Discrepancy between antibiotics administered in acute exacerbations of chronic bronchitis and susceptibility of isolated pathogens in respiratory samples: multicentre study in the primary care setting.

A national multicentre prevalence study was undertaken to determine the bacterial strains associated with mild-to-moderate acute exacerbations of chronic bronchitis (AECB) in the primary care setting and the susceptibility of isolated pathogens to different antimicrobials usually prescribed to these patients. All samples were processed by a central reference laboratory. Microdilution tests were carried out to establish the minimum inhibitory concentration (MIC) of various antimicrobials. A double-disk test was performed to establish the macrolide resistance phenotype in Streptococcus pneumoniae. Tests to detect the presence of beta-lactamase in Haemophilus influenzae and Moraxella catarrhalis and polymerase chain reaction to detect the presence of ermB and mefA genes in S. pneumoniae isolates were also performed. A total of 1537 patients were included in the trial and 468 microorganisms were isolated from sputum samples, with the most frequent isolates being S. pneumoniae (34.8%), M. catarrhalis (23.9%) and H. influenzae (12.6%). Resistance rates of pneumococci were 47.2% for penicillin, 1.2% for amoxicillin, 34.3% for macrolides (87.5% of which showed high-level resistance), 13.6% for cefuroxime/axetil and 4.2% for levofloxacin. No bacterial isolates showed resistance to telithromycin. Empirical antibiotic treatment was prescribed to 98.3% of patients, including macrolides to 36.6%, amoxicillin with or without clavulanic acid to 32.3% and fluoroquinolones to 16.1%. In conclusion, S. pneumoniae was the most frequently isolated bacteria in patients with mild-to-moderate AECB. Despite the high rates of resistance of pneumococci to macrolides, they continue to be the most widely used antibiotics in primary care to treat AECB.

Study of the in vitro susceptibility of M. tuberculosis to ofloxacin in Spain. Spanish Study Group of M. tuberculosis resistance.

The aim of this study was to determine the proportion of antituberculosis ofloxacin resistance among Mycobacterium tuberculosis strain isolates in Spain. Over a period of one month, 213 M. tuberculosis strains collected from 14 different hospitals were studied, including strains both susceptible and resistant to primary antituberculosis drugs. In 28.1% of the strains, a minimum inhibitory concentration (MIC) for ofloxacin of 0.25 microg/ml was obtained; in 43.6% the MIC was 0.5 microg/ml; in 22.06% it was 1 microg/ml; and in 6.1% it was > or =2 microg/ml. Ofloxacin currently seems to be an effective antimicrobial in vitro against susceptible or multiresistant strains of M. tuberculosis in human immunodeficiency virus (HIV)-negative or HIV-positive patients in Spain.

[Profile of bacterial isolates and antimicrobial susceptibility: Multicenter study using a one-day cut-off]. / Perfil de aislamientos bacterianos y sensibilidad antimicrobiana. Estudio multicéntrico mediante corte de un día.

The frequency and antimicrobial susceptibility of bacterial isolates from the largest clinical samples collected in 19 Spanish hospitals were studied. A total of 523 strains were identified and grouped by sample. Blood stream: Staphylococcus coagulase-negative (41%) and Escherichia coli (19.7%); oxacillin resistance occurred in 44% of coagulase-negative strains, strains which were also resistant to nonbetalactam agents. All antimicrobial agents tested had good activity against E. coli, with the exception of penicillins (25 to 33% susceptible). Urine: E. coli (59.1%) and Enterococcus faecalis (15%); aminoglycosides and third generation cephalosporins were the most active compounds against E. coli, whereas penicillins and cotrimoxazole were the least active. E. faecalis isolates showed low rates of resistance to the antibiotics tested and no glycopeptide-resistant strains were detected. Skin and soft tissues: Staphylococcus aureus (24.1%), Pseudomonas aeruginosa (17.7.%); oxacillin resistance occurred in 15.8% of S. aureus strains and co-resistance to nonbetalactam agents was frequently observed among these strains. Ceftazidime susceptibility was elevated among P. aeruginosa (76.9%) and the most active agents were aminoglycosides (100% susceptibility). Lower respiratory tract: P. aeruginosa (21.4%) and Haemophilus influenzae (15.5%). Aminoglycosides (88.8 to 94.4%) and ceftazidime (72%) presented the highest susceptibility rates in P. aeruginosa. All the agents tested were very active against H. influenzae (89% susceptibility). Among Gram-positive cocci, no vancomycin and/or teicoplanin-resistant strains were detected.

