Direct detection of resistance to fluoroquinolones/SLIDs in sputum specimen by GenoType MTBDRsl v.2.0 assay A study from Eastern Uttar Pradesh, India.

BACKGROUND: According to World Health Organization (WHO), drug-resistant tuberculosis (DR-TB) is a major contributor to antimicrobial resistance globally and continues to be a public health threat. Annually, about half a million people fall ill with DR-TB globally. The gradual increase in resistance to fluoroquinolones (FQs) and second-line injectable drugs (SLIDs), poses a serious threat to effective TB control and adequate patient management. Therefore, WHO suggests the use of GenoType MTBDRsl v.2.0 assay for detection of multiple mutations associated with FQs and SLIDs. Hence, the study was conducted to determine the prevalence of resistance to FQs and SLIDs by comparing direct GenoType MTBDRsl v.2.0 assay with phenotypic drug susceptibility testing (DST). METHODS: The study was conducted on 1320 smear positive sputum samples from a total of 2536 RR-TB, confirmed by GeneXpert MTB/RIF. The smear positive specimens were decontaminated, and DNA extraction was performed. Furthermore, the extracted DNA was used for GenoType MTBDRsl v.2.0 assay. While 20% of the decontaminated specimens were inoculated in Mycobacterium growth indicator tube (MGIT) for drug susceptibility testing (DST). RESULTS: Out of 1320 smear positive sputum samples, 1178 were identified as Mycobacterium tuberculosis complex (MTBC) and remaining were negative by GenoType MTBDRsl v.2.0 assay. Of the 1178 MTBC positive, 26.6% were sensitive to both FQs and SLIDs, whereas 57.3% were only FQs resistant and 15.9% were resistant to both FQs and SLIDs. Further DST of 225 isolates by liquid culture showed that 17% were sensitive to both FQs and SLIDs, 61.3% were only FQs resistant and 21.3% were resistant to both. The specificity for FQs and SLIDs was 92.31% and 100% whereas sensitivity was 100% respectively by GenoType MTBDRsl v.2.0 assay in direct sputum samples. CONCLUSIONS: Our study clearly suggests that GenoType MTBDRsl v.2.0 assay is a reliable test for the rapid detection of resistance to second-line drugs after confirmation by GeneXpert MTB/RIF assay for RR-TB. Though, high rate FQ (ofloxacin) resistance was seen in our setting, moxifloxacin could be used as treatment option owing to very low resistance.

Treatment Outcomes of Patients Switching From an Injectable Drug to Bedaquiline During Short Standardized Treatment for Multidrug-resistant Tuberculosis in Mozambique.

Bedaquiline was recommended by the World Health Organization as the preferred option in treatment of multidrug-resistant tuberculosis (MDR-TB) with long regimens. However, no recommendation was given for the short MDR-TB regimen. Data from our small cohort of patients who switched from injectable drug to bedaquiline suggest that a bedaquiline-based short regimen is effective and safe.

Evaluation of the GenoType MTBDRsl Version 2.0 Assay for Second-Line Drug Resistance Detection of Mycobacterium tuberculosis Isolates in South Africa.

Early detection of resistance to second-line antituberculosis drugs is important for the management of multidrug-resistant tuberculosis (MDR-TB). The GenoType MTBDRsl version 2.0 (VER 2.0) line probe assay has been redesigned for molecular detection of resistance-conferring mutations of fluoroquinolones (FLQ) (gyrA and gyrB genes) and second-line injectable drugs (SLID) (rrs and eis genes). The study evaluated the diagnostic performance of the GenoType MTBDRsl VER 2.0 assay for the detection of second-line drug resistance compared with phenotypic drug susceptibility testing (DST), using the Bactec MGIT 960 system on Mycobacterium tuberculosis complex isolates from South Africa. A total of 268 repository isolates collected between 2012 and 2014, which were rifampin monoresistant or MDR based on DST, were selected. MTBDRsl VER 2.0 testing was performed on these isolates and the results analyzed. The MTBDRsl VER 2.0 sensitivity and specificity indices for culture isolates were the following: FLQ, 100% (95% confidence interval [CI] 95.8 to 100%) and 98.9% (95% CI, 96.1 to 99.9%); SLID, 89.2% (95% CI, 79.1 to 95.6%) and 98.5% (95% CI, 95.7 to 99.7%). The sensitivity and specificity observed for individual SLID were the following: amikacin, 93.8% (95% CI, 79.2 to 99.2%) and 98.5% (95% CI, 95.5 to 99.7%); kanamycin, 89.2% (95% CI, 79.1 to 95.6%) and 98.5% (95% CI, 95.5 to 99.7%); and capreomycin, 86.2% (95% CI, 68.3 to 96.1%) and 95.9% (95% CI, 92.2 to 98.2%). An interoperator reproducibility of 100% and an overall interlaboratory performance of 93% to 96% were found. The overall improvement in sensitivity and specificity with excellent reproducibility makes the GenoType MTBDRsl VER 2.0 a highly suitable tool for rapid screening of clinical isolates for second-line drug resistance for use in high-burden TB/HIV settings.

