Posts filed under ‘Resistencia bacteriana’

Clinical manifestations of invasive pneumococcal disease by vaccine and non-vaccine types

Eur Respir J 2014 44:6, 1646-1657

Sarah Browall, Erik Backhaus, Pontus Naucler, Ilias Galanis, Karin Sjöström, Diana Karlsson, Stefan Berg, Joachim Luthander, Margareta Eriksson, Carl Spindler, Mikael Ejdebäck, Birger Trollfors, Jessica Darenberg, Mats Kalin, Åke Örtqvist, Rune Andersson, and Birgitta Henriques-Normark

1Dept of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden

2Dept of Infectious Diseases, Skaraborg Hospital, Skövde, Sweden

3Dept of Infectious Diseases, Karolinska University Hospital, Solna, Sweden

4Systems Biology Research Centre, School of Biosciences, University of Skövde, Skövde, Sweden

5Queen Silvia Children’s Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden

6Dept of Paediatrics, Karolinska University Hospital, Solna, Sweden

7Public Health Agency of Sweden, Solna, Sweden

8Dept of Communicable Diseases Control and Prevention, Stockholm County Council, Stockholm, Sweden

9Dept of Medicine, Unit of Infectious Diseases, Karolinska Institutet, Solna, Sweden

10Dept of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden

11Dept of Clinical Microbiology, Karolinska University Hospital, Stockholm, Sweden

12Both authors contributed equally

Birgitta Henriques-Normark, Dept of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Nobelsväg 16, 171 77 Stockholm, Sweden. E-mail: birgitta.henriques{at}ki.se 

 

Pneumococcal conjugated vaccines (PCVs) have shown protection against invasive pneumococcal disease by vaccine serotypes, but an increase in non-vaccine serotype disease has been observed. Type-specific effects on clinical manifestation need to be explored.

Clinical data from 2096 adults and 192 children with invasive pneumococcal disease were correlated to pneumococcal molecular serotypes. Invasive disease potential for pneumococcal serotypes were calculated using 165 invasive and 550 carriage isolates from children.

The invasive disease potential was lower for non-PCV13 compared to vaccine-type strains. Patients infected with non-PCV13 strains had more underlying diseases, were less likely to have pneumonia and, in adults, tended to have a higher mortality. Furthermore, patients infected with pneumococci belonging to clonal serotypes only expressing non-PCV13 capsules had a higher risk for septicaemia and mortality.

PCV vaccination will probably lead to a decrease in invasive pneumococcal disease but an alteration in the clinical manifestation of invasive pneumococcal disease. Genetic lineages causing invasive pneumococcal disease in adults often express non-vaccine serotypes, which can expand after vaccination with an increased risk of infection in patients with underlying diseases.

PDF

http://erj.ersjournals.com/content/44/6/1646.full.pdf+html

May 23, 2015 at 6:02 pm

Clindamycin versus trimethoprim-sulfamethoxazole for uncomplicated skin infections.

N Engl J Med March 19, 2015 V.372  P.1093-1103

Loren G. Miller, M.D., M.P.H., Robert S. Daum, M.D., C.M., C. Buddy Creech, M.D., M.P.H., David Young, M.D., Michele D. Downing, R.N., M.S.N., Samantha J. Eells, M.P.H., Stephanie Pettibone, B.S., Rebecca J. Hoagland, M.S., and Henry F. Chambers, M.D. for the DMID 07-0051 Team

From the Los Angeles Biomedical Research Institute (L.G.M., S.J.E.) and Division of Infectious Diseases, Harbor–UCLA (University of California, Los Angeles) Medical Center (L.G.M., S.J.E.), Torrance, David

Geffen School of Medicine at UCLA, Los Angeles (L.G.M., S.J.E.), Division of Plastic and Reconstructive Surgery, University of California, San Francisco (UCSF) (D.Y.), and Division of Infectious Diseases, San Francisco General Hospital and UCSF (M.D.D., H.F.C.), San Francisco — all in California; Division of Pediatric Infectious Diseases, University of Chicago, Chicago (R.S.D.); Division of Pediatric Infectious Diseases, Vanderbilt University, Nashville (C.B.C.); the EMMES Corporation, Rockville, MD (S.P.); and Cota Enterprises, Meriden, KS (R.J.H.). Address reprint requests to Dr. Miller at the Division of Infectious Diseases, Harbor–UCLA Medical Center, 1000 W. Carson St., Box 466, Torrance, CA 90509, or at lgmiller@ ucla.edu    

BACKGROUND

Skin and skin-structure infections are common in ambulatory settings. However, the efficacy of various antibiotic regimens in the era of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is unclear.