[Multicenter study of resistance in enterococci. The role of teicoplanin. Spanish Group for Study and Surveillance of Resistance]. / Estudio multicéntrico de resistencias en enterococos. Papel de la teicoplanina. Grupo Espãnol de Estudio y Vigilancia de Resistencias.

Enterococci are a frequent cause of nosocomial and community infections, especially the E. faecalis and E. faecium species. They often show intrinsic resistance to cephalosporins and quinolones, and acquired resistance to other antimicrobials, such as glycopeptides, has also been described. In order to test the impact of antibiotic resistance in enterococci isolated from infections, we carried out a multicenter study in 19 hospitals in Spain. We verified whether resistance to a high concentration of aminopenicillins and aminoglycosides was high (30.86% for ampicillin, 32.32% for gentamicin at a 500 micrograms dose, 55.93% for streptomycin at a 1000 micrograms dose) while the resistance to glycopeptides was low (1.8% for vancomycin and 1% for teicoplanin). It was also shown that teicoplanin had greater intrinsic activity than vancomycin, with teicoplanin 0.5 mg/l inhibiting 86.1% of the strains studied, whereas only 12.8% were inhibited with the same concentration of vancomycin.

[Pharmacoeconomic analysis of community-acquired pneumonia treatment with telithromycin or clarithromycin]. / Analisis farmacoeconomico del tratamiento de la neumonia adquirida en la comunidad con telitromicina o claritromicina.

A pharmacoeconomic analysis was carried out comparing the efficacy of two treatment options for community-acquired pneumonia (CAP): telithromycin and clarithromycin. It was a retrospective analysis using a decision tree model. The efficacy of the two treatment options was estimated from a randomized, double-blind clinical trial, in which 800 mg/day oral telithromycin for 10 days was compared to 1000 mg/day oral clarithromycin for 10 days in patients with CAP (162 and 156 respectively). The use of resources was estimated based on the clinical trial and Spanish sources, and the unit costs from a Spanish health costs database. Costs were evaluated for the acquisition of antibiotic treatments, change of antibiotic due to therapeutic failure, hospital admissions, adverse reactions to treatment, primary care visits, tests and indirect costs (working days lost). The model was validated by a panel of Spanish clinical experts. As the clinical trial was designed to show equivalence, there were no significant differences in efficacy between the treatment options (clinical cure rate 88.3% and 88.5%, respectively), and a cost minimization analysis was performed. In the base case, the average cost of the disease per patient was 308.29 euros with telithromycin and 331.5 euros with clarithromycin (a difference of 23.21 euros). The results were stable in the susceptibility analysis, with differences favorable to telithromycin ranging between 5.50 and 45.45 euros. Telithromycin results in a cost savings of up to 45.45 euros per CAP patient compared to clarithromycin.

Bacteriological conversion in twenty urinary tuberculosis patients treated with ofloxacin, rifampin and isoniazid: a 10-year follow-up study.

