Posts filed under ‘Resistencia bacteriana’
Pan-Resistant New Delhi Metallo-Beta-Lactamase-Producing Klebsiella pneumoniae — Washoe County, Nevada, 2016
MMWR January 13, 2017 V.66 N.1 P.33
On August 25, 2016, the Washoe County Health District in Reno, Nevada, was notified of a patient at an acute care hospital with carbapenem-resistant Enterobacteriaceae (CRE) that was resistant to all available antimicrobial drugs.
The specific CRE, Klebsiella pneumoniae, was isolated from a wound specimen collected on August 19, 2016. After CRE was identified, the patient was placed in a single room under contact precautions.
The patient had a history of recent hospitalization outside the United States. Therefore, based on CDC guidance (1), the isolate was sent to CDC for testing to determine the mechanism of antimicrobial resistance, which confirmed the presence of New Delhi metallo-beta-lactamase (NDM).
The patient was a female Washoe County resident in her 70s who arrived in the United States in early August 2016 after an extended visit to India.
She was admitted to the acute care hospital on August 18 with a primary diagnosis of systemic inflammatory response syndrome, likely resulting from an infected right hip seroma.
The patient developed septic shock and died in early September.
During the 2 years preceding this U.S. hospitalization, the patient had multiple hospitalizations in India related to a right femur fracture and subsequent osteomyelitis of the right femur and hip; the most recent hospitalization in India had been in June 2016….
Efficacy and Safety of Adjunctive Corticosteroids Therapy for Severe Community-Acquired Pneumonia in Adults: An Updated Systematic Review and Meta-Analysis.
PLoS One. 2016 Nov 15;11(11):e0165942. doi: 10.1371/journal.pone.0165942. eCollection 2016.
Bi J1, Yang J1, Wang Y1, Yao C2, Mei J1, Liu Y2, Cao J3, Lu Y1.
1Department of Respiratory Medicine, the Second Affiliated Hospital of Anhui Medical University, Hefei, China.
2School of Public Health, Anhui Medical University, Hefei, China.
3The Teaching Center for Preventive Medicine, School of Public Health, Anhui Medical University, Hefei, China.
Adjunctive corticosteroids therapy is an attractive option for community-acquired pneumonia (CAP) treatment. However, the effectiveness of adjunctive corticosteroids on mortality of CAP remains inconsistent, especially in severe CAP. We performed a meta-analysis to evaluate the efficacy and safety of adjunctive corticosteroids in severe CAP patients.
Three databases of PubMed, EMBASE and Cochrane Library were searched for related studies published in English up to December, 2015. Randomized controlled trials (RCTs) of corticosteroids in hospitalized adults with severe CAP were included. Meta-analysis was performed by a random-effect model with STATA 11.0 software. We estimated the summary risk ratios (RRs) or effect size (ES) with its corresponding 95% confidence interval (95%CI) to assess the outcomes.
We included 8 RCTs enrolling 528 severe CAP patients. Adjunctive corticosteroids significantly reduced all-cause mortality (RR = 0.46, 95%CI: 0.28 to 0.77, p = 0.003), risk of adult respiratory distress syndrome (ARDS) (RR = 0.23, 95%CI: 0.07 to 0.80, p = 0.02) and need for mechanical ventilation (RR = 0.50, 95%CI: 0.27 to 0.92, p = 0.026). Adjunctive corticosteroids did not increase frequency of hyperglycemia requiring treatment (RR = 1.03, 95%CI: 0.61 to 1.72, p = 0.91) or gastrointestinal hemorrhage (RR = 0.66, 95%CI: 0.19 to 2.31, p = 0.52). In subgroup analysis by duration of corticosteroids, we found that prolonged corticosteroids therapy significantly reduced all-cause mortality (RR = 0.41, 95%CI: 0.20 to 0.83, p = 0.01) and length of hospital stay (-4.76 days, 95% CI:-8.13 to -1.40, p = 0.006).
Results from this meta-analysis suggested that adjunctive corticosteroids therapy was safe and beneficial for severe CAP. In addition, prolonged corticosteroids therapy was more effective. These results should be confirmed by adequately powered studies in the future.
Are laboratory-based antibiograms reliable to guide the selection of empirical antimicrobial treatment in patients with hospital-acquired infections?
J Antimicrob Chemother. 2007 Jan;59(1):140-3. Epub 2006 Oct 31.
Bantar C1, Alcazar G, Franco D, Salamone F, Vesco E, Stieben T, Obaid F, Fiorillo A, Izaguirre M, Oliva ME.
1Department of Infection Control, Hospital San Martín, Perón 450 (3100) Paraná, Entre Ríos, Argentina. email@example.com
Antibiograms are often taken into account to define a rational selection of an empirical antimicrobial therapy for treating patients with hospital-acquired infections. In this study, we performed a paired comparison between the antibiogram constructed with laboratory-based data and that formed with data subjected to prior clinical validation.
