Assessment of tissue levels of miR-146a and proinflammatory cytokines in experimental cerebral toxoplasmosis following atovaquone and clindamycin treatment: An in vivo study.

BACKGROUND: Despite recent advances for treating cerebral toxoplasmosis (CT), monitoring the parasite burden and treatment response is still challenging. miRNAs are small non-coding RNAs with regulatory functions that can be used in diagnosis and treatment monitoring. We investigated the changes in miR-146a, BAG-1 gene, IL-6, and IL-10 tissue levels in the brain of BALB/c mice with chronic CT caused by the PRU strain of T. gondii following anti-parasitic and antibiotic treatment. METHOD: Fifty-three 6-to 8-week-old BALB/c mice were infected using intraperitoneal inoculation of cerebral cysts of T. gondii PRU strain and then divided into five groups as follows: group 1 included mice treated with 100 mg/kg/d Atovaquone (AT), group 2 included mice treated with 400 mg/kg/d clindamycin (CL), group 3 included mice treated with combination therapy (AT + CL), group 4 included infected untreated mice as a positive control (PC), and; group 5 included uninfected untreated mice as negative control (NC). After the completion of the treatment course, tissue level of mir-146a, miR-155, BAG-1 gene, IL-6, and IL-10 was investigated with real-time polymerase chain reaction. The IL-6/IL-10 ratio was calculated as an indicator of immune response. Moreover, brain cyst numbers were counted on autopsy samples. RESULTS: miR-146a, IL-6, IL-10, and BAG-1 genes were expressed in PC, but not in the NC group; miR-146a, IL-6, IL-10, and BAG-1 gene expression were significantly lower in AT, CL, and AT + CL compared with PC. MiR-146a and BAG-1 levels in AT and CL were not different statistically, however, they both had lower levels compared to AT + CL (P < 0.01). There was no difference in the expression of IL-6 and IL-10 between treatment groups. BAG-1 expression was significantly lower in AT, than in CL and AT + CL (P < 0.0089 and < 0.002, respectively). The PC group showed a higher ratio of IL-6/IL-10, although this increase was not statistically significant. It is noteworthy that the treatment with AT reduced this ratio; in the inter-group comparison, this ratio showed a decrease in the AT and AT + CL compared to the PC. The number of brain tissue cysts was significantly lower in AT, CL, and AT + CL, than in PC (p < 0.0001). AT had significantly lower brain cysts than CL and AT + CL (P < 0.0001). CONCLUSION: It seems that the factors studied in the current research (microRNA and cytokines) are a suitable index for evaluating the response to antiparasitic and antibiotic treatment. However, more studies should be conducted in the future to confirm our findings.

Activity of omadacycline in vitro against Clostridioides difficile and preliminary efficacy assessment in a hamster model of C. difficile-associated diarrhoea.

OBJECTIVES: Antibiotics are associated with increased risk of Clostridioides difficile infection, which has limited treatment options. We assessed in vitro activity of omadacycline (an aminomethylcycline antibiotic) against the C. difficile infection strain and efficacy in a hamster model of C. difficile-associated diarrhoea. METHODS: Omadacycline, clindamycin, tigecycline, vancomycin, and metronidazole minimum inhibitory concentrations (MICs) for the infection-model strain (C. difficile ATCC 43596) were determined. Hamsters were pretreated with subcutaneous clindamycin (10 mg/kg) and infected 24 h later with C. difficile ATCC 43596; 24 h post infection, they received oral omadacycline (50 mg/kg/day), vancomycin (50 mg/kg/day), or vehicle for 5 days. Efficacy was reported as survival. RESULTS: Omadacycline was as active as tigecycline, vancomycin, and metronidazole (MIC 0.06 mg/L); clindamycin showed no activity. Median survival in hamsters was: 12 days, omadacycline; 2 days, vancomycin; 4 days, clindamycin pretreatment only. CONCLUSION: Omadacycline exhibited potent in vitro activity against C. difficile and showed efficacy in a model of C. difficile-associated diarrhoea.

Emergency department medication dispensing reduces return visits and admissions.

OBJECTIVES: Return visits to the emergency department (ED) and subsequent readmissions are common for patients who are unable to fill their prescriptions. We sought to determine if dispensing medications to patients in an ED was a cost-effective way to decrease return ED visits and hospital admissions for skin and soft tissue infections (SSTIs). METHODS: A retrospective review of ED visits for SSTIs, during the 24 weeks before and after the implementation of a medication dispensing program, was conducted. Charts were analyzed for both ED return visits and hospital admissions within 7 days and 30 days of the initial ED visit. Return visits were further reviewed to determine if the clinical conditions on subsequent visits were related to the initial ED presentation. A cost analysis comparing the cost of treatment to cost savings for return visits was also performed. RESULTS: Before the implementation of the medication dispensing program, the return rate in 7 days for the same condition was 9.1% and the rate of admission was 2.8%. The return rate for the same condition in 8-30 days was 2.1% and the rate of admission was 1.0%. After the implementation of the medication dispensing program, the return rate for the same condition in 7 days was 8.0%, and the admission rate was 1.7%. The return rate for the same condition in 8-30 days was 0.8%, and the admission rate was 0%. The total cost of dispensed medications was $4050, while total cost savings were estimated to be $95,477. CONCLUSION: A medication dispensing program in the ED led to a reduction in return visits and admissions for SSTIs at both 7 days and 30 days. For a cost of only $4050, an estimated total of $95,477 was saved. A medication dispensing program is a cost-effective way to reduce return visits to the ED and subsequent admissions for certain conditions.

Compliance with national guidelines for antibiotic prophylaxis in hip fracture patients: a quality assessment study of 13 329 patients in the Norwegian Hip Fracture Register.

OBJECTIVE: We assessed compliance with new guidelines for prophylactic antibiotics in hip fracture surgery in Norway introduced in 2013. DESIGN: The data from the Norwegian Hip Fracture Register was used to assess the proportion of antibiotics given according to the national guidelines. SETTING: All hospitals in Norway performing hip fracture surgery in the period from 2011 to 2016. PARTICIPANTS: We studied 13 329 hemiarthroplasties (HAs) for acute hip fracture. MAIN OUTCOME MEASURE: Type and timing between first and last dose of prophylactic antibiotics compared with the national guidelines. RESULTS: Before the guidelines were introduced, the recommended drugs cephalotin or clindamycin was used in only 86.2% of all HAs. In 2016, one of the two recommended drugs was administered in 99.2% of HAs. However, hospitals' adaption of the recommended administration of the two drugs improved slowly, and by the end of the study period, only three out of five HAs were performed with the correct drug administered in the correct manner. We found major differences in compliance between hospitals. CONCLUSIONS: The change towards correct administration of antibiotic prophylaxis was varied both when investigating university and non-university hospitals. We suggest that both hospital leaders and the national Directorate of Health need to investigate routines for better dissemination of information and education to involved parties. Strong leadership concerning evidence-based guidelines on antibiotic prophylaxis in surgery may take away some autonomy from executing healthcare professionals, but will result in better patient care and antibiotic stewardship.

Silver-impregnated, antibiotic-impregnated or non-impregnated ventriculoperitoneal shunts to prevent shunt infection: the BASICS three-arm RCT.