Twenty patients with urinary tuberculosis were treated with ofloxacin (200 mg/day, 6 months), rifampin (600 mg/day, 3 months) and isoniazid (300 mg/day, 3 months) between 1989 and 1990. All patients were new cases, diagnosed by observation and/or isolation of Mycobacterium tuberculosis in one of the three morning urine samples. Bacteriological culture conversion (negativization) was assessed as a clinical guide of efficacy, comparing it, as the only parameter, against a control group (150 patients) with urinary tuberculosis who received conventional therapy. Bacteriological follow-up studies were performed in both groups monthly for 6 months, then again 6 months later and then every year for 10 years after completion of treatment. In the 20 patients, the initial culture was positive with over 100 colonies per culture (>50%); the smear was positive in 45% of the patients (most were 2+). All strains were susceptible to rifampin, isoniazid and ofloxacin. Two patients discontinued treatment. Beginning with the first month of treatment, the bacteriological conversion was 100%, 89.5% and 100% in the remaining controls. In the control group, which received conventional treatment, the conversion was: 90%, 87%, 93% and 100% in the remaining controls. Treatment with ofloxacin resulted in a bacteriological conversion similar to that following conventional treatment ( p>0.05, Fisher's exact test). After 10 years of patient follow-up, we conclude that ofloxacin, in combination with rifampin and isoniazid (both for 3 months only is effective against M. tuberculosis, providing satisfactory bacteriological and clinical efficacy.

[Pharmacoeconomic analysis of patients with acute exacerbation of chronic bronchitis treated with telithromycin or cefuroxime-axetil]. / Análisis farmacoeconómico del tratamiento de pacientes con exacerbación aguda de la bronquitis crónica con telitromicina o cefuroxima-axetilo.

INTRODUCTION: A pharmacoeconomic analysis was done to compare the efficiency of two treatments in the acute exacerbation of chronic bronchitis: telithromycin and cefuroxime-axetil. METHODS: Restrospective analysis, modeled through a decision tree. The effectiveness of the treatments was estimated through a randomized and double-blind clinical trial in which 800 mg/day (5 days) of telithromycin were compared with 1,000 mg/day (10 days) of cefuroxime-axetil in patients with acute exacerbation of chronic bronchitis (140 and 142 patients, respectively). Resources use was estimated from clinical trial and from Spanish data, and the unit costs through a health costs dabatase. The model was validated by a panel of Spanish clinical experts. RESULTS: Since the clinical trial was designed to demonstrate equivalence, there were no significant differences of effectiveness among both treatments (with a rate of clinical cure of 86.4% and 83.1%, respectively) which means that an analysis of costs minimization was done. In the average case, the average cost of the disease by patient was 174.83 Euros with telithromycin and 194.68 Euros with cefuroxime-axetil (a difference of 19.85 Euros). The results were maintained in the analysis of sensitivity, with favorable differences for telithromycin that ranged between 18.04 Euros and 22.25 Euros. CONCLUSIONS: With telithromycin up to 22 Euros by patient with acute exacerbation of chronic bronchitis could be saved, in comparison with cefuroxime-axetil.

Capacidad de la tomografía de coherencia óptica (OCT), láser confocal de barrido (HRT-II) y polarimetría láser (GDx) en la detección de daño estructural en el glaucoma crónico simple / Diagnostic usefulness of optical coherence tomography (OCT), scanning laser tomography (HRT-II) and laser polarimetry (GDx) in open-angle glaucoma

Objetivos: Evaluar la capacidad diagnóstica de tres técnicas de análisis digital de imagen (OCT, HRT-II y GDx VCC) para detectar la presencia de daño glaucomatoso. Material y métodos: Se incluyeron en este estudio transversal un total de 427 ojos de 427 sujetos, que fueron clasificados en normales, hipertensos oculares y glaucomatosos según sus cifras de presión intraocular, perimetría automatizada convencional y morfología de la cabeza del nervio óptico. A todos ellos se les realizó una exploración mediante HRT, OCT y GDx. Se trazaron las curvas ROC de cada parámetro y se calcularon los niveles de sensibilidad para especificidades prefijadas en el 85% y el 95%. Resultados: Los parámetros que proporcionaron mayor rentabilidad diagnóstica fueron la función discriminante FSM del HRT-II (AUC=0,899), el espesor medio de la capa de fibras nerviosas de la retina del OCT (AUC=0,929) y el NFI (AUC=0,879), sin detectarse diferencias estadísticamente significativas entre ellos. Conclusión: El HRT-II, el OCT y el GDx VCC proporcionan parámetros morfométricos de la capa de fibras nerviosas de la retina y de la cabeza del nervio óptico con una elevada capacidad discriminativa en la enfermedad glaucomatosa