[Evaluation of administration errors of injectable drugs in neonatology]. / Évaluation des erreurs d'administration des médicaments injectables en néonatologie.

OBJECTIVE: Use of injectable drugs in newborns represents more than 90% of prescriptions and requires special precautions in order to ensure more safety and efficiency. The aim of this study is to gather errors relating to the administration of injectable drugs and to suggest corrective actions. METHODS: This descriptive and transversal study has evaluated 300 injectable drug administrations in a neonatology unit. Two hundred and sixty-one administrations have contained an error. Data are collected by direct observations of administrative act. RESULTS: Errors observed are: an inappropriate mixture (2.6% of cases); an incorrect delivery rate (33.7% of cases); incorrect dilutions (26.7% of cases); error in calculation of the dose to be injected (16.7% of cases); error while sampling small volumes (6.3% of cases); error or omission of administration schedule (1% of cases). CONCLUSION: These data have enabled us to evaluate administration of injectable drugs in neonatology. Different types of errors observed could be a source of therapeutic inefficiency, extended lengths of stay or iatrogenic drug. Following these observations, corrective actions have been undertaken by pharmacists and consist of: organizing training sessions for nursing; developing an explanatory guide for dilution and administration of injectable medicines, which was made available to the clinical service. Collaborative strategies doctor-nurse-pharmacist can help to reduce errors in the medication process especially during his administration. It permits improvement of injectable drugs use, offering more security and better efficiency and contribute to guarantee ideal therapy for patients.

Adverse Drug Reactions with Drugs Used in Multiple Sclerosis: An Analysis from the Italian Pharmacovigilance Database.

Given the importance of inflammation at the onset of multiple sclerosis (MS), therapy is mainly based on the use of anti-inflammatory drugs including disease modifying therapies (DMTs). Considering the recent approval of some DMTs, pharmacovigilance becomes a fundamental tool for the acquisition of new safety data. The aim of the study was to analyze adverse drug reactions (ADRs) related to the use of drugs approved for MS. All national publicly-available aggregated ADR reports recorded from 2002 to 2020 into the Reports of Adverse Reactions of Medicines (RAM) system and all complete Sicilian data reported into the Italian spontaneous reporting system (SRS) database having as suspected drugs interferon ß-1a (IFN ß-1a), interferon ß-1b (IFN ß-1b), peginterferon ß-1a (PEG-IFN ß-1a), glatiramer acetate (GA), natalizumab (NTZ), fingolimod (FNG), teriflunomide (TRF), dimethyl fumarate (DMF), alemtuzumab (Alem), ocrelizumab (OCZ), or cladribine (Cladr), were collected. Descriptive analyses of national, publicly-available aggregated data and full-access regional data were performed to assess demographic characteristics and drug-related variables followed by a more in-depth analysis of all Sicilian ADRs with a case-by-case assessment and a disproportionality analysis of unexpected ADRs. A total of 13,880 national reports have been collected from 2002 to 2020: they were mainly not serious ADRs (67.9% vs. 26.1%) and related to females (71.7% vs. 26.3%) in the age group 18-65 years (76.5%). The most reported ADRs were general and administration site conditions (n = 6,565; 47.3%), followed by nervous (n = 3,090; 22.3%), skin (n = 2,763; 19.9%) and blood disorders (n = 2,180; 15.7%). Some unexpected Sicilian ADRs were shown, including dyslipidemia for FNG (n = 10; ROR 28.5, CI 14.3-59.6), NTZ (n = 5; 10.3, 4.1-25.8), and IFN ß-1a (n = 4; 8.7, 3.1-24.1), abortion and alopecia for NTZ (n = 9; 208.1, 73.4-590.1; n = 3; 4.9, 1.5-15.7), and vitamin D deficiency for GA (n = 3; 121.2, 30.9-475.3). Moreover, breast cancer with DMF (n = 4, 62.8, 20.5-191.9) and hypothyroidism with Cladr (n = 3; 89.2, 25.9-307.5) were also unexpected. The reporting of drugs-related ADRs in MS were mostly reported in the literature, but some unknown ADRs were also found. However, further studies are necessary to increase the awareness about the safety profiles of new drugs on the market.