BACKGROUND: Insertion of a ventriculoperitoneal shunt to treat hydrocephalus is one of the most common neurosurgical procedures worldwide. Shunt infection affects up to 15% of patients, resulting in long hospital stays, multiple surgeries and reduced cognition and quality of life. OBJECTIVES: The aim of this trial was to determine whether or not antibiotic-impregnated ventriculoperitoneal shunts (hereafter referred to as antibiotic shunts) (e.g. impregnated with rifampicin and clindamycin) or silver-impregnated ventriculoperitoneal shunts (hereafter referred to as silver shunts) reduce infection compared with standard ventriculoperitoneal shunts (hereafter referred to as standard shunts). DESIGN: This was a three-arm, superiority, multicentre, parallel-group randomised controlled trial. Patients and a central primary outcome review panel, but not surgeons or operating staff, were blinded to the type of ventriculoperitoneal shunt inserted. SETTING: The trial was set in 21 neurosurgical wards across the UK and the Republic of Ireland. PARTICIPANTS: Participants were patients with hydrocephalus of any aetiology who were undergoing insertion of their first ventriculoperitoneal shunt. INTERVENTIONS: Participants were allocated 1 : 1 : 1 by pressure-sealed envelope to receive a standard non-impregnated, silver-impregnated or antibiotic-impregnated ventriculoperitoneal shunt at the time of insertion. Ventriculoperitoneal shunts are medical devices, and were used in accordance with the manufacturer's instructions for their intended purpose. MAIN OUTCOME MEASURES: The primary outcome was time to ventriculoperitoneal shunt failure due to infection. Secondary outcomes were time to failure for any cause, reason for failure (infection, mechanical), types of ventriculoperitoneal shunt infection, rate of infection after first clean (non-infected) revision and health economics. Outcomes were analysed by intention to treat. RESULTS: Between 26 June 2013 and 9 October 2017, 1605 patients from neonate to 91 years of age were randomised to the trial: n = 36 to the standard shunt, n = 538 to the antibiotic shunt and n = 531 to the silver shunt. Patients who did not receive a ventriculoperitoneal shunt (n = 4) or who had an infection at the time of insertion (n = 7) were not assessed for the primary outcome. Infection occurred in 6.0% (n = 32/533) of those who received the standard shunt, in 2.2% (n = 12/535) of those who received the antibiotic shunt and in 5.9% (n = 31/526) of those who received the silver shunt. Compared with the standard shunt, antibiotic shunts were associated with a lower rate of infection (cause-specific hazard ratio 0.38, 97.5% confidence interval 0.18 to 0.80) and a decreased probability of infection (subdistribution hazard ratio 0.38, 97.5% confidence interval 0.18 to 0.80). Silver shunts were not associated with a lower rate of infection than standard shunts (cause-specific hazard ratio 0.99, 97.5% confidence interval 0.56 to 1.74). The ventriculoperitoneal shunt failure rate attributable to any cause was 25.0% overall and did not differ between arms. Antibiotic shunts save £135,753 per infection avoided. There were no serious adverse events. LIMITATIONS: It was not possible to blind treating neurosurgeons to the ventriculoperitoneal shunt type. The return rate for patient-reported outcomes was low. Limitations to the economic evaluation included failure to obtain Hospital Episode Statistics data from NHS Digital, as per protocol. Reliance on patient-level information and costing systems data mitigated these limitations. CONCLUSIONS: Antibiotic shunts have a reduced infection rate compared with standard shunts, whereas silver shunts do not. Antibiotic shunts are cost-saving. FUTURE WORK: A sample collection has been established that will enable the study of surrogate markers of ventriculoperitoneal shunt infection in cerebrospinal fluid or blood using molecular techniques. A post hoc analysis to study factors related to shunt failure will be performed as part of a future study. An impact analysis to assess change in practice is planned. TRIAL REGISTRATION: Current Controlled Trials ISRCTN49474281. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 17. See the NIHR Journals Library website for further project information.

Hydrocephalus (commonly known as 'water on the brain') is a condition that can affect all age groups, from babies to the elderly. In hydrocephalus, there is an accumulation of the normal brain fluid in the fluid cavities (ventricles) of the brain. Untreated, hydrocephalus can be life-threatening. The most common treatment involves an operation to insert a tube into the swollen ventricles to drain off the excess fluid. This is called a ventriculoperitoneal shunt. In the UK, 3000­3500 shunt operations are performed each year. The main risks of a shunt operation are infection (surgical meningitis) and blockage without infection. Infection results in the need for at least two further surgeries, antibiotic treatment and a prolonged hospital stay (minimum of 2 weeks). Shunt infections can affect mental abilities and can be life-threatening. People who have blockages without infection, on the other hand, usually need only a single operation to replace the blocked part and only a few days in hospital. Two new types of shunt catheter have been introduced to try to reduce shunt infection: antibiotic-impregnated shunts and silver-impregnated shunts. This study was designed to assess whether or not either of these new shunts reduce infection compared with standard shunts. This study also included an analysis of the cost and health benefits of the different shunts used. A total of 1605 children and adults, who were treated in neurosurgical units across the UK and the Republic of Ireland, participated in this study. Consent was provided by all participants in the trial. Each participant had an equal chance of receiving one of the three shunt types. Shunt infection occurred in 6% of participants receiving standard shunts, 5.9% of participants receiving silver-impregnated shunts and 2.2% of participants receiving antibiotic-impregnated shunts. This study has demonstrated a major reduction in shunt infections in new shunts when using antibiotic-impregnated shunts compared with standard or silver-impregnated shunts. A health economic analysis has indicated that antibiotic-impregnated shunts are cost-saving.

Clindamicina 300 mg associada com rifampicina 300 mg para o tratamento de hidradenite supurativa moderada / Clindamycin 300 mg associated with rifampicin 300 mg for the treatment of moderate suppurative hydradenitis