Purpose: To evaluate the diagnostic ability of three digital imaging technologies (HRT-II, OCT and GDx VCC) in detecting glaucomatous damage. Methods: A total of 427 eyes from 427 subjects were included in this cross-sectional study. Each subject was classified as healthy, ocular hypertensive or glaucomatous, according to intraocular pressure levels, standard automated perimetry and optic disc morphology. All of them underwent examination by means of HRT, OCT and GDx VCC. Receiver operating characteristic (ROC) curves were plotted and sensitivities at fixed specificities (85% and 95%) were calculated for each parameter assessed. Results: The parameters with the higher diagnostic ability were: FSM discriminant function from HRTII (AUC=0.899), retinal nerve fiber layer average thickness from OCT (AUC=0.929) and NFI from GDx VCC (AUC=0.879), with no statistically significant differences between them. Conclusion: The HRT-II, OCT and GDx VCC provide measurements of the retinal nerve fiber layer and the optic nerve head with high discriminating ability in open-angle glaucoma

Faringoamigdalitis aguda. Papel de la telitromicina / Acute pharyngoamygdalitis: The role of telithromycin

La infección respiratoria es una de las principales causas de consulta urgente en Atención Primaria y en los servicios de urgencias hospitalarios. La faringoamigdalitis es el segundo diagnóstico más frecuente (20,4 por ciento) por detrás del catarro común. En cuanto a la etiología, los agentes responsables más frecuentes son los virus. Dentro de las bacterias el microorganismo más frecuentemente involucrado es el estreptococo betahemolítico del grupo A o Streptococcus pyogenes. El tratamiento antibiótico de elección de la faringoamigdalitis estreptocócica sigue siendo en la actualidad la penicilina y sus derivados. En diversas publicaciones se han comunicado fracasos terapéuticos con dicha medicación. Las cifras oscilan entre el 10 y el 30 por ciento. Los macrólidos han constituido el tratamiento alternativo de la faringoamigdalitis en aquellos pacientes alérgicos a los beta-lactámicos. También se han recomendado en los casos de fracaso con penicilina. Se han ido encontrando en la década de los 90, incrementos importantes de resistencias a los macrólidos que oscilan entre el 42 por ciento de Polonia y el 0 por ciento de Austria. En España se ha detectado en los últimos años un aumento progresivo de la resistencia a los macrólidos en S. pyogenes con porcentajes comprendidos entre un 20 y 40 por ciento. El incremento de las resistencias a macrólidos constituye un problema terapéutico importante en los pacientes alérgicos a la penicilina, lo que hace necesario la búsqueda de nuevos agentes eficaces como alternativas. Telitromicina pertenece a una nueva familia de antibióticos, los ketólidos, los cuales debido a su nueva estructura química no inducen resistencia cruzada con los antibióticos del grupo MLSB y tienen buena actividad frente a las cepas con el fenotipo de resistencia MLSB. Presenta patrones farmacocinéticos superiores a los de los macrólidos. Se absorbe rápidamente y su penetración en tejidos es superior a la de los betalactámicos. Posee un patrón microbiológico de erradicación de los microorganismos más frecuentemente implicados en la infección respiratoria excelente y es bactericida frente a los mismos. La eficacia clínica observada en los estudios de fase IIIb, todos ellos doble ciego y comparativos frente a la terapia estándar, fue superior al 90 por ciento en la visita del test de curación. Por lo tanto, la utilización de este nuevo antibiótico en el tratamiento de la faringoamigdalitis producida por S. pyogenes se basa en: su potente actividad in vitro frente a S. pyogenes, su perfil farmacocinético que asegura el mantenimiento de concentraciones elevadas en amígdalas y saliva, su comodidad posológica que facilita el cumplimiento, la resolución más rápida de los síntomas que penicilina V y su eficacia y seguridad mostrada en los ensayos clínicos (AU)

