Ceftazidime/avibactam-resistant meropenem-susceptible KPC-producing Klebsiella pneumoniae: Analysis of cases and evaluation of in vitro activity of fosfomycin-containing combinations.

OBJECTIVES: Little is known regarding outcomes and optimal therapeutic regimens of infections caused by Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae (KPC-Kp) resistant to ceftazidime/avibactam (CZA) and susceptible to meropenem (MEM). Although susceptible to MEM in vitro, the possibility of developing MEM resistance overtime is a concern. We describe the clinical characteristics of patients with colonization/infection due to KPC variants with a focus on the in vitro activity of fosfomycin (FOS)-containing combinations. METHODS: Patients with colonization/infection due to a KPC variant were included. Fosfomycin susceptibility was performed by agar dilution method. Synergistic activity of FOS-based combinations was evaluated by gradient strip-agar diffusion method. The emergence of in vitro MEM resistance was also tested. RESULTS: Eleven patients were included: eight with infection [four with ventilator-associated pneumonia and four with bloodstream infections] and three with colonization. Previous therapy with CZA was administered to all patients (with a mean cumulative duration of 23 days). All subjects with infection received meropenem, in monotherapy (n = 4) or with amikacin (n = 2) or fosfomycin (n = 2), and achieved clinical cure. A new CZA-susceptible and MEM-resistant KPC-Kp strain was subsequently isolated in three patients (27.3%). Meropenem/vaborbactam (MVB) showed high in vitro activity, while FOS+MEM combination was synergistic in 40% of cases. In vitro resistance to MEM was observed with maintenance of CZA resistance. CONCLUSIONS: Detection of KPC variants may occur within the same patient, especially if CZA has been previously administered. Although clinical success has been obtained with carbapenems, the emergence of MEM resistance is a concern. Fosfomycin plus meropenem is synergistic and may be a valuable combination option for KPC variants, while MVB may be considered in monotherapy. The detection of KPC variants in an endemic setting for KPC-Kp represents a worryingly emerging condition. The optimal therapeutic approach is still unknown and the development of meropenem resistance is of concern, which may lead to therapeutic failure in clinical practice. In these cases, the addition of fosfomycin to meropenem, or a more potent antibiotic, such as meropenem/vaborbactam, may be valuable therapeutic options.

In vitro activity of fosfomycin against mucoid and non-mucoid Pseudomonas aeruginosa strains.

OBJECTIVES: Pseudomonas aeruginosa is the most frequent infectious agent in cystic fibrosis patients. P. aeruginosa resistance to first line antibiotics limits therapeutic options, but the therapeutic potential of older generation antibiotics, such as fosfomycin is under investigation. Fosfomycin does not belong to any other antibiotic class and acts by inhibiting the biosynthesis of the bacterial cell wall during the initial phases. A major problem for the use of fosfomycin against P. aeruginosa is the absence of a clinical breakpoint, the last one of 32 µg/mL was proposed in 2013 by the CA-SFM (Comité de l'Antibiogramme de la Société Française de Microbiologie). METHODS: Sixty-one strains of P. aeruginosa (thirty mucoid and thirty-one non mucoid) were collected from respiratory samples of cystic fibrosis patients. All isolates were identified by MALDI-TOF (Bruker, Bremen, Germany). Fosfomycin MICs against P. aeruginosa were measured using an automated system and confirmed by the gold standard method. RESULTS: There was no significant difference between mucoid and non-mucoid strains. MIC distribution and susceptibility rates were obtained by agar dilution method and from this data we measured MIC50 and MIC90 which were equal to 32 µg/mL and 64 µg/mL, respectively. From automated method results we measured a very major error (VME), major error (ME) and categorical agreement (CA) which were equal to 0%, 11% and 89%, respectively. Comparing automated and agar dilution methods, a Cohen's kappa equal to 73% (0.726) was measured. CONCLUSIONS: Our data suggest that fosfomycin has good effect against mucoid and non-mucoid strains of P. aeruginosa and automated systems can be implemented in clinical microbiology laboratories to assess fosfomycin with rapid and reproducible results.

How appropriate is the use of rehabilitation facilities? Assessment by an evaluation tool based on the AEP protocol.