Regulatory Science Approach in Pharmaceutical Development of Follow-on Versions of Non-Biological Complex Drug Products.

Scientific and technological breakthroughs in the field of Nanotechnology have been a driving force throughout the development and approval of Non-Biological Complex Drugs (NBCDs). However, the fast-growing expansion of NBCDs and the emergence of their follow-on versions have brought with them several scientific, technological, and regulatory challenges. The definition of NBCDs is still not officially recognized by the regulatory authorities, and there is no dedicated regulatory pathway addressing the particular features of NBCDs and their follow-on versions. The lack of clear and consistent regulatory guidance documents in this field, as well as, the inconsistency across different regulatory agencies, impact negatively on the acceptance and enormous potential of these drug products. Patient access to high-quality NBCDs follow-on versions may be compromised by regulatory uncertainty resulting from the use of different regulatory approaches across the globe, as well as within the same class of products. Accordingly, there is a real need to develop a specific regulatory pathway compliant with the complexity of NBCDs and their follow-on versions or, alternatively, make better use of available regulatory pathways. The main goal of the review is to deeply investigate and provide a critical overview of the regulatory landscape of NBCDs and follow-on versions currently adopted by the regulatory authorities. The dissemination of knowledge and discussion in this field can contribute to clarifying regulations, policies, and regulatory approaches to complex generics, thereby filling regulatory and scientific gaps in the establishment of therapeutic equivalence.

Long-acting Injectable vs. Oral Antipsychotics: Adherence, Persistence and Switching over three Years of Real-life Analysis.

BACKGROUND: Persistence and adherence to treatment are considered efficacy outcomes in psychiatric disorders. One of the best ways to improve these values in patients with psychiatric disorders is to prefer Long-Acting Injectable (LAI) drugs to oral AP. OBJECTIVE: The objective of this study is to evaluate adherence, persistence and switching of antipsychotics and compare in real life long-acting with oral formulations. MATERIALS AND METHODS: This pharmacological, observational, retrospective and non-interventional study involved all patients of the ASL of Pescara treated in the front-line with AP in the period between January 2011 and February 2019. Adherence was measured using the ratio between the received daily dose and prescribed daily dose. Persistence to treatment with antipsychotics was calculated as the daily difference between the beginning and end of treatment. RESULTS: We examined 840 patients treated with aripiprazole, 130 patients treated with paliperidone and 925 patients treated with risperidone. Adherence was significantly better in long-acting formulations with values of 0.89 (aripiprazole) and 0.82 (paliperidone and risperidone) than in oral formulations with values of 0.78, 0.70 and 0.58, respectively (p> 0.999, p= 0.0091, p=< 0.0001). Threeyear persistence curves relating to three study drugs did not show a statistically significant difference (p = 0.3314). Persistence curves based on formulation have not shown a statistically significant difference (p= 0, 4658, p=0, 4794, p=0, 2199 for ariprazolo, paliperidone and risperidone, respectively). 7% of patients were treated with aripiprazole, 12% of patients were treated with risperidone and 28% of patients were treated with paliperidone switched therapy. CONCLUSION: In all the drugs of present study, adherence values were better in LAI than in OA, whereas no statistically significant difference was found in persistence values.

Performance of the GenoType MTBDRsl V 2.0 for detecting second-line drugs resistance of Mycobacterium tuberculosis isolates in Tunisia.