Perfil de aislamientos bacterianos y sensibilidad antimicrobiana. Estudio multicéntrico mediante corte de un día / Profile of bacterial isolates and antimicrobial susceptibility: Multicenter study using a one-day cut-off

Se estudió la representatividad de los distintos aislamientos bacterianos de muestras clínicas y su sensibilidad a diferentes antimicrobianos en 19 hospitales españoles mediante corte de un día. En total se identificaron 523 bacterias, que se agruparon según la muestra. Hemocultivos: estafilococos coagulasa negativos (41 por ciento) y Escherichia coli (19,7 por ciento); el 44 por ciento de los estafilococos coagulasa negativos fueron resistentes a la meticilina, presentando resistencia asociada a prácticamente todos los antibióticos no betalactámicos, y las cepas de E. coli presentaron una buena sensibilidad a todos los antibióticos excepto a las penicilinas (25 por ciento a 33 por ciento). Orina: E. coli (59,1 por ciento) y Enterococcus faecalis (15 por ciento); para E. coli los porcentajes más altos de sensibilidad se obtuvieron con aminoglucósidos y cefalosporinas de tercera generación, mientras que los más bajos fueron para cotrimoxazol y penicilinas, y para E. faecalis la resistencia fue muy baja y nula para los glucopéptidos. Piel y tejidos blandos: Staphylococcus aureus (24,1 por ciento) y Pseudomonas aeruginosa (17,7 por ciento); el 15,8 por ciento de las cepas de S. aureus fueron resistentes a meticilina y presentaron resistencia asociada a los no betalactámicos, y las cepas de P. aeruginosa mantuvieron una buena sensibilidad a la ceftazidima (76,9 por ciento) y excelente a los aminoglucósidos (100 por ciento). Vías respiratorias bajas: P. aeruginosa (21,4 por ciento) y Haemophilus influenzae (15,5 por ciento); las mayores tasas de sensibilidad en P. aeruginosa se obtuvieron con los aminoglucósidos (88,8 por ciento a 94,4 por ciento), seguidos de la ceftazidima (72,2 por ciento), y H. influenzae presentó unos porcentajes de sensibilidad superiores al 89 por ciento con todos los antibióticos. Todos los aislamientos de cocos grampositivos estudiados fueron sensibles a vancomicina y teicoplanina. (AU)

Bacteriological conversion in twenty urinary tuberculosis patients treated with ofloxacin, rifampin and isoniazid: a 10-year follow-up study

Twenty patients with urinary tuberculosis were treated with ofloxacin (200 mg/day, 6 months), rifampin (600 mg/day, 3 months) and isoniazid (300 mg/day, 3 months) between 1989 and 1990. All patients were new cases, diagnosed by observation and/or isolation of Mycobacterium tuberculosis in one of the three morning urine samples. Bacteriological culture conversion (negativization) was assessed as a clinical guide of efficacy, comparing it, as the only parameter, against a control group (150 patients) with urinary tuberculosis who received conventional therapy. Bacteriological follow-up studies were performed in both groups monthly for 6 months, then again 6 months later and then every year for 10 years after completion of treatment. In the 20 patients, the initial culture was positive with over 100 colonies per culture (>50%); the smear was positive in 45% of the patients (most were 2+). All strains were susceptible to rifampin, isoniazid and ofloxacin. Two patients discontinued treatment. Beginning with the first month of treatment, the bacteriological conversion was 100%, 89.5% and 100% in the remaining controls. In the control group, which received conventional treatment, the conversion was: 90%, 87%, 93% and 100% in the remaining controls. Treatment with ofloxacin resulted in a bacteriological conversion similar to that following conventional treatment ( p>0.05, Fisher's exact test). After 10 years of patient follow-up, we conclude that ofloxacin, in combination with rifampin and isoniazid (both for 3 months only is effective against M. tuberculosis, providing satisfactory bacteriological and clinical efficacy (AU)