BACKGROUND: During the last few decades, an increasing attention has been drawn to public health expenditure and resource use. The increasing aging population has highlighted the need to deliver post-acute care and to assess its appropriateness. The "PRUO rehab" (Protocollo di Revisione dell'Utilizzo dell'Ospedale riabilitativo) protocol was realized and validated to assess the appropriateness of use of rehabilitation units. The aims of this study were to test the validity of the PRUO-rehab tool and to analyse the causes for Inappropriate Hospital Stay (IPS) in rehabilitation units. METHODS: The PRUO rehab tool was retrospectively applied to the medical records of 502 patients who stayed at least overnight in one of ten different rehabilitation units set in Northern Italy, during 2007. RESULTS: The tool was valid and the inappropriate patient stay (IPS) score was 25.0%. CONCLUSION: Although reasonably low, the IPS indicates that the rehabilitation structures analysed could be used more efficiently.

Influence of post placement in the fracture resistance of endodontically treated incisors veneered with direct composite.

STATEMENT OF PROBLEM: Veneer preparations are considered to weaken endodontically treated maxillary incisors. Prefabricated posts have been controversially indicated to reinforce endodontically treated teeth before final restoration. PURPOSE: This in vitro study evaluated whether (1) veneer preparation in enamel or in enamel/dentin weakens endodontically treated maxillary incisors, (2) bonding of direct composite veneer restores the original strength of the unprepared teeth, and (3) use of prefabricated metal posts increases fracture resistance of prepared and restored teeth. MATERIAL AND METHODS: Ninety extracted human maxillary central incisors were submitted to conventional root canal treatment. Specimens were randomly divided into 8 experimental groups (veneer preparation in enamel or dentin with/without post and with/without direct composite veneer restoration) and a control group (n = 10). Specimens were loaded to fracture, and the data were analyzed statistically. RESULTS: Statistical analysis revealed that a conservative veneer preparation does not significantly reduce maxillary incisors' fracture resistance. For prepared incisors, bonding of direct composite veneer restored their original strength, and the use of posts did not increase their fracture resistance. CONCLUSION: Conservative veneer preparations involving enamel and enamel/dentin did not significantly reduce the fracture resistance of endodontically treated maxillary incisors. In addition, restoration of the intraenamel preparations with direct composite resulted in teeth more resistant to fracture than teeth having restorations in dentin. The use of posts did not improve fracture resistance of endodontically treated maxillary incisors reduced and veneered with direct composite.

The use of natural teeth to make removable partial prostheses and complete prostheses: case reports.

Human natural teeth were used in manufacturing two complete prostheses and two partial removable dentures in three patients. All four prostheses continue to function satisfactorily. The practitioner, by utilizing the patient's natural teeth in preference to artificial teeth, achieves an excellent means of solving the patient's esthetic problems.

Bicyclic compounds with potential antiulcer and/or antisecretory activity. II. 1(or 3),4,6,7-Tetrahydro-1(3)H-pyrano[3,4-d]imidazoles and 1(or 3),4,6,7-tetrahydro-1(3)H-thiopyrano[3,4-d]imidazoles.

Owing to our current interest in synthesizing and evaluating the antiulcer and antisecretory activity of bicyclic compounds, a series of 1(or 3),4,6,7-tetrahydropyrano- and 1(or 3),4,6,7-tetrahydrothiopyrano-[3,4-d]imidazoles was synthesized and tested. The biological results were compared with those of some previously described 4,5,6,7-tetrahydroimidazo-[4,5-c]pyridine and 4,5,6,7-tetrahydrobenzimidazole derivatives.

7-trans-(2-Pyridylethenyl)-5H-thiazolo[3,2-a]pyrimidine-5-ones: synthesis and pharmacological activity.

A series of 7-trans-(2-pyridylethenyl)-5H-thiazolo[3,2-a]pyrimidine-5-ones was synthesized and evaluated for their pharmacological activity. Some compounds were found to be effective in inhibiting restraint ulcers in the rat. Two of them also showed interesting antiinflammatory activity.

Bicyclic compounds with potential antiulcer and/or antisecretory activity. I. 4,5,6,7-Tetrahydrobenzimidazoles.