INTRODUÇÃO: Hidradenite supurativa/acne inversa (HS) é uma doença cutânea, inflamatória e crônica, do folículo piloso, caracterizada por nódulos e abscessos dolorosos e recorrentes que se rompem e levam a tratos sinusais e cicatrizes. HS tipicamente ocorre após a puberdade, com a idade média de início na segunda ou terceira décadas de vida e com predomínio do sexo feminino. Dados de um estudo de prevalência populacional no Brasil estimou uma prevalência geral de 0,41%, sem diferenças entre as regiões brasileiras. A idade média foi de 40,4 anos, e a HS foi mais prevalente entre adolescentes e adultos do que crianças e idosos. PERGUNTA: O uso de clindamicina oral associado à rifampicina oral é seguro, eficaz e custo-efetivo para o tratamento da hidradenite supurativa moderada? TECNOLOGIA: cloridrato de clindamicina 300 mg (Clindamin - C®; Dalacin C® ecloridrato de clindamicina); rifampicina 300 mg (Rifaldin®; Furp-Rifampicina e rifampicina). AVALIAÇÃO DE IMPACTO ORÇAMENTÁRIO: Considerando uma prevalência de 0,41% de acordo com dados de estudo epidemiológico realizado no Brasil, e de acordo com o percentual de uso de antibióticos orais por indivíduos com HS moderada, o impacto do fornecimento de clindamicina e rifampicina para tratamento da HS moderada seria em torno de 85 milhões no primeiro ano. EXPERIÊNCIA INTERNACIONAL: Não foi encontrada nenhuma avaliação da clindamicina em associação com rifampicina para tratamento da HS em nenhuma das agências de Avaliação de Tecnologias em Saúde, da Escócia (SMC), Canadá (CADTH) e Inglaterra (NICE). No entanto, na avaliação do adalimumabe para HS moderada a grave, realizada pelo NICE recomendou o adalimumabe apenas se a doença não estiver respondendo a outros tratamentos convencionais (antibióticos tópicos e orais). MONITORAMENTO DO HORIZONTE TECNOLÓGICO: Não foram detectados medicamentos não biológicos para o tratamento da doença no estágio de desenvolvimento clínico considerado na análise.Apontou-se um medicamento potencial para o tratamento da hidradenite supurativa moderada, o anticorpo monoclonal secuquinumabe. CONSIDERAÇÕES: A evidência do uso de clindamicina oral associado à rifampicina oral é baseado em sete séries de casos e uma revisão sistemática. Apesar da fragilidade do delineamento e da qualidade destes estudos, os resultados gerais são promissores, com taxas de melhora relatadas entre 56 e 82%. A conduta terapêutica atual geralmente segue uma abordagem gradual, dependendo da gravidade da doença, começando com tratamento tópico para doença leve, cursos prolongados de antibióticos orais para doença leve a moderada e imunossupressores sistêmicos ou cirurgia para doença mais grave. CONSULTA PÚBLICA: Foram recebidas 303 contribuições, sendo que 90% destas foram excluídas por abordarem um tema diferente ou por não conter informação. por meio do formulário técnico-científico foram 44 contribuições, destas 93% concordaram com a recomendação preliminar da CONITEC. Foram seis contribuições alusivas às evidências clínicas, todas favoráveis à recomendação inicial. Essas contribuições se basearam nos seguintes argumentos: eficácia dos medicamentos; restrição para uso por um período de 12 a 16 semanas; a necessidade de acompanhamento médico e de farmacêutico; e indicação como segunda linha de tratamento, após a falha de uma ciclina. Não houve contribuições sobre avaliação econômica e a análise do impacto orçamentário. Foram recebidas cinco contribuições sobre experiência com a tecnologia, sendo que três eram a favor e duas contrárias a recomendação inicial da CONITEC. Os argumentos se basearam nos seguintes fundamentos: inexistência de outra opção terapêutica no SUS; medicamentos já recomendado nos guidelines internacionais. Após apreciação das contribuições encaminhadas pela Consulta Pública, o plenário da CONITEC entendeu que não houve argumentação suficiente para alterar a recomendação inicial. RECOMENDAÇÃO FINAL: Os membros da CONITEC presentes na 77ª reunião ordinária, no dia 09 de maio de 2019, deliberaram, por unanimidade, por recomendar a incorporação no SUS da clindamicina 300 mg associada a rifampicina 300 mg para o tratamento de hidradenite supurativa moderada, mediante Protocolo Clínico e Diretrizes Terapêuticas. Foi assinado o Registro de Deliberação nº 445/2019. DECISÃO: Incorporar a clindamicina 300mg associada com rifampicina 300mg para o tratamento de hidradenite supurativa moderada, mediante Protocolo Clínico e Diretrizes Terapêuticas, no âmbito do Sistema Único de Saúde ­ SUS. Dada pela Portaria nº 30 de 11 de junho de 2019, publicada no Diário Oficial da União (DOU) nº 112, seção 1, página 126, no dia 12 de junho de 2019.

Clindamicina 1% tópica para o tratamento de lesões superficiais na hidradenite supurativa / Topical 1% clindamycin for the treatment of superficial lesions in suppurative hydradenitis

INTRODUÇÃO: Hidradenite supurativa/acne inversa (HS) é uma doença cutânea, inflamatória e crônica, do folículo piloso, caracterizada por nódulos e abscessos dolorosos e recorrentes que se rompem e levam a tratos sinusais e cicatrizes. HS tipicamente ocorre após a puberdade, com a idade média de início na segunda ou terceira décadas de vida e com predomínio do sexo feminino.Dados de um estudo de prevalência populacional no Brasil estimou uma prevalência geral de 0,41%, sem diferenças entre as regiões brasileiras. A idade média foi de 40,4 anos, e a HS foi mais prevalente entre adolescentes e adultos do que crianças e idosos. TECNOLOGIA: Clindamicina 1% gel ou loção (Clindacne®, Dalacin T® e Clinagel®). PERGUNTA: O uso de clindamicina 1% tópica é seguro, eficaz e custo-efetivo para o tratamento de lesões superficiais na hidradenite supurativa? EVIDÊNCIAS CIENTÍFICAS: Apenas um ensaio clínicoavaliou a eficácia da clindamicina tópica no tratamento da HS. A eficácia do tratamento foi avaliada com um sistema de pontuação projetado para avaliar a "carga" da doença. O estudo mostrou que houve melhoria significativa na pontuação globalde pacientes tratados com clindamicina quando comparado com placebo em todos os momentos do estudo (um, dois e três meses após o início do tratamento) (+350 v.s. -90; p <0,01) Houve uma redução significativa no número de pápulas e pústulas, mas não de nódulos ou abscessos inflamatórios, sugerindo sua indicação para lesões não profundas, e localizadas, comuns nos estágios I e II de Hurley. AVALIAÇÃO DE IMPACTO ORÇAMENTÁRIO: Considerando a população elegível para uso de clindamicina tópica, o impacto orçamentário em 2019 seria cerca de 7 milhões para oferecer o medicamento para indivíduos com menor gravidade da doença (Hurley 1), e cerca de 6 milhões para Hurley 2. Em cinco anos, os gastos com pacientes Hurley 1 e 2 seria de R$ 70.938.810,23. Caso o medicamento fosse disponibilizado para o MS com descontos variando de 40, 60 e 80% no valor PMVG 18%, os custos com tratamento de indivíduos classificados como Hurley 1 e 2, em cinco anos, seriam cerca de 45 milhões, 28,3 milhões e 14 milhões respectivamente. EXPERIÊNCIA INTERNACIONAL: Não foi encontrada nenhuma avaliação da clindamicina tópica para tratamento da HS em nenhuma das agências de Avaliação de Tecnologias em Saúde da Escócia (SMC), Canadá (CADTH) e Inglaterra (NICE).No entanto, na avaliação do adalimumabe para HS moderada a grave, realizada pelo NICE, recomenda o adalimumabe apenas se a doença não estiver respondendo a outros tratamentos convencionais (antibióticos tópicos e orais). MONITORAMENTO DO HORIZONTE TECNOLÓGICO: A análise do monitoramento do horizonte temporal apontou não haver medicamentos nessas fases de desenvolvimento clínico para o tratamento da hidradenite supurativa leve. CONSIDERAÇÕES: Não foi encontrado evidências de alta qualidade para determinar a eficácia da clindamicina tópica nas lesões superficiais na HS. Apesar da pouca evidência, a terapia tem seu uso consagrado na prática clínica e vem sendo recomendado nas diretrizes internacionais de gestão da doença. As diretrizes daEuropean Dermatology Forume consenso de dermatologistas suíços, recomendam a clindamicina tópica duas vezes ao dia por três meses como primeira linha em HS leve a moderada, especialmente quando não há lesões inflamatórias profundas (abscessos). CONSULTA PÚBLICA: Foram recebidas 33 contribuições, sendo que 90% destas foram excluídas por abordarem um tema diferente ou por não conter informação. Por meio do formulário técnicocientífico foram recebidas 10 contribuições, destas 90% concordaram com a recomendação preliminar da CONITEC. Foram três contribuições alusivas às evidências clínicas, todas favoráveis à recomendação inicial, que se basearam nos seguintes argumentos: indicação para as formas superficiais de HS; tem o uso bem difundido pelos especialistas e há consenso entre os experts no assunto quanto a sua utilização. Não houve contribuições sobre avaliação econômica e a análise do impacto orçamentário. Foram recebidas cinco contribuições sobre experiência com a tecnologia, sendo que três de profissionais de saúde e uma de pacientes, todas a favor da recomendação inicial da CONITEC. Os argumentos se basearam nos seguintes fundamentos: eficácia para os casos leves e ineficaz para os estágios Hurley 2 e 3. Após apreciação das contribuições encaminhadas pela Consulta Pública, o plenário da CONITEC entendeu que não houve argumentação suficiente para alterar a recomendação inicial. RECOMENDAÇÃO FINAL: Os membros da CONITEC presentes na 77ª reunião ordinária, no dia 09 de maio de 2019, deliberaram, por unanimidade, por recomendar a incorporação no SUS da clindamicina 1% tópica para o tratamento de lesões superficiais na hidradenite supurativa, mediante Protocolo Clínico e Diretrizes Terapêuticas. Foi assinado o Registro de Deliberação nº 446/2019. DECISÃO: Incorporar a clindamicina 1% tópica para o tratamento de lesões superficiais na hidradenite supurativa, mediante Protocolo Clínico e Diretrizes Terapêuticas, no âmbito do Sistema Único de Saúde ­ SUS. Dada pela Portaria nº 28 de 11 de junho de 2019, publicada no Diário Oficial da União (DOU) nº 112, seção 1, página 126, no dia 12 de junho de 2019.