Between 2003 and 2005, the laboratory of microbiology printed in duplicate every individual susceptibility report corresponding to hospitalized patients and the copy was sent to the department of infection control. Every individual report was assessed in real time at the bedside of the patient by a multidisciplinary team for clinical significance and appropriateness of the specimen, as well as for the type, source and origin of the infection. Cumulative resistance rates were estimated in parallel at the laboratory with the whole data, and at the infection control department with data subjected to prior clinical validation. These rates were designated as ‘laboratory-based’ and ‘clinically based’, respectively.
A total of 2305 individual susceptibility reports were assessed. Only 1429 (62.0%) were considered as clinically significant by the multidisciplinary team. Escherichia coli, Enterobacter cloacae, Citrobacter freundii group, Klebsiella species and Proteus mirabilis resistant to broad-spectrum cephalosporins, as well as methicillin-resistant Staphylococcus aureus, were significantly more frequent in the clinically based rates (P < or = 0.03).
Laboratory-based data underestimate the frequency of several major resistant organisms in patients with hospital-acquired infection. Previous clinical validation of the individual susceptibility reports seems to be a suitable strategy to get more reliable data.
Does a reduction in antibiotic consumption always represent a favorable outcome from an intervention program on prescribing practice?
Int J Infect Dis. 2006 May;10(3):231-5. Epub 2006 Feb 9.
Bantar C1, Franco D, Heft C, Vesco E, Arango C, Izaguirre M, Oliva ME.
1Services of Infection Control, Hospital San Martín, Paraná, Entre Ríos, Argentina. firstname.lastname@example.org
In our hospital, a continuous intervention program aimed at optimizing the quality of antibiotic use was introduced by late 1999 and antibiotic consumption was a major outcome for assessment.
However, healthcare conditions have been subject to change over the last five years, and a pronounced economic crisis in 2002 affected the availability of antibiotics.
Therefore, we hypothesized that the consumption of these drugs could be a suitable indirect marker of the crisis.
We performed segmented regression analysis between different periods. Variations in antibiotic consumption during periods corresponding to the four-phase intervention program (from 1999 to the first six months of 2001) were assumed to be ‘intervention-induced’, while those observed during the crisis period were considered as ‘situation-enforced’.
Whereas the intervention-induced (desirable) decrease of total antibiotic and carbapenem consumption proved to correlate with a decreased crude mortality rate during the control period prior to the crisis (R2, 0.82 and 0.91, respectively), the crisis-induced (undesirable) decrease in total antibiotic and carbapenem consumption correlated with an increased mortality during this phase (R2, 0.80 and 0.75, respectively).
Our results illustrate that a reduction in antibiotic consumption does not always represent a favorable outcome from an intervention program on prescribing practice. Moreover, it may be a sensitive indirect marker of a deficient healthcare condition leading to an increase in in-hospital mortality.
Replacement of broad-spectrum cephalosporins by piperacillin-tazobactam: impact on sustained high rates of bacterial resistance.
Antimicrob Agents Chemother. 2004 Feb;48(2):392-5.
Bantar C1, Vesco E, Heft C, Salamone F, Krayeski M, Gomez H, Coassolo MA, Fiorillo A, Franco D, Arango C, Duret F, Oliva ME.
1Committee for Prevention and Control of Nosocomial Infection, Hospital San Martín, Paraná, Entre Ríos, Argentina.
We have previously observed a significant reduction of ceftriaxone resistance in Proteus mirabilis associated with an increase in the use of cefepime, along with a decrease in the consumption of broad-spectrum cephalosporins (CEP).
However, we did not observe such a reduction with Klebsiella pneumoniae. Therefore, we sought to determine whether replacement of CEP by piperacillin-tazobactam might be useful in reducing sustained high rates of CEP resistance by this organism.
We used a 6-month “before and after model”; during the second (intervention) period, most prescriptions of CEP were changed to piperacillin-tazobactam at the pharmacy. No additional barrier precautions were undertaken.
During intervention, consumption of ceftazidime decreased from 17.73 to 1.14 defined daily doses (DDD) per 1,000 patient-days (P < 0.0001), whereas that of piperacillin-tazobactam increased from 0 to 30.57 DDD per 1,000 patient-days (P < 0.0001).
The levels of resistance to CEP by K. pneumoniae and P. mirabilis decreased from 68.4 and 57.9% to 37.5 and 29.4%, respectively (P < 0.05).
We conclude that replacement of ceftazidime by piperacillin-tazobactam might be a suitable strategy to decrease endemic CEP resistance by K. pneumoniae and P. mirabilis, even where there are high bacterial resistance rates and irrespective of any additional precautions for controlling nosocomial infection.