Rapid detection of the second-line drug (SLD) resistant tuberculosis (TB) strains is challenging to prescribe an immediate adequate treatment and limit the transmission of SLD resistant strains. The study aimed to evaluate the performance of GenoType MTBDRsl V2.0 compared to phenotypic drug susceptibility testing (pDST:MGIT960) to detect resistance to SLD of Mycobacterium tuberculosis (MTB) isolates in Tunisia, between May 2015 and December 2019. As a matter of fact, 103 rifampicin-resistant and multidrug-resistant MTB strains were included. Discrepancies between pDST and MTBDRsl were solved by whole genome sequencing. Compared to pDST, MTBDRsl V2.0 showed a sensitivity of 92.8% (68.5%-98.7%) in detecting resistance to fluoroquinolones. As for second-line injectable drugs, it presented a sensitivity of 80.0% (49.0%-94.3%). MTBDRsl had sensitivities of 100.0% (67.5%-100.0%), 75.0% (40.9%-92.8%) and 100.0% (60.9%-100.0%) respectively for kanamycin, capreomycin and amikacin. The specificity was 100.0% for all the drugs evaluated. As for diagnosing XDR-TB, it had a sensitivity of 57.1% (25.0%-84.1%) and a specificity of 100.0% (96.1%-100.0%). MTBDRsl V2.0 showed a high performance in detecting SLD resistance with a short turnaround time compared with pDST, which made it possible to start an early treatment and to maintain a low prevalence of SLD resistance and XDR-TB in Tunisia.

Resistance to Second-Line Anti-TB Drugs in Cambodia: A Phenotypic and Genetic Study.

BACKGROUND: Due to the emergence of Mycobacterium tuberculosis (M.tb) clinical isolates resistant to most potent first-line drugs (FLD), second-line drugs (SLD) are being prescribed more frequently. We explore the genetic characteristics and molecular mechanisms of M.tb isolates phenotypically resistant to SLD, including pre-extensively drug-resistant (pre-XDR) and extensively drug-resistant (XDR) isolates. METHODS: Drug-resistant (DR) M.tb isolates collected from 2012 to 2017 were tested using sequencing and phenotypic drug susceptibility testing. Genotypes were determined to explore their links with SLD resistance patterns. RESULTS: Of the 272 DR M.tb isolates, 6 non-multidrug resistant (non-MDR) isolates were fluoroquinolones (FQ)-resistant, 3 were XDR and 16 were pre-XDR (14 resistant to FQ and 2 to second-line injectable drugs). The most frequent mutations in FQ-resistant and second-line injectable drugs resistant isolates were gyrA D94G (15/23) and rrs a1401g (3/5), respectively. Seventy-five percent of pre-XDR isolates and 100% of XDR isolates harbored mutations conferring resistance to pyrazinamide. All XDR isolates belonged to the Beijing genotype, of which one, named XDR+, was resistant to all drugs tested. One cluster including pre-XDR and XDR isolates was observed. CONCLUSION: This is the first description of SLD resistance in Cambodia. The data suggest that the proportion of XDR and pre-XDR isolates remains low but is on the rise compared to previous reports. The characterization of the XDR+ isolate in a patient who refused treatment underlines the risk of transmission in the population. In addition, genotypic results show, as expected, that the Beijing family is the main involved in pre-XDR and XDR isolates and that the spread of the Beijing pre-XDR strain is capable of evolving into XDR strain. This study strongly indicates the need for rapid interventions in terms of diagnostic and treatment to prevent the spread of the pre-XDR and XDR strains and the emergence of more resistant ones.

An evaluation of cabotegravir for HIV treatment and prevention.

