to , and a greater use of , the material s developed to enhance practice . The authors infer that practice changes may be due to many factors , including AAP guidelines and associated implementation efforts . Changing physician practice s needs to be sustained through a continuing process that requires multiple , varying , sustained efforts directed at physicians , other providers , and families OBJECTIVES To investigate the incidence of symptomatic and asymptomatic bacteriuria and to assess patient satisfaction after flexible cystoscopy  ( FC ) and  urodynamic ( UD ) evaluation in a prospect i ve survey . The incidence of urinary tract infection after FC and UD studies and the use of prophylactic antibiotics are issues of debate . The tolerability and acceptance of FC and UD studies by patients have not been thoroughly documented . It would be helpful to be able to give such information to patients before performing these procedures . METHODS A total of 215 nonconsecutive patients seen as out patients for FC and UD studies to evaluate various indications were studied . A midstream urine sample was taken before and 48 hours after the procedures . Patients were given a question naire that inquired about the presence of lower urinary tract symptoms before and 48 hours after the procedures . The self-administered question naire included questions to assess patients ' tolerance of the procedures and how it compared with their expectations . RESULTS Of the 201 patients analyzed ( FC 103 , UD studies 98 ) , 9 patients ( 4 . 5 % ) developed significant bacteriuria within 48 hours of FC and UD studies . Only 2 patients with significant bacteriuria reported newly developed symptoms within 48 hours . In a subgroup of 25 patients who were given prophylactic antibiotics for various reasons , 6 ( 24 % ) reported new symptoms , although none developed significant bacteriuria . The association between patients who had preprocedure pyuria ( n = 7 ) and the development of significant growth after the procedure ( n = 6 ) was significant ( P < 0.01 ) . In response to the patient-satisfaction question naire , 166 ( 82.5 % ) reported that the procedure was not as bad as they expected , and 200 ( 99.5 % ) said that they would undergo the test again if necessary . CONCLUSIONS FC and UD studies are safe , well-tolerated procedures . The addition of prophylactic antibiotics in these procedures is unnecessary , unless specific indications are present GUIDELINE QUESTIONS 1 ) Does G-CSF reduce the incidence of important adverse clinical outcomes due to infections in patients with cancer treated with myelosuppressive therapy ? 2 ) Does G-CSF allow maintenance of the chemotherapy dose with the goal of improving survival ? OBJECTIVE To evaluate the evidence for the role of G-CSF in patients receiving myelosuppressive chemotherapy for the treatment of cancer . OUTCOMES Clinical outcomes reflecting events that may affect quality of life and /or re source utilization ( e.g. , rates and duration of hospitalization , antibiotic use ) ; outcomes reflecting the effect of treatment on infection rates , tumour response and survival and those related to the biological effect of G-CSF . PERSPECTIVE ( VALUES ) Evidence was selected , review ed and synthesized by members of the Provincial Systemic Treatment Disease Site Group ( DSG ) of the Cancer Care Ontario Practice Guidelines Initiative . Drafts of this document have been circulated and review ed by members of the Systemic Treatment DSG . The DSG comprises medical oncologists , pharmacists , supportive care personnel and administrators . Evaluation by clinicians was considered in the final practice guideline . Community representatives did not participate in the development of this report but will in future reports . Guidelines approval does require participation by community representatives . QUALITY OF EVIDENCE Two published guidelines and an up date of one guideline were identified . Ten eligible r and omized controlled trials published in English were included . BENEFITS A meta- analysis of data from 8 trials showed that the odds of experiencing febrile neutropenia with G-CSF were significantly reduced ( odds ratio 0.38 ; 95 % confidence interval [ CI ] 0.27 to 0.52 ; p < 0.00001 ) . G-CSF reduced the risk of febrile neutropenia by 34 % ( risk ratio 0.66 ; 95 % CI 0.51 to 0.86 ; p = 0.0015 ) . The use of G-CSF was associated with a significant reduction in antibiotic usage and days spent in hospital in 2 trials and had no effect in the other 4 in which it was measured . Five trials reported no difference in overall median survival , with 2 small trials detecting a significant increase related to G-CSF . However , further research is necessary to confirm these results . HARMS The toxic effects of G-CSF are relatively mild . The most consistent clinical symptom attributed to G-CSF is bone pain , reported in incidence rates ranging from 20 % to 50 % in 3 trials . Except for one case , reported bone pain was mild . PRACTICE GUIDELINE In cancer patients receiving myelosuppressive chemotherapy , granulocyte colony-stimulating factor ( G-CSF ) may be beneficial for some patients . If a reduction in the number of febrile neutropenic episodes , or in the duration of such episodes , is expected to improve quality of life , then G-CSF is a reasonable treatment option for selected patients . A clear justification for the use of G-CSF should be stated . If the objective of using G-CSF is to maintain dose intensity of antitumour agents , then G-CSF can be recommended where reduction in dose intensity has been shown in r and omized controlled trials to reduce survival or disease-free survival . Although the evidence is weaker , the Systemic Treatment DSG would support the practice endorsed by other guidelines ( American Society of Clinical Oncology , Ontario Drug Benefit Plan ) and would recommend G-CSF for patients receiving potentially curative chemotherapy : i ) as primary prophylaxis ; that is , where dose reductions below a specified level are required because of a known high risk of febrile neutropenia , or ii ) as secondary prophylaxis in patients receiving chemotherapy of established efficacy who have suffered a prior serious episode of febrile neutropenia due to the same chemotherapy regimen . The exact cut-off for dose reductions is unknown at this time and ought to be left to the judgement of the clinician . In general , the use of  G-CSF  for dose reductions lower than 20 % is not recommended . ( ABSTRACT TRUNCATED Objective : The aim of this study was to determine whether single – dose parenteral antibacterial therapy significantly alters the rate of infection in patients undergoing flexible cystourethroscopy . Patients and Methods : 162 patients were studied prospect ively having either received parenteral antibacterial chemoprophylaxis prior to flexible cystourethroscopy or not . Pre– and postprocedure mid stream sample s of urine ( MSSU ) were obtained to objective ly evaluate the presence of infection . Results : Gentamicin prophylaxis reduced the rate of post – cystoscopy – positive MSSUs from 21 to 5 % . Conclusion : The surprisingly high rate of infection after flexible cystoscopy was significantly reduced by a single dose of gentamicin OBJECTIVE To evaluate national practice for antibiotic prophylaxis in cardiac surgery with respect to the use of protocol s , agent selection and duration of administration . DESIGN , SETTING AND PARTICIPANTS Two point-prevalence surveys of intensive care units in 24 public and 27 private hospitals performing cardiac surgery in Australia , conducted in 2004 and 2008 , using a structured telephone question naire of the attending senior intensive care clinician in each unit . MAIN OUTCOME MEASURES Existence of a protocol in the unit for antibiotic prophylaxis , specific antibiotic agents used and their duration of administration . RESULTS Between 2004 and 2008 , reported protocol use increased from 58 % to 80 % ( P = 0.02 ) , while concordance with version 13 of the Australian Therapeutic guidelines : antibiotic for both choice of agent and timing ( duration of administration ) remained around 10 % . Use of multiple agents was common , as was continued antibiotic administration after completion of surgery . Over 4 years , the proportion of cardiac surgical units reporting  vancomycin administration  for routine valve surgery prophylaxis doubled to 62 % ( P < 0.001 ) . CONCLUSION Despite an increase in reported protocol use for antibiotic prophylaxis in cardiac surgery , concordance with national antibiotic guidelines remained low , with duration of antibiotic administration deviating most from recommendations . Prophylactic  vancomycin  use appears to have increased substantially in recent years . Clinical implementation of recommended perioperative cardiac surgical antibiotic prophylaxis may not occur until supported by evidence from either a large prospect i ve r and omised study or st and ardised national surveillance of cardiac surgical site infection rates BACKGROUND In 2010 , the Canadian Thoracic Society ( CTS ) published a Consensus Summary for the diagnosis and management of asthma in children six years of age and older , and adults , including an up date d Asthma Management Continuum . The CTS Asthma Clinical Assembly subsequently began a formal clinical practice guideline up date process , focusing , in this first iteration , on topics of controversy and ⁄or gaps in the previous guidelines . METHODS Four clinical questions were identified as a focus for the up date d guideline : the role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy ; the initiation of adjunct therapy to inhaled corticosteroids ( ICS ) for uncontrolled asthma ; the role of a single inhaler of an ICS⁄long-acting beta(2)-agonist combination as a reliever , and as a reliever and a controller ; and the escalation of controller medication for acute loss of asthma control as part of a self-management action plan . The expert panel followed an adaptation process to identify and appraise existing guidelines on the specified topics . In addition , literature search es were performed to identify relevant systematic review s and r and omized controlled trials . The panel formally assessed and grade d the evidence , and made 34 recommendations . RESULTS The up date d guideline recommendations outline a role for inclusion of assessment of sputum eosinophils , in addition to st and ard measures of asthma control , to guide adjustment of controller therapy in adults with moderate to severe asthma . Appraisal of the evidence regarding which adjunct controller therapy to add to ICS and at what ICS dose to begin adjunct therapy in children and adults with poor asthma control supported the 2010 CTS Consensus Summary recommendations . New recommendations for the adjustment of controller medication within written action plans are provided . Finally , priority areas for future research were identified . CONCLUSIONS The present clinical practice guideline is the first up date of the CTS Asthma Guidelines following the Canadian Respiratory Guidelines Committee 's new guideline development process . Tools and strategies to support guideline implementation will be developed and the CTS will continue to regularly provide up date s reflecting new evidence
Conclusions : Antibiotic prophylaxis did confer a reduction in cases of symptomatic and asymptomatic bacteriuria but the NNT were high .
Introduction : The role of antibiotic prophylaxis for routine flexible cystoscopy ( FC ) is not clear due to the varying practice s of individual clinicians .
There are no formal guidelines , and this may be due to a lack of formal summary of the data .