METHODS

We enrolled outpatients with uncomplicated skin infections who had cellulitis, abscesses larger than 5 cm in diameter (smaller for younger children), or both. Patients were enrolled at four study sites. All abscesses underwent incision and drainage. Patients were randomly assigned in a 1:1 ratio to receive either clindamycin or trimethoprim–sulfamethoxazole (TMP-SMX) for 10 days. Patients and investigators were unaware of the treatment assignments and microbiologic test results. The primary outcome was clinical cure 7 to 10 days after the end of treatment.

RESULTS

A total of 524 patients were enrolled (264 in the clindamycin group and 260 in the TMP-SMX group), including 155 children (29.6%). One hundred sixty patients (30.5%) had an abscess, 280 (53.4%) had cellulitis, and 82 (15.6%) had mixed infection, defined as at least one abscess lesion and one cellulitis lesion. S. aureus was isolated from the lesions of 217 patients (41.4%); the isolates in 167 (77.0%) of these patients were MRSA. The proportion of patients cured was similar in the two treatment groups in the intention-to-treat population (80.3% in the clindamycin group and 77.7% in the TMP-SMX group; difference, −2.6 percentage points; 95% confidence interval [CI], −10.2 to 4.9; P=0.52) and in the populations of patients who could be evaluated (466 patients; 89.5% in the clindamycin group and 88.2% in the TMP-SMX group; difference, −1.2 percentage points; 95% CI, −7.6 to 5.1; P=0.77). Cure rates did not differ significantly between the two treatments in the subgroups of children, adults, and patients with abscess versus cellulitis. The proportion of patients with adverse events was similar in the two groups.

CONCLUSIONS

We found no significant difference between clindamycin and TMP-SMX, with respect to either efficacy or side-effect profile, for the treatment of uncomplicated skin infections, including both cellulitis and abscesses. (Funded by the National Institute of Allergy and Infectious Diseases and the National Center for Advancing Translational Sciences, National Institutes of Health; ClinicalTrials.gov number, NCT00730028.)

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1403789

May 16, 2015 at 11:44 am

Management of Skin Abscesses in the Era of Methicillin-Resistant Staphylococcus aureus

N Engl J Med March 13, 2014 V.370 P.1039-1047

REVIEW ARTICLE

Adam J. Singer, M.D., and David A. Talan, M.D.

From the Department of Emergency Medicine, Stony Brook University, Stony Brook, NY (A.J.S.); the Departments of Emergency Medicine and Medicine, Division of Infectious Diseases, Olive View–UCLA Medical Center, Sylmar, CA (D.A.T.); and the David Geffen School of Medicine at UCLA, Los Angeles (D.A.T.).

Address reprint requests to Dr. Singer at the Department of Emergency Medicine, Stony Brook University, HSC-L4-080, Stony Brook, NY 11794-8350, or at adam.singer@stonybrook.edu

Abscesses are one of the most common skin conditions managed by general practitioners and emergency physicians.

The incidence of skin abscesses has increased, and this increase has coincided with the emergence of community-associated methicillin-resistant Staphylococcus aureus (MRSA).

In many parts of the world, MRSA infections are now the most common cause of skin abscesses.6 Community-associated MRSA has also been found to cause severe infections — including necrotizing pneumonia, necrotizing fasciitis, purpura fulminans, and severe sepsis — in nonimmunocompromised hosts; however, its apparently increased virulence as compared with that of health care–associated strains and methicillin-susceptible S. aureus is incompletely understood.

Along with the increases in the incidence of skin abscesses and MRSA infections, other changes that potentially affect abscess care have occurred. Bedside ultrasonography has become increasingly available in emergency departments and hospitals. Traditional surgical practices have been systematically tested, and new techniques developed.