Introduction: Oral pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) represent the cornerstones of HIV infection prevention and treatment. However, despite their high efficacy, the need to take daily oral pill(s) negatively impacts long-term patient adherence. In some cases, it can also be associated with drug-drug interactions and adverse gastrointestinal effects, as well as being a constant reminder to individuals of their HIV status. The availability of long-acting non-orally administered antiretroviral drugs could, therefore, be extremely useful. Cabotegravir (CAB) is a second-generation integrase strand transfer inhibitor, characterized by a relatively high genetic barrier and good antiretroviral potency, which is administrable as a long-acting injectable suspension (LAI CAB).Areas covered: The authors present and discuss the efficacy and available safety data of LAI CAB, either when co-administered with rilpivirine (RPV; LAI CAB + RPV) for the treatment of HIV infection, or when used as single agent for PrEP.Expert opinion: Cabotegravir has the potential to play a primary role in the treatment and prevention of HIV infection. The future availability of LAI CAB + RPV and LAI CAB may mark the beginning of an era of LAI ART and PrEP, respectively.

Detection of Resistance to Fluoroquinolones and Second-Line Injectable Drugs Among Mycobacterium tuberculosis by a Reverse Dot Blot Hybridization Assay.

BACKGROUND: Reliable and timely determination of second-line drug resistance is essential for early initiation effective anti-tubercular treatment among multi-drug resistant (MDR) patients and blocking the spread of MDR and extensively drug-resistant tuberculosis. Molecular methods have the potency to provide accurate and rapid drug susceptibility results. We aimed to establish and evaluate the accuracy of a reverse dot blot hybridization (RDBH) assay to simultaneously detect the resistance of fluoroquinolones (FQs), kanamycin (KN), amikacin (AMK), capreomycin (CPM) and second-line injectable drugs (SLIDs) in Mycobacterium tuberculosis. METHODS: We established and evaluated the accuracy of the RDBH assay by comparing to the phenotypic drug susceptibility testing (DST) and sequencing in 170 M. tuberculosis, of which 94 and 27 were respectively resistant to ofloxacin (OFX) and SLIDs. RESULTS: The results show that, compared to phenotypic DST, the sensitivity and specificity of the RDBH assay for resistance detection were 63.8% and 100.0% for OFX, 60.0% and 100.0% for KN, 61.5% and 98.1% for AMK, 50.0% and 99.3% for CPM, and 55.6% and 100% for SLIDs, respectively; compared to sequencing, the sensitivity and specificity of the RDBH assay were 95.2% and 100.0% for OFX, 93.8% and 100.0% for SLIDs or KN (both based on mutations in rrs 1400 region and eis promoter), and 91.6% and 100.0% for AMK or CPM (both based on mutations in rrs 1400 region), respectively. The turnaround time of the RDBH assay was 7 h for testing 42 samples. CONCLUSION: Our data suggested that compared to sequencing, the RDBH assay could serve as a rapid and reliable method for testing the resistance of M. tuberculosis against OFX and SLIDs, enabling early administration of appropriate treatment regimens among MDR tuberculosis patients.

Burden of baseline resistance of Mycobacterium tuberculosis to fluoroquinolones and second-line injectables in central India.

BACKGROUND: Drug-resistant TB is a serious public health problem in India. Pre-existing resistance to fluoroquinolones (FQs) and second-line injectable drugs (SLIDs) in strains of Mycobacterium tuberculosis (MTB) resistant to rifampicin (RIF) and/or isoniazid (INH) contributes to treatment failures and consequent transmission of drug-resistant TB. A baseline assessment of resistance of MTB to FQs and SLIDs may help guide policies to further improve management of drug-resistant TB in India. This study aims to determine the prevalence of resistance to FQs and SLIDs among MTB strains having RIF and/or INH resistance in central India. METHOD: A total of 1032 smear positive sputum samples were subjected to line probe assay (GenoType MTBDRsl version 2) to test for resistance to FQs and SLIDs, according to the integrated diagnostic algorithm of the revised national TB control programme. RESULTS: Of 1032 samples, 92 (8.91%) were not interpretable and hence excluded, 295 (31.38%) were resistant to FQs alone, 13 (1.38%) were resistant to SLIDs alone, 15 (1.59%) were resistant to both FQs as well as SLIDs and 617 (65.63%) were sensitive to both FQs and SLIDs. The most common mutations in gyrA and gyrB genes were observed at codons D94G and E540V, respectively. Mutations at codon A1401G in rrs genes and in the C-14 T region of eis genes were most frequently observed. CONCLUSION: High levels of FQ resistance points towards indiscriminate use of this class of drugs. Regulation for judicial use of FQs is an urgent requirement.