Vulvovaginitis: screening for and management of trichomoniasis, vulvovaginal candidiasis, and bacterial vaginosis.

OBJECTIVE: To review the evidence and provide recommendations on screening for and management of vulvovaginal candidiasis, trichomoniasis, and bacterial vaginosis. OUTCOMES: OUTCOMES evaluated include the efficacy of antibiotic treatment, cure rates for simple and complicated infections, and the implications of these conditions in pregnancy. EVIDENCE: Published literature was retrieved through searches of MEDLINE, EMBASE, CINAHL, and The Cochrane Library in June 2013 using appropriate controlled vocabulary (e.g., vaginitis, trichomoniasis, vaginal candidiasis) and key words (bacterial vaginosis, yeast, candidiasis, trichomonas vaginalis, trichomoniasis, vaginitis, treatment). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to May 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, and national and international medical specialty societies. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Summary Statements 1. Vulvovaginal candidiasis affects 75% of women at least once. Topical and oral antifungal azole medications are equally effective. (I) 2. Recurrent vulvovaginal candidiasis is defined as 4 or more episodes per year. (II-2) 3. Trichomonas vaginalis is a common non-viral sexually transmitted infection that is best detected by antigen testing using vaginal swabs collected and evaluated by immunoassay or nucleic acid amplification test. (II-2) 4. Cure rates are equal at up to 88% for trichomoniasis treated with oral metronidazole 2 g once or 500 mg twice daily for 7 days. Partner treatment, even without screening, enhances cure rates. (I-A) 5. Current evidence of the efficacy of alternative therapies for bacterial vaginosis (probiotics, vitamin C) is limited. (I) Recommendations 1. Following initial therapy, treatment success of recurrent vulvovaginal candidiasis is enhanced by maintenance of weekly oral fluconazole for up to 6 months. (II-2A) 2. Symptomatic vulvovaginal candidiasis treated with topical azoles may require longer courses of therapy to be resolved. (1-A) 3. Test of cure following treatment of trichomoniasis with oral metronidazole is not recommended. (I-D) 4. Higher-dose therapy may be needed for treatment-resistant cases of trichomoniasis. (I-A) 5. In pregnancy, treatment of symptomatic Trichomonas vaginalis with oral metronidazole is warranted for the prevention of preterm birth. (I-A) 6. Bacterial vaginosis should be diagnosed using either clinical (Amsel's) or laboratory (Gram stain with objective scoring system) criteria. (II-2A) 7. Symptomatic bacterial vaginosis should be treated with oral metronidazole 500 mg twice daily for 7 days. Alternatives include vaginal metronidazole gel and oral or vaginal clindamycin cream. (I-A) 8. Longer courses of therapy for bacterial vaginosis are recommended for women with documented multiple recurrences. (I-A).

Objectif : Analyser les données probantes et formuler des recommandations quant au dépistage et à la prise en charge de la candidose vulvovaginale, de la trichomonase et de la vaginose bactérienne. Issues : Parmi les issues évaluées, on trouve l'efficacité de l'antibiothérapie, les taux de guérison en ce qui concerne les infections simples et compliquées, et les implications de ces pathologies pendant la grossesse. Résultats : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans MEDLINE, EMBASE, CINAHL et The Cochrane Library en juin 2013 au moyen d'un vocabulaire contrôlé (p. ex. «â€¯vaginitis ¼, «â€¯trichomoniasis ¼, «â€¯vaginal candidiasis ¼) et de mots clés (p. ex. «â€¯bacterial vaginosis ¼, «â€¯yeast ¼, «â€¯candidiasis ¼, «â€¯trichomonas vaginalis ¼, «â€¯trichomoniasis ¼, «â€¯vaginitis ¼, «â€¯treatment ¼) appropriés. Les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles. Aucune restriction n'a été appliquée en matière de date, mais les résultats ont été limités aux documents rédigés en anglais ou en français. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en mai 2014. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats est évaluée au moyen des critères décrits par le Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Déclarations sommaires 1. La candidose vulvovaginale affecte 75 % des femmes à au moins une reprise. Les azoles antifongiques topiques et oraux comptent une efficacité équivalente. (I) 2. Pour être qualifiée de récurrente, la candidose vulvovaginale doit donner lieu à quatre épisodes ou plus par année. (II-2) 3. Trichomonas vaginalis est un organisme à l'origine d'une infection transmissible sexuellement non virale courante. Le dépistage des antigènes (écouvillonnages vaginaux analysés au moyen d'un immunoessai ou d'un test d'amplification des acides nucléiques) constitue la meilleure façon d'en détecter la présence. (II-2) 4. La prise en charge de la trichomonase au moyen de métronidazole oral, que ce soit à raison de 2 g en une dose unique ou de 500 mg deux fois par jour pendant 7 jours, permet l'obtention de taux de guérison équivalents pouvant atteindre 88 %. Le traitement du partenaire, même sans dépistage préalable, améliore les taux de guérison. (I-A) 5. Les données probantes dont nous disposons à l'heure actuelle quant à l'efficacité des traitements de médecine parallèle contre la vaginose bactérienne (probiotiques, vitamine C) sont limitées. (I) Recommandations 1. À la suite du traitement initial, la réussite de la prise en charge de la candidose vulvovaginale récurrente est favorisée par la mise en œuvre d'un traitement d'entretien hebdomadaire au fluconazole oral pendant une période pouvant atteindre six mois. (II-2A) 2. La résolution de la candidose vulvovaginale symptomatique prise en charge au moyen d'azoles topiques pourrait nécessiter un traitement d'une durée prolongée. (1-A) 3. À la suite de la prise en charge de la trichomonase au moyen de métronidazole oral, la tenue d'un test de guérison n'est pas recommandée. (I-D) 4. Le recours à des doses accrues pourrait être requis dans les cas de trichomonase qui présentent une résistance au traitement. (I-A) 5. En présence d'une infection à Trichomonas vaginalis symptomatique pendant la grossesse, la prévention de l'accouchement préterme justifie la mise en œuvre d'un traitement au métronidazole oral. (I-A) 6. La vaginose bactérienne devrait être diagnostiquée au moyen de critères cliniques (Amsel) ou de laboratoire (coloration de Gram et système objectif de notation). (II-2A) 7. La vaginose bactérienne symptomatique devrait être prise en charge au moyen de métronidazole oral, à raison de 500 mg deux fois par jour pendant sept jours. Parmi les solutions de rechange, on trouve le gel vaginal de métronidazole et la clindamycine (comprimés oraux ou crème vaginale). (I-A) 8. Chez les femmes qui présentent de multiples récurrences documentées, la prolongation du traitement contre la vaginose bactérienne est recommandée. (I-A).