Prevention strategies have also been investigated. Despite these changes, the management of skin abscesses is highly variable……

PDF

http://www.nejm.org/doi/pdf/10.1056/NEJMra1212788

 

May 16, 2015 at 11:42 am

Treatment of acute periprosthetic infections with prosthesis retention: Review of current concepts.

World J Orthop. 2014 Nov 18;5(5):667-76.

Kuiper JW1, Willink RT1, Moojen DJ1, van den Bekerom MP1, Colen S1.

1Jesse WP Kuiper, Center for Orthopaedic Research Alkmaar, Medical Center Alkmaar, 1815 JD, Alkmaar, The Netherlands.

Abstract

Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty, occurring in approximately 1%-2% of all cases.

With growing populations and increasing age, PJI will have a growing effect on health care costs.

Many risk factors have been identified that increase the risk of developing PJI, including obesity, immune system deficiencies, malignancy, previous surgery of the same joint and longer operating time.

Acute PJI occurs either postoperatively (4 wk to 3 mo after initial arthroplasty, depending on the classification system), or via hematogenous spreading after a period in which the prosthesis had functioned properly.

Diagnosis and the choice of treatment are the cornerstones to success. Although different definitions for PJI have been used in the past, most are more or less similar and include the presence of a sinus tract, blood infection values, synovial white blood cell count, signs of infection on histopathological analysis and one or more positive culture results.

Debridement, antibiotics and implant retention (DAIR) is the primary treatment for acute PJI, and should be performed as soon as possible after the development of symptoms. Success rates differ, but most studies report success rates of around 60%-80%. Whether single or multiple debridement procedures are more successful remains unclear.

The use of local antibiotics in addition to the administration of systemic antibiotic agents is also subject to debate, and its pro’s and con’s should be carefully considered. Systemic treatment, based on culture results, is of importance for all PJI treatments. Additionally, rifampin should be given in Staphylococcal PJIs, unless all foreign material is removed.

The most important factors contributing to treatment failure are longer duration of symptoms, a longer time after initial arthroplasty, the need for more debridement procedures, the retention of exchangeable components, and PJI caused by Staphylococcus (aureus or coagulase negative).

If DAIR treatment is unsuccessful, the following treatment option should be based on the patient health status and his or her expectations. For the best functional outcome, one- or two-stage revision should be performed after DAIR failure.

In conclusion, DAIR is the obvious choice for treatment of acute PJI, with good success rates in selected patients

PDF

http://www.wjgnet.com/2218-5836/pdf/v5/i5/667.pdf

May 15, 2015 at 1:22 pm

Direct susceptibility testing by disk diffusion on clinical samples: a rapid and accurate tool for antibiotic stewardship

Europ J of Clinical Microb & ID V.34 N.6 June 2015

Coorevits, J. Boelens, G. Claeys

PDF

http://download-v2.springer.com/static/pdf/38/art%253A10.1007%252Fs10096-015-2349-2.pdf?token2=exp=1431364453~acl=%2Fstatic%2Fpdf%2F38%2Fart%25253A10.1007%25252Fs10096-015-2349-2.pdf*~hmac=b75f3c2392bf1716cc60b327c79a5017648ee7afa86bcf1bef1f79fd8634562a

May 11, 2015 at 2:02 pm

Duration of Colonization With Methicillin-Resistant Staphylococcus aureus: A Question With Many Answers

Clin Infect Dis. (2015) 60 (10): 1497-1499

Editorial Commentary

Michael S. Calderwood

Emergency room visits and hospital admissions for skin and soft tissue infections (SSTIs) have been increasing [1, 2], with a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) cultured from the site of infection [3]. By recent estimates, approximately 7% of patients in US hospitals are colonized with MRSA [4]. This includes an increase in colonization with community-acquired strains commonly associated with SSTIs [5, 6].

According to the Society for Healthcare Epidemiology of America, the duration of colonization remains an unresolved issue [7]. Data have shown that individuals remain at increased risk of MRSA infection and death until they are no longer colonized [8]. However, there is a wide range of estimates for the median time to clearance, ranging from 7 to 9 months [9–11] to well beyond a year [12–14]. Thus, many US hospitals recommend waiting 6 months or more prior to screening for clearance of MRSA colonization [15].