Study of prescription of injectable drugs and intravenous fluids to inpatients in a teaching hospital in Western Nepal.

Unnecessary, excessive and poor injection practices in the South East Asia region (including Nepal) have been observed previously. The authors aim to study prescription of injectable drugs to inpatients in a teaching hospital in Western Nepal. Prescription of injectable drugs (IDs) and intravenous fluids (IVFs) to inpatients discharged from the wards of the Manipal Teaching Hospital during 1st January to 30th June 2006 was studied. The mean number of drugs, IDs and IVFs administered, median cost of drugs and of IDs/IVFs per prescription calculated. Comparison of ID/IVF use in the four major hospital departments (Medicine, Obstetrics and Gynecology, Pediatrics and Surgery) was done. The administration of IDs/IVFs and injectable antimicrobials were measured in Defined Daily Dose (DDD)/100 bed-days and of Intravenous fluid in Liters (L)/100 bed-days. Of the 1131 patients discharged, 938 (82.94%) patients received one or more IDs/IVFs. The mean number of drugs, IDs and IVFs prescribed were 8.75, 4.72 and 1.42. Median cost of drugs and IDs/IVFs per prescription were 8.26US$ and 5.12US$ respectively. IDs/IVFs accounted for 81.37% of total drug cost. The most commonly used ID, injectable antimicrobial and IVF were Diclofenac (19.3 DDD/100 bed-days), Metronidazole (7.68 DDD/100 bed-days) and Dextrose normal saline (8.56 L/100 bed-days), respectively. The total IVF consumption was 24.25 L/100 bed-days. Significant differences between departments were observed (p<0.05). In conclusion, the use of IDs/IVFs was higher compared to other studies. Interventions to improve IDs/IVFs prescribing practices may be required.

Patient preferences for treatment in type 2 diabetes: the Italian discrete-choice experiment analysis.

AIMS: Several drug classes are now available to achieve a satisfactory metabolic control in patients with type 2 diabetes (T2DM), but patients' preferences may differ. METHODS: In a discrete-choice experiment, we tested T2DM patients' preferences for recent antidiabetic drugs, in the event that their treatment might require intensification. The following attributes were considered: (a) route of administration; (b) type of delivery; (c) timing; (d) risk of adverse events; (e) effects on body weight. Twenty-two possible scenarios were built, transferred into 192 paired choices and proposed to 491 cases naïve to injectable treatments and 171 treated by GLP-1 receptor agonists (GLP-1RAs). Analyses were performed by descriptive statistics and random effects logit regression model. RESULTS: Preferences according to dosing frequency, risk of nausea and urinary tract infections (UTls) were similar across groups, age, sex and BMI. Administration route and delivery type accounted for 1/3 of relative importance; the risk of UTIs, nausea and dosing frequency for ≈ 20% each, and weight loss for only 6%. Two significant interactions emerged (p < 0.01): type of delivery × group, and weight change × BMI class. Irrespective of previous treatment, the three preferred choices were injectable, coupled with weekly dosing and a ready-to-use device (first two choices). In a regression model, being naïve or non-naïve changed the ranking of preferences (p < 0.001), and the order was systematically shifted towards injectable medications in non-naïve subjects. CONCLUSION: Easy-to-deliver, injectable treatment is preferred in T2DM, independently of treatment history, and previous experience with GLP-1RAs strengthens patients' willingness to accept injectable drugs.

Where are we with injectables against HIV infection and what are the remaining challenges?

INTRODUCTION: Drug adherence has been a recurring issue in the field of HIV treatment, and low treatment adherence is typically associated with emergence of drug resistance, treatment failure and increased risks of transmission. Injectable antiretroviral drugs offer a unique opportunity to counter this issue for the treatment of HIV-positive individuals. In addition, injectables offer a remarkable opportunity to reduce new HIV infections, if applied in the context of both treatment-as-prevention and pre-exposure prophylaxis. Areas covered: Researchers and drug companies are developing long-acting agents that possess long biological half-life and excellent pharmacokinetic profiles that can be administered intramuscularly, intravenously, or subcutaneously. These long-acting injectables are categorized as drugs that target different steps of HIV replication cycle or monoclonal antibodies that target HIV entry. Expert commentary: Injectables against HIV have the potential to revolutionize the fight against HIV by facilitating both treatment and prevention in a wide variety of clinical settings. Several challenges remain including the identification of potent two-drug combinations of drugs that can be formulated as injectables, and thorough drug-drug interaction studies with a broad variety of medications. Finally we believe that the healthcare benefits of injectables will require regulatory changes to allow self-injection before they reach their full potential.