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La infección respiratoria en los servicios de urgencias hospitalarios. Estudio DIRA / Respiratory tract infection in hospitalary emergency outpatient clinics: the DIRA study

La infección respiratoria (IR) es uno de los motivos de consulta más frecuentes en los servicios de urgencia hospitalaria (SUH), en los que constituye la infección más diagnosticada. Objetivos: 1. Estudiar la prevalencia y formas de presentación de la IR en urgencias. 2. Conocer las prácticas actuales de manejo de la IR en los SUH. Metodología: Se analizaron prospectivamente en los SUH de 50 hospitales repartidos por toda España las IR atendidas los días 21 de octubre de 1998, 21 de enero, de abril y de julio de 1999 recogiéndose los datos epidemiológicos y clínicos y de manejo de la infección en un cuestionario. Los datos recogidos fueron analizados mediante el análisis de varianza (ANOVA) en variables continuas y test de chi cuadrado en comparación de proporciones. Se utilizó el programa estadístico SPSS v 9.0.Resultados: Se recogieron datos de 1.248 pacientes mayores de 14 años, de los cuales 737 eran varones (59,1 por ciento); la edad media fue de 58,5 años (DS 22,8). El 63,9 por ciento de los enfermos padecían una enfermedad de base. El diagnóstico más frecuente fue bronquitis aguda (28,4 por ciento), seguido de neumonía (22,1 por ciento) y agudización de EPOC (20,4 por ciento). No se observaron diferencias en cuanto al destino final del enfermo o el uso de antibióticos. Un 81 por ciento de los enfermos fueron tratados con antibióticos, siendo el más utilizado en todos los cortes amoxicilina-clavulánico. Un tercio de los enfermos (416) ingresaron; de ellos el 51 por ciento padecía una neumonía, un 27 por ciento una agudización de EPOC y un 19 por ciento una bronquitis aguda. Conclusiones: 1) La IR más frecuente en los SUH es la bronquitis aguda, lo que sugiere una utilización inadecuada del SUH. 2) La mayoría de las IR son tratadas con antibióticos. 3) Los hábitos de manejo de la IR no varían significativamente en las cuatro estaciones del año (AU)

Análisis farmacoeconómico del tratamiento de la neumonía adquirida en la comunidad con telitromicina o claritromicina / Pharmacoeconomic analysis of community-acquired pneumonia treatment with telithromycin or clarithromycin

Se realizó un análisis farmacoeconómico para comparar la eficiencia de dos tratamientos en la neumonía adquirida en la comunidad: telitromicina y claritromicina. El estudio fue retrospectivo, modelizado mediante un árbol de decisiones. La eficacia de los tratamientos se estimó a partir de un ensayo clínico, aleatorizado y doble ciego, en el que se compararon 800 mg/día de telitromicina oral (10 días) con 1000 mg/día de claritromicina oral (10 días) en pacientes con neumonía adquirida en la comunidad (162 y 156, respectivamente). La utilización de recursos se estimó a partir del ensayo clínico y de fuentes españolas, y los costes unitarios mediante una base de datos de costes sanitarios. El modelo fue validado por un panel de expertos españoles. Como el ensayo clínico se diseñó para demostrar equivalencia, no hubo diferencias significativas de eficacia entre los tratamientos (con una tasa de curación clínica del 88,3 por ciento y el 88,5 por ciento, respectivamente), por lo que se hizo un análisis de minimización de costes. En el caso base, el coste medio de la enfermedad por paciente fue de 308,29 euros con telitromicina y de 331,5 euros con claritromicina (diferencia de 23,21 euros). Los resultados fueron estables en el análisis de sensibilidad, con diferencias favorables a telitromicina que oscilaron entre 5,50 y 45,45 euros. Un mayor coste de adquisición no implica necesariamente un mayor coste de la enfermedad. Con telitromicina se podría ahorrar hasta 45,45 euros por paciente con neumonía de adquisición en la comunidad, en comparación con claritromicina (AU)