In this issue of Clinical Infectious Diseases, the study by Cluzet et al adds to the debate on the duration of MRSA colonization, looking at clearance following diagnosis of an SSTI with a positive MRSA culture [16]. In this longitudinal sampling study, MRSA surveillance cultures were collected from nares, axilla, and groin every 2 weeks for up to 6 months on both index cases and their household members. The first finding of interest was a median duration of MRSA …

PDF

http://cid.oxfordjournals.org/content/60/10/1497.full.pdf+html

May 8, 2015 at 1:13 pm

Ceftolozane/Tazobactam Plus Metronidazole for Complicated Intra-abdominal Infections in an Era of Multidrug Resistance: Results From a Randomized, Double-Blind, Phase 3 Trial (ASPECT-cIAI)

Clin Infec Dis May 15, 2015 V.60 N.10 P.1462-1471

Joseph Solomkin, Ellie Hershberger, Benjamin Miller, Myra Popejoy, Ian Friedland, Judith Steenbergen, Minjung Yoon, Sylva Collins, Guojun Yuan, Philip S. Barie, and Christian Eckmann

1Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio

2Cubist Pharmaceuticals, Lexington, Massachusetts

3Departments of Surgery and Medicine, Weill Cornell Medical College, New York, New York

4Department of General, Visceral and Thoracic Surgery, Academic Hospital of Medical University Hannover, Peine, Germany

Correspondence: Joseph Solomkin, MD, Department of Surgery, University of Cincinnati College of Medicine, 6005 Given Rd, Cincinnati, Ohio 45243 (solomkjs{at}ucmail.uc.edu) . 

Background

Increasing antimicrobial resistance among pathogens causing complicated intra-abdominal infections (cIAIs) supports the development of new antimicrobials. Ceftolozane/tazobactam, a novel antimicrobial therapy, is active against multidrug-resistant Pseudomonas aeruginosa and most extended-spectrum β-lactamase (ESBL)–producing Enterobacteriaceae.

Methods

ASPECT-cIAI (Assessment of the Safety Profile and Efficacy of Ceftolozane/Tazobactam in Complicated Intra-abdominal Infections) was a prospective, randomized, double-blind trial. Hospitalized patients with cIAI received either ceftolozane/tazobactam (1.5 g) plus metronidazole (500 mg) every 8 hours or meropenem (1 g) every 8 hours intravenously for 4–14 days. The prospectively defined objectives were to demonstrate statistical noninferiority in clinical cure rates at the test-of-cure visit (24–32 days from start of therapy) in the microbiological intent-to-treat (primary) and microbiologically evaluable (secondary) populations using a noninferiority margin of 10%. Microbiological outcomes and safety were also evaluated.

Results

Ceftolozane/tazobactam plus metronidazole was noninferior to meropenem in the primary (83.0% [323/389] vs 87.3% [364/417]; weighted difference, −4.2%; 95% confidence interval [CI], −8.91 to .54) and secondary (94.2% [259/275] vs 94.7% [304/321]; weighted difference, −1.0%; 95% CI, −4.52 to 2.59) endpoints, meeting the prespecified noninferiority margin. In patients with ESBL-producing Enterobacteriaceae, clinical cure rates were 95.8% (23/24) and 88.5% (23/26) in the ceftolozane/tazobactam plus metronidazole and meropenem groups, respectively, and 100% (13/13) and 72.7% (8/11) in patients with CTX-M-14/15 ESBLs. The frequency of adverse events (AEs) was similar in both treatment groups (44.0% vs 42.7%); the most common AEs in either group were nausea and diarrhea.

Conclusions

Treatment with ceftolozane/tazobactam plus metronidazole was noninferior to meropenem in adult patients with cIAI, including infections caused by multidrug-resistant pathogens.

Clinical Trials Registration.NCT01445665 and NCT01445678.

PDF

http://cid.oxfordjournals.org/content/60/10/1462.full.pdf+html

April 30, 2015 at 2:16 pm

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