Alternative treatment approach to cerebral toxoplasmosis in HIV/AIDS: experience from a resource-poor setting.

The current standard treatment for cerebral toxoplasmosis (pyrimethamine/sulfadiazine) often encounters problems of poor tolerability, adverse effects, frequent dropouts and non-availability of pyrimethamine/sulfadiazine in some parts of India. We have had to use the combination of two effective alternative agents for toxoplasmosis, cotrimoxazole and clindamycin, on compassionate grounds. This retrospective observational study reports superior efficacy and better tolerability of cotrimoxazole/clindamycin compared to the recommended regimen. Primary end-point (complete response) was defined as more than 50% improvement of clinical status or more than 50% decrease in the size of brain lesions after two weeks of treatment initiation. Complete response occurred more commonly with cotrimoxazole/clindamycin than with pyrimethamine/sulfadiazine group (80% vs. 31.25%, respectively, relative risk 2.56, 95% confidence interval: 1.21-5.43). There was a trend towards higher on-treatment mortality in the pyrimethamine/sulfadiazine group in comparison to the cotrimoxazole/clindamycin (mortality rate 37.5% in pyrimethamine/sulfadiazine vs 12% in cotrimoxazole/clindamycin, p = 0.07, relative risk = 3.125, 95% confidence interval: 0.91-10.75). Overall, 62.5% (10/16) of patients on pyrimethamine/sulfadiazine suffered drug-related adverse reactions compared to 24% (6/25) on cotrimoxazole/clindamycin (p = 0.02, relative risk = 2.60, 95% confidence interval: 1.17-5.76). The commonest complication of pyrimethamine/sulfadiazine was severe thrombocytopenia with major bleeding (4/16, 25%). We propose that the new combination chemotherapy, which is widely available, effective and safe, can be used in developing countries.

[Research-based assessment of antibiotic resistance of beta hemolytic group B streptococci]. / Ocena opornosci paciorkowców beta hemolizujacych grupy B na podstawie badan wlasnych.

UNLABELLED: Since the 1950s, beta hemolytic streptococcus group B have constituted the major etiological factor of perinatal infections. GBS colonization of the genital tract among pregnant women is diagnosed between 35 and 37 weeks of gestation, and is associated with approximately 25% risk of neonatal early-onset infections (EOD). The infection is severe among 1-3% of the newborns, and usually results in sepsis or pneumonia. beta-lactam antibiotics are drugs of choice to prevent vertical infection of group B streptococcus. In case of hypersensitivity to penicillin among pregnant women, second line drugs are macrolides and lincosamides. OBJECTIVE: In light of numerous reports on the decreasing susceptibility of GBS, the aim of this study was to characterize the isolated strains of Streptococcus agalactiae in terms of their resistance to antibiotics. MATERIAL: The study included 395 pregnant women in the third trimester of pregnancy hospitalized in the Department of Perinatology and Department of Gynecology and Obstetrics, Medical University of Lodz, between 02.2010 -02.2012. METHODS: Vagino-rectal swabs were collected from all pregnant women. We recovered 121 GBS positive isolates. Identification was based on the streptococcal agglutination test. Antimicrobial susceptibility was determined by disk diffusion method. RESULTS: A positive result for GBS colonization was found among 89 patients, representing 22.5% of the studied population. Inducible MLSB resistance to erythromycin and clindamycin was 23.1% and 10.7% of the isolated strains, respectively Constitutive MLSB resistance was detected in 14.9% of the cases. CONCLUSIONS: The obtained results confirm that all GBS isolates are sensitive to beta-lactam antibiotics and prove that phenotypes resistant to macrolides and clindamycin are becoming more widespread. This leads to the conclusion that regular supervision of drug sensitivity of Streptococcus agalactiae is necessary

The trends in antibiotic use by general dental practitioners in the Czech Republic (2006-2012).

We assessed antibiotic prescribing in practical dentistry in the Czech Republic, as antibiotics are widely prescribed by dental practitioners and warning signals of their overuse can be observed. The individual antibiotic prescriptions were extracted from the database of the General Health Insurance Company and further analysed. The proportion of dentists' prescription within the whole primary health-care sector and the rate of prescriptions of particular antibiotics were both in defined daily doses per 1,000 insurees and day (DID) and in number of prescriptions calculated. The proportion of antibiotic use in dentistry increased from 0.63 DID in 2006 to 0.75 DID. We found a decline in use of narrow-spectrum penicillins by 4.8%, tetracyclines by 3.5% and macrolides by 3.6%, accompanied by increasing rate of prescription of aminopenicillins combined with beta-lactamase inhibitor by 8.9% and lincosamides by 8.5%. The consumption of clindamycin and amoxicillin combined with clavulanate in DID has increased by approximately 60% since 2006 thanks to the exclusive prescribing of two commercial oral products only. Factors contributing to this unfavourable trend are commercial influence or defensive medicine practice.

A practical guide to community-acquired MRSA.

As the number of CA-MRSA skin and soft tissue infections continues to grow, it's important to know which patients are at greatest risk and which evidence-based treatment protocols to turn to when needed.