Performing a preliminary hazard analysis applied to administration of injectable drugs to infants.

RATIONALE, AIMS AND OBJECTIVES: Errors in hospitals during the preparation and administration of intravenous drugs to infants and children have been reported to a rate of 13% to 84%. This study aimed to investigate the potential for hazardous events that may lead to an accident for preparation and administration of drug injection in a pediatric department and to describe a reduction plan of risks. METHODS: The preliminary hazard analysis (PHA) method was implemented by a multidisciplinary working group over a period of 5 months (April-August 2014) in infants aged from 28 days to 2 years. The group identified required hazard controls and follow-up actions to reduce the error risk. To analyze the results, the STATCART APR software was used. RESULTS: During the analysis, 34 hazardous situations were identified, among 17 were quoted very critical and drawn 69 risk scenarios. After follow-up actions, the scenarios with unacceptable risk declined from 17.4% to 0%, and these with acceptable under control from 46.4% to 43.5%. CONCLUSION: The PHA can be used as an aid in the prioritization of corrective actions and the implementation of control measures to reduce risk. The PHA is a complement of the a posteriori risk management already exists.

Molecular analysis of genetic mutations among cross-resistant second-line injectable drugs reveals a new resistant mutation in Mycobacterium tuberculosis.

Mutations causing mono and cross-resistance among amikacin, kanamycin and capreomycin of second-line injectable drugs (SLIDs) namely are not well understood. We investigated 124 isolates of Mycobacterium tuberculosis for mutations within rrs, eis, tlyA and efflux pump (Rv1258c and Rv0194) genes involved in resistance towards SLIDs. The distribution of mutations across these genes were significantly different in strains with mono-resistance or cross-resistance. A new mutation G878A was found in rrs gene, among strains with capreomycin mono-resistant, or in strains with cross-resistance of capreomycin, kanamycin and amikacin. This mutation was associated with the Euro-American X3 lineage (P < 0.0001). Mutations in the two efflux genes Rv1258c and Rv0194 were confined to strains with only capreomycin/amikacin/kanamycin cross-resistance. We further investigated the minimum inhibitory concentration of capreomycin on isolates with new G878A mutation ranging from 8 µg/mL to 64 µg/mL. Inclusion of G878A on new molecular assays could increase the sensitivity of capreomycin resistance detection.

Diagnostic accuracy study of multiplex PCR for detecting tuberculosis drug resistance.

OBJECTIVE: To study the diagnostic accuracy of a multiplex real-time PCR (Anyplex II MTB/MDR/XDR, Seegene, Corea) that detects Mycobacterium tuberculosis resistant to isoniazid (INH), rifampicin (RIF), fluoroquinolones (FLQ) and injectable drugs (kanamycin [KAN], amikacin [AMK] and capreomycin [CAP]) in isolates and specimens. METHODS: One hundred fourteen cultured isolates and 73 sputum specimens were retrospectively selected. Results obtained with multiplex PCR were compared with those obtained with BACTEC. Discordant results between multiplex PCR and BACTEC were tested by alternative molecular methods. RESULTS: Sensitivity and specificity of multiplex PCR for detecting drug resistance in isolates were 76.5% and 100%, respectively, for INH; 97.2% and 96.0%, respectively, for RIF; 70.4% and 87.9%, respectively, for FLQ; 81.5% and 84.8%, respectively, for KAN; 100% and 60%, respectively, for AMK, and 100% and 72.3%, respectively, for CAP. Sensitivity and specificity of Anyplex for detecting drug resistance in specimens were 93.3% and 100%, respectively, for INH; 100% and 100%, respectively, for RIF; 50.0% and 100%, respectively, for FLQ; and 100% and 94.4%, respectively, for both KAN and CAP. Among the discordant results, 87.7% (71/81) of results obtained with the multiplex PCR were concordant with at least one of the alternative molecular methods. CONCLUSIONS: This multiplex PCR may be a useful tool for the rapid identification of drug resistant tuberculosis in isolates and specimens, thus allowing an initial therapeutic approach. Nevertheless, for a correct management of patients, results should be confirmed by a phenotypic method.