The remarkable antiulcer and antisecretory activity of some previously described 4,5,6,7-tetrahydroimidazo[4,5-c]pyridine derivatives prompted us to further investigate related bicyclic systems. Accordingly, a series of 5-amino- and 5-aminomethyl-4,5,6,7-tetrahydrobenzimidazoles, regiospecifically alkylated in position 1, were synthesized and tested. Only a few 1-ethyl-5-amino derivatives displayed a reasonable antiulcer activity in comparison with our former class of compounds.

New derivatives of pyrrolo and pyrido[2,1-b] quinazoline as antiulcer agents.

A series of 3-benzylidene-1,2,3,9-tetrahydro-9-oxopyrrolo-[2,1-b] quinazolinecarboxylic acids and 6-benzylidene-6,7,8,9-tetrahydro-11-oxo-11H-pyrido[2,1-b] quinazolinecarboxylic acid was synthesized and evaluated for their antiulcer activity by the test of inhibition of restraint ulcers in the rat, and for gastric antisecretory activity using the technique of Shay. Some compounds appear potentially useful for therapeutic application.

Anti-ulcer and antisecretory activity of selected imidazopiperidines.

New thioureas and ureas with an interesting anti-ulcer and antisecretory activity are disclosed. The chemical synthesis, determination of the structure, and structure-activity relationships of the compounds are discussed.

Antinociceptive, prolactin releasing and intestinal motility inhibiting activities of dermorphin and analogues after subcutaneous administration in the rat.

A series of analogues and shorter homologues of dermorphin (DM), a frog skin heptapeptide with potent morphine-like activity, have been assayed in the rat after subcutaneous (SC) administration at the screening dose of 4 mg/kg. The effects taken into account are: analgesia (tail-pinch test), stimulation of prolactin (PRL) secretion, and inhibition of gastro-intestinal (GI) motility (charcoal meal transit). Effective doses were calculated for the most active compounds. The potency of DM (H-Tyr-D-Ala-Phe-Gly-Tyr-Pro-Ser-NH2) in the different tests was: tail-pinch: ED50 = 0.83 mg/kg; PRL release: ED100 = 0.3 mg/kg; inhibition of GI motility: ED30 = 1.8 mg/kg.

Antihypertensive ergolinepropionamides.

The synthesis and the antihypertensive activity in rats of a series of 6-methylergolin-8 beta-yl-propionic acid derivatives are reported. The prolactin lowering activity (nidation inhibition test) in rats and the acute toxicity in mice were also studied as a measure of the specificity and safety of the potential antihypertensive compounds. From the structure-activity considerations reported here it is clear how modifications at the C8 side chain can improve the selectivity of the antihypertensive effects, whilst introducing substituents in other positions of the ergoline skeleton afforded unfavourable results in this respect. Compound 5, namely 2(R,S)-cyano-3-(6-methylergolin-8 beta-yl)-propionamide, emerged as the most interesting antihypertensive derivative.

[A review of pharmacological studies on nicergoline]. / Ubersicht über pharmokologische Studien mit Nicergolin.

10-Methoxy-1,6-dimethyl-ergoline-8 beta-methanol-(5-bromonicotinate) (nicergoline, Sermion) shows a strong alpha-blocking activity both in vitro and in vivo. Various studies (dog, cat, rabbit, rat, mouse, guinea-pig) show that nicergoline affects only slightly blood pressure and heart rate and increases the blood flow in brain and hind limb without affecting the splanchnic and aortic flow in normal animals. Nicergoline does not interfere with CNS functions unless applied in high doses. It stimulates the muscle oxidative metabolism and function and lacks any emetic and hallucinogenic activity. Its acute and chronic toxicity in different animal species is very low.

Ergoline derivatives with oral, prolonged, alpha-adrenolytic activity.

The alpha-adrenolytic activity of 1-methyl-10-methoxydihydrolysergol 2-(3,5-dimethyl)pyrrolcarboxylate (XV, formula II) is, both in vitro and parenterally, quite similar to that of dihydroergotamine. By oral route the new compound is more active, and longer lasting than dihydroergotamine.

Ergoline derivatives. Note XIII (1) alpha-adrenergic blocking drugs.

The synthesis and the pharmacological activities of 24 analogues of the alpha-adrenergic blocking drug, nicergoline (I b), are reported. The majority of the new compounds were found to be less active than (I b): the structure-activity relationships are presented and discussed.