Uso de cemento con antibióticos en la artroplastía total primaria de cadera y rodilla / Use of antibiotic-loaded bone cement in primary hip and knee arthroplasty

INTRODUCCIÓN: La Artroplastia total primaria de cadera (ATC) y la Artroplastia total primaria de rodilla (ATR) consisten en reemplazar las superficies articulares enfermas con materiales sintéticos, para aliviar el dolor, mejorar la movilidad, la función articular y la calidad de vida. Una de las complicaciones graves y comunes a ATC y ATR es la infección, que no supera el 1% pero puede suponer incluso la reintervención o retirada de la prótesis. Para evitar la infección se utiliza profilaxis antibiótica sistémica preoperatoria como estándar de cuidado para todos los pacientes sometidos a ATC y ATR primaria. Se postula el uso de cemento con antibiótico añadido a la profilaxis antibiótica sistémica ya que podría potencialmente disminuir la tasa de infección y revisión. TECNOLOGÍA: El cemento óseo es una resina acrílica para la fijación de la prótesis al tejido óseo receptor. Permite la liberación de antibiótico (gentamicina, eritromicina, colistina, tobramicina, vancomicina, clindamicina o ácido fusídico) directamente en el sitio de la intervención donde podría desarrollarse infección. OBJETIVO: El objetivo del presente informe es evaluar la evidencia disponible acerca de la eficacia, seguridad y aspectos relacionados a las políticas de cobertura del uso de cemento con antibiótico en la artroplastia primaria de cadera y rodilla. MÉTODOS: Se realizó una búsqueda en las principales bases de datos bibliográficas DARE, NHS EED en buscadores genéricos de Internet, agencias de evaluación de tecnologías sanitarias y financiadores de salud. Se priorizó la inclusión de revisiones sistemáticas, ensayos clínicos controlados aleatorizados (ECAs), evaluaciones de tecnologías sanitarias (ETS) y económicas (EE), guías de práctica clínica y políticas de cobertura de otros sistemas de salud. RESULTADOS: Se incluyeron tres revisiones sistemáticas, cinco ECAs, un registro de artroplastia, una ETS, una EE y tres guías de práctica clínica. Artroplastia de cadera: Dos ECAs de 2006 y 2012 incluyeron 60 y 23 pacientes respectivamente. No encontraron diferencias estadísticamente significativas en ninguno de los resultados medidos entre las ATC primarias tratadas con cemento con ATB versus cemento sin ATB. Un análisis retrospectivo del registro noruego de artroplastia publicado en 2003 incluyó 15.740 ATC, en las que se usó profilaxis sistémica combinada con cemento con ATB y 5.986 donde se usó solo ATB sistémico. Mostró un mayor riesgo de revisión en pacientes tratados con profilaxis sistémica sola. Reportaron un HR de revisión para todas las causas de 1,4 (IC95% 1,1- 1,7), un HR cuando la causa fue infección de 1,8 (IC95% 1,1 ­ 3) y un HR de revisión por aflojamiento aséptico de 1,3 (IC 95% 1,0-1,7), para aquellos que recibieron profilaxis sistémica sola. Artroplastia de rodilla: Un ECA de 2001 que se realizó en pacientes diabéticos (78 ATR) y otro ECA de 2002 (340 ATR), aleatorizaron pacientes a recibir profilaxis antibiótica sistémica más cemento con cefuroxima o más cemento sin ATB. La media de seguimiento fue de 50 meses. Para los pacientes diabéticos reportaron una tasa de infección profunda de 0% en los pacientes tratados con cemento con ATB versus 13,5% en los pacientes tratados con cemento sin ATB (p<0,05). En el estudio de 2002 reportaron una tasa de infección profunda de 0% en los tratados con cemento con cefuroxima versus 3,1% en los pacientes tratados con cemento sin ATB (p<0,05). Otro ECA de 2013 aleatorizó 2948 ATR a recibir profilaxis sistémica más cemento con ATB (eritromicina y colestina) o más cemento sin ATB. No encontraron diferencias estadísticamente significativas en la tasa de infección profunda ni en la tasa de infección superficial entre los dos grupos. No registraron efectos adversos relacionados con el uso de cemento con ATB. Las guías de práctica clínica recomiendan como estrategia más efectiva para la prevención de la infección la combinación de antibióticos sistémicos más cemento con ATB; salvo una de ellas que recomienda la adición de cemento con ATB únicamente en pacientes de alto riesgo. Una ETS alemana de 2010 evaluó la efectividad y costo-efectividad del cemento con ATB para ATC primaria. Concluyó que en los quirófanos sin medidas de limpieza de aire el cemento con ATB debería ser usado adicionalmente a la profilaxis intravenosa. Recomienda realizar nuevos estudios con mayor calidad metodológica. CONCLUSIONES: La evidencia encontrada para ATC primaria fue de moderada calidad y mostró que el cemento con ATB podría aportar beneficio clínico adicional a la profilaxis sistémica, si bien no existen ECAs de adecuada calidad que avalen esta indicación. La evidencia encontrada para ATR fue de alta calidad aunque contradictoria en cuanto a los resultados. Algunos estudios mostraron beneficios al añadir cemento con antibiótico a la profilaxis antibiótica sistémica, sin embargo el ECA más reciente y con mayor número de pacientes no encontró beneficio clínico asociado con el uso de cementos con antibiótico. A pesar de que tanto en el caso de ATC como de ATR la evidencia no es concluyente las guías de práctica clínica suelen avalar su uso, aunque en algunos casos limitan su utilización solo para pacientes considerados de alto riesgo.(AU)

INTRODUCTION: Total primary hip arthroplasty (THA) and total primary knee arthroplasty (TKA) involve replacing the diseased joint surfaces with synthetic materials to relieve pain, improve motion, joint function and quality of life. One of the most common and severe complications of THA and TKA is infection, not exceeding 1%, but it even may involve new surgical interventions or prosthesis removal. To prevent infections, preoperative systemic antibiotic prophylaxis is used as standard of care for all patients undergoing primary THA and TKA. The use of antibiotic-loaded bone cement in combination with systemic antibiotic prophylaxis has been postulated since it might decrease the rate of infection and revision surgery. TECHNOLOGY: Bone cement is an acrylic resin used to fix the prosthesis to the host bone tissue. It allows antibiotic release (gentamicin, erythromycin, colistin, tobramycin, vancomycin, clindamycin or fusidic acid) directly in the surgical area where the infection might develop. PURPOSE: The purpose of this report is to assess the evidence available on the efficacy, safety and coverage policy related issues on the use of antibiotic-loaded bone cement in primary hip and knee arthroplasty. METHODS: A bibliographic search was carried out on the main databases: DARE, NHS EED, on Internet general search engines, in health technology evaluation agencies and health sponsors. Priority was given to the inclusion of systematic reviews; controlled randomized clinical trials (RCTs); health technology assessments (HTAs) and economic evaluations (EEs); clinical practice guidelines and coverage policies of other health systems. RESULTS: Three systematic reviews, five RCTs, one arthroplasty record, one HTA, one EE and three clinical practice guidelines were included. Hip arthroplasty: Two RCTs from 2006 and 2012 included 60 and 23 patients, respectively. No statistically significant differences were found in any of the results measured between primary THA treated with antibiotic-loaded bone cement vs. cement without antibiotics (ATB). A retrospective analysis from the Arthroplasty Norwegian Registry published in 2003 included 15,740 THAs, where systemic prophylaxis combined with ATB-loaded bone cement was used and 5,986 cases where only systemic ATB was used. It showed a higher risk of revision surgery inpatients treated with systemic prophylaxis alone. A HR for all cause revision surgery of 1.4 (95%CI 1.1 - 1.7) was reported; a 1.8 HR when the cause was infection (95%CI 1.1 ­ 3) and a 1.3 HR for revision surgery due to aseptic loosening (95%CI 1.0 - 1.7), for those who received systemic prophylaxis alone. Knee arthroplasty: One RCT from 2001 conducted on diabetic patients (78 THAs) and another RCT from 2002 (320 TKAs) randomized patients to systemic antibiotic prophylaxis plus cefuroxime-loaded cement or cement without ATB. The mean follow-up was 50 months. For diabetic patients the rate of deep infections reported was 0% in patients treated with ATB-loaded cement vs. 13.5% in patients treated with cement without ATB (p<0.05). In the study conducted in 2002, the reported rate of deep infections was 0% in the patients treated with cefuroxime-loaded cement vs. 3.1% in the patients treated with cement without ATB (p<0.05). Another RCT from 2013, randomized 2,948 TKA patients to systemic prophylaxis plus ATB-loaded cement (erythromycin and colistin) or plus cement without ATB. No statistically significant differences were found in the rate of deep infections or in the rate of superficial infections between both groups. No other related adverse effects were reported with the use of ATB-loaded cement. Clinical practice guidelines recommend preventing infections, to combine systemic antibiotics plus ATB-loaded cement as a more effective strategy; except one which recommends adding ATB-loaded cement only for high risk patients. One German HTA from 2010 evaluated the effectiveness and cost-effectiveness of using ATB-loaded cement for primary THA. It concluded that in surgical rooms with no air purifying measures, the ATB-loaded cement should be used only in addition to intravenous prophylaxis. It recommends performing new studies of better methodological quality. CONCLUSIONS: The evidence found for primary THA was of moderate quality and it showed that ATB-loaded cement might add some clinical benefit to systemic prophylaxis, although there are no RCTs of adequate quality supporting this indication. The evidence found for TKAs was of good quality although contradictory regarding results. Some studies showed the benefits of adding ATB-loaded cement to the systemic antibiotic prophylaxis, however the most recent RCT, with the largest number of patients enrolled, found no clinical benefits associated to the use of antibiotic-loaded cement. In spite of the fact that evidence is not conclusive for THA and TKA, the clinical practice guidelines usually support its use, although in some cases they restrict it to patients considered at high risk.(AU)