Pyrosequencing for rapid detection of Mycobacterium tuberculosis second-line drugs and ethambutol resistance.

The aim of this work was to study the diagnostic accuracy of pyrosequencing to detect resistance to fluoroquinolones, kanamycin, amikacin, capreomycin, and ethambutol (EMB) in Mycobacterium tuberculosis clinical strains. One hundred four clinical isolates previously characterized by BACTEC 460TB/MGIT 960 were included. Specific mutations were targeted in gyrA, rrs, eis promoter, and embB. When there was a discordant result between BACTEC and pyrosequencing, Genotype MTBDRsl (Hain Lifescience, Nehren, Germany) was performed. Sensitivity and specificity of pyrosequencing were 70.6% and 100%, respectively, for fluoroquinolones; 93.3% and 81.7%, respectively, for kanamycin; 94.1% and 95.9%, respectively, for amikacin; 90.0% and 100%, respectively, for capreomycin; and 64.8% and 87.8%, respectively, for EMB. This study shows that pyrosequencing may be a useful tool for making early decisions regarding second-line drugs and EMB resistance. However, for a correct management of patients with suspected extensively drug-resistant tuberculosis, susceptibility results obtained by molecular methods should be confirmed by a phenotypic method.

Avaliação dos ensaios microbiológicos realizados em uma área limpa e elaboração de um plano de monitoramento ambiental para manipulação de injetáveis utilizados em terapia anti-câncer / Evaluation of the microbiological tests carried out in a clean room and elaboration of an environmental monitoring plan for the manipulation of injectables used in anticancer therapy

A manipulação de medicamentos injetáveis para tratamento oncológico é uma atividade de grande relevância realizada pela farmácia hospitalar. A manipulação é realizada por técnica asséptica de forma a prevenir a introdução de contaminantes e, por isso, cada etapa do processo de produção deve ser realizada de forma rigorosa e em um ambiente de alta qualidade. A fim de verificar o nível de contaminação desses ambientes de produção, oriundos de diversas fontes como ar, água, materiais, equipamentos e funcionários do processo produtivo, o monitoramento ambiental torna-se uma ferramenta importante em processos assépticos com a finalidade de garantir maior qualidade dos produtos injetáveis. O presente estudo tem como objetivos: avaliar as condutas e os ensaios realizados por uma empresa contratada por um hospital de grande porte para a amostragem de partículas viáveis, comparar os resultados da amostragem realizada pela empresa com os resultados obtidos no estudo, descrever um plano de monitoramento ambiental para a área limpa de manipulação de injetáveis desse hospital, definir os limites de alerta de contaminação das áreas Grau A e C e condutas em caso de desvio. A partir do acompanhamento das práticas de amostragem de partículas viáveis realizada pela empresa contratada, foi possível identificar pontos de fragilidade dos processos e do controle ambiental da área limpa do estudo. Ao comparar os dados foi visto uma maior contaminação nas superfícies amostradas no estudo. Em relação à amostragem ativa do ar, não houve diferença significativa na contagem total de colônias nos resultados obtidos no estudo e pela empresa. A partir do somatório de colônias de bactérias e fungos recuperadas no estudo e pela empresa por amostragem ativa foi verificada a prevalência de fungos na área limpa estudada. Na amostragem passiva do ar, foi visto menor crescimento de colônias totais na sala de manipulação de nutrição parenteral. Na comparação entre o método ativo e passivo em um mesmo local de amostragem na sala de manipulação de medicamentos de suporte, o método ativo apresentou recuperação de micro-organismos muito superior ao resultado da amostragem passiva. Foi elaborado um manual com o plano de monitoramento ambiental, estabelecido os limites de alerta para os ambientes Grau A e C (ar e superfícies) das áreas de manipulação a partir dos dados históricos e ações a serem realizadas em casos de desvio e reincidência do desvio