INTRODUÇÃO: A Artroplastia total primária de quadril (ATQ) e a Artroplastia total primária de joelho (ATJ) consistem em substituir as superfícies articulares doentes com materiais sintéticos, para aliviar a dor, melhorar a mobilidade, a função articular e a qualidade de vida. Uma das complicações graves e comuns à ATQ e ATJ é a infecção, que não supera 1%, mas pode supor inclusive a re-intervenção ou retirada da prótese. Para evitar a infecção utiliza-se profilaxia antibiótica sistêmica pré-operatória como padrão de cuidado para todos os pacientes submetidos a ATQ e ATJ primária. Postula-se o uso de cimento com antibiótico adicional à profilaxia antibiótica sistêmica já que poderia potencialmente diminuir a taxa de infecção e revisão. TECNOLOGIA: O cimento ósseo é uma resina acrílica para a fixação da prótese ao tecido ósseo receptor. Permite a liberação de antibiótica (gentamicina, eritromicina, colistina, tobramicina, vancomicina, clindamicina ou ácido fusídico) diretamente no local la intervenção onde poderia desenvolver-se a infecção. OBJETIVO: O objetivo do presente informe é avaliar a evidência disponível sobre a eficácia, segurança e aspectos relacionados às políticas de cobertura do uso de cimento com antibiótico na artroplastia primária de quadril e joelho. MÉTODOS: Realizou-se uma busca nas principais bases de dados bibliográficos DARE, NHS EED, em buscadores genéricos de Internet, agências de avaliação de tecnologias sanitárias e financiadores de saúde. Priorizou-se a inclusão de revisões sistemáticas, ensaios clínicos controlados aleatorizados (ECAs), avaliações de tecnologias em saúde (ATS) e econômicas (EE), guias de práticas clínica (GPC) e políticas de cobertura de outros sistemas de saúde. RESULTADOS: Incluíram-se três revisões sistemáticas, cinco ECAs, um registro de artroplastia, uma ATS, uma EE, três GPC. Artroplastia de quadril: Dois ECAs de 2006 e 2012 incluíram 60 e 23 pacientes respectivamente. Não encontraram diferenças estatisticamente significativas em nenhum dos resultados medidos entre as ATQ primárias tratadas com cimento com ATB versus cimente sem ATB. Uma análise retrospectiva do registro norueguês de artroplastia publicado em 2003 incluiu 15.740 ATQ, nas que se usou profilaxia sistêmica combinada com cimento com ATB e 5.986 onde se usou somente ATB sistêmico. Mostrou um maior risco de revisão em pacientes tratados com somente a profilaxia sistêmica. Reportou um HR de revisão por todas as causas de 1,4 (IC95% 1,1 a 1,7), um HR quando a causa foi infecção de 1,8 (IC95% 1,1, a 3) e um HR de revisão por afrouxamento asséptico de 1,3 (IC95% 1,0 a 1,7), para aqueles que receberam profilaxia sistêmica somente. Artroplastia de joelho: Um ECA de 2001 que se realizou em pacientes diabéticos (78 ATJ) e outro ECA de 2002 (340 ATQ) randomizaram pacientes a receber profilaxia antibiótica sistêmica mais cimento com cefuroxima ou mais cimento sem ATB. A média de seguimento foi de 50 meses. Para os pacientes diabéticos reportaram uma taxa de infecção profunda de 0% nos pacientes tratados com cimento com ATB versus 13,5% nos pacientes tratados com cimento sem ATB (p<0,05). No estudo de 2002 reportaram uma taxa de infecção profunda de 0% nos tratados com cimento com cefuroxima versus 3,1% nos pacientes tratados com cimento sem ATb (p<0,05). Outro ECA de 2013 randomizou 2948 ATJ a receber profilaxia sistêmica mais cimento com ATB (eritromicina e colestina) ou mais cimente sem ATB. Não se encontraram diferenças estatisticamente significativas na taxa de infecção profunda nem na taxa de infecção superficial entre os dois grupos. Não registraram efeitos adversos relacionados com o uso do cimento com ATB. Os guias de prática clínica recomendam como estratégia mais efetiva para a prevenção da infecção combinado de antibióticos sistêmicos mais cimento com ATB; salvo uma delas que recomenda a adição de cimento com ATB unicamente para pacientes de alto risco. Uma ATS alemã de 2010 avaliou a efetividade e custo-efetividade do cimento com ATB para a ATQ primária. Concluiu que nas salas cirúrgicas sem medidas de limpeza de ar, o cimento com ATB deveria ser usado adicionalmente à profilaxia intravenosa. Recomenda realizar novos estudos com maior qualidade metodológica. CONCLUSÕES: A evidencia encontrada para ATQ primária foi de moderada qualidade e mostrou que o cimento com ATB poderia aportar benefício clínico adicional à profilaxia sistêmica, se bem não existe ECAs de adequada qualidade que sustente esta indicação. A evidência encontrada para ATJ foi de alta qualidade ainda que contraditória quanto aos resultados. Alguns estudos mostraram benefícios ao adicionar cimento com antibiótico à profilaxia antibiótica sistêmica, embora o ECA mais recente e com maior número de pacientes não encontrou benefício clinico associado com o uso de cimentos com antibiótico. A pesar de que tanto no caso da ATQ como da ATJ a evidencia não é conclusiva, as guias de práticas clinica costumam sustentar seu uso, ainda quem em alguns casos limitam sua utilização somente para paciente considerados de alto risco.(AU)

Assessment of methicillin and clindamycin resistance patterns in Staphylococcus aureus isolated from a tertiary hospital in Turkey.

In order to detect the methicillin susceptibility and determine the prevalence of constitutive and inducible clindamycin resistance in Staphylococcus aureus strains, a total of 254 S. aureus isolates, including 139 (54.7%) methicillin-sensitive and 115 (45.3%) methicillin-resistant, were tested for clindamycin and erythromycin by Kirby-Bauer disk diffusion method. The disk diffusion induction test or D-test was performed on erythromycin-resistant and clindamycin-sensitive strains using the disk diffusion method. The erythromycin-resistant and clindamycin-sensitive strains with a D-shaped zone around the clindamycin disk were considered positive for inducible clindamycin resistance. If a strain was found to be both erythromycin-resistant and clindamycin-resistant, it was considered to have constitutive clindamycin resistance. Overall, ten (3.9%) strains, including two methicillin-resistant S. aureus and eight methicillin-sensitive S. aureus, were found to be erythromycin-resistant and clindamycin-sensitive according to the disk diffusion method and all of these strains showed inducible clindamycin resistance by the D-test method. Constitutive clindamycin resistance was detected in 100 of all MRSA strains. In conclusion, the presence of inducible clindamycin-resistant strains may lead to clindamycin treatment failure in patients with S. aureus infection. The D-test method should be used for antimicrobial susceptibility testing of clindamycin.

Comparing a combination of penicillin G and gentamicin to a combination of clindamycin and amikacin as prophylactic antibiotic regimens in prevention of clean contaminated wound infections in cancer surgery.

BACKGROUND AND AIM: Appropriate antibiotic selection and timing of administration for prophylaxis are crucial to reduce the likelihood of surgical site infection (SSI) after a clean contaminated cancer surgery. Our aim is to compare the use of two prophylactic antibiotic (PA) regimens as regards efficacy, timing, and cost. PATIENTS AND METHODS: Two hundred patients with gastric, bladder, or colorectal cancer were randomized to receive preoperative PA, group A received penicillin G sodium and gentamicin and group B received clindamycin and amikacin intravenously. The demographic data of patients were collected, and they were observed for wound infections. RESULTS: Infected wounds occurred in 19 patients with a rate of 9.5%. Highest incidence of SSI was among bladder cancer patients (14.2%); p=0.044. The rate of SSI was 11% in group A, and 8% in group B, p=0.469. The cost of PA administered in group A was significantly less than that of group B (21.96±3.22LE versus 117.05±12.74LE, respectively; p<0.001). SSI tended to be higher among those who had longer time for antibiotic and incision (≥30min) than those who had shorter time interval (<30min), (13% vs. 6.5%, respectively). CONCLUSION: Both penicillin+gentamicin and clindamycin+amikacin are safe and effective for the prevention of SSI in clean contaminated operative procedures. In a resource limited hospital, a regimen including penicillin+gentamicin is a cost-effective alternative for the more expensive and broader coverage of clindamycin+amikacin. Timing of PA is effective in preventing SSIs when administered 30min before the start of surgery.

Aborto infectado: epidemiologia, diagnóstico e conduta na urgência: [revisão] / Infected abortion: epidemiology, diagnosis and management in emergency: [review]

Abortamento é a expulsão ou extração de um produto da concepção sem sinais de vida com menos de 500 gramas ou 22 semanas de gestação. O aborto infectado ou séptico decorre da eliminação incompleta do ovo, do embrião ou da placenta, que mantém aberto o canal cervical, favorecendo a ascensão de bactérias da microbiota vaginal e intestinal à cavidade uterina. A real magnitude do abortamento é desconhecida devido à sua ilegalidade. No Brasil, há subnotificação de casos e complicações, pois nem todas as mulheres demandam assistência pós-abortamento. Ainda assim, os dados oficiais justificam a adoção de medidas preventivas e de promoção da saúde reprodutiva. O diagnóstico de aborto séptico deve ser considerado quando uma mulher na menacme apresentar atraso menstrual, sangramento vaginal, febre, dor hipogástrica e à mobilização do colo uterino. Exige tratamento imediato. Prefere-se a associação gentamicina/clindamicina.

Abortion is the expulsion or extraction of a product of conception, with no signs of life, with less than 500 grams or 22 weeks of gestation. Infected or septic abortion stems from partial removal of the egg, embryo or placenta, which keeps open the cervical channel, encouraging the rise of intestinal and vaginal bacteria to the uterine cavity. The real magnitude of abortion is unknown due to its illegality. In Brazil, there is underreporting of cases and complications because not all women require assistance in post-abortion care services. Still, official data justify the adoption of preventive measures and of reproductive healthÆs promotion. The diagnosis of septic abortion should be considered when a woman of childbearing age has missed period, vaginal bleeding, fever, hypogastric pain and pain by the cervix mobilization. It requires immediate treatment. The association of gentamicin/clindamycin is chosen.

Antibiotic selection for purulent skin and soft-tissue infections in ambulatory care: a decision-analytic approach.

OBJECTIVE: Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has caused a nationwide epidemic of skin and soft-tissue infections in ambulatory pediatrics. Antibiotic treatment recommendations suggest incorporating local epidemiology for the prevalence of CA-MRSA. We sought to identify the antibiotic strategy with the highest probability of activity and to identify threshold values for epidemiologic variables including bacterial prevalence and antibiotic resistance. METHODS: We used decision analysis to evaluate 3 empiric antibiotic strategies: clindamycin, trimethoprim/sulfamethoxazole (T/S), and cephalexin. We calculated the probability of activity against the bacteria causing the infection (CA-MRSA, methicillin-sensitive S. aureus and group A Streptococcus [GAS]) by incorporating estimates of prevalence and antibiotic resistance to determine the optimal strategy. Sensitivity analysis was used to identify thresholds for prevalence and antibiotic resistance where 2 strategies were equal. RESULTS: Clindamycin (0.95) and T/S (0.89) had substantially higher probability of activity than cephalexin (0.28) using baseline estimates for bacterial prevalence and antibiotic resistance. Cephalexin was the optimal antibiotic only when CA-MRSA prevalence was <10%. The probability of activity for clindamycin and T/S was highly sensitive to changes in the values for bacterial prevalence (both CA-MRSA and GAS) and CA-MRSA resistance to clindamycin. CONCLUSIONS: Empiric treatment of skin and soft-tissue infections with either clindamycin or T/S maximizes the probability that the antibiotic will be active when CA-MRSA prevalence is >10%. Deciding between T/S and clindamycin requires consideration of antibiotic resistance and prevalence of GAS. This model can be customized to local communities and illustrates the importance of ongoing epidemiologic surveillance in primary care settings.

[Cost-effectiveness of the treatment of acute and chronic rhinosinusitis at the IMSS]. / Costo-efectividad del tratamiento de rinosinusitis aguda y crónica en el IMSS.

INTRODUCTION: Rhinosinusitis is one of the more common diseases encountered in outpatient visits to health care. The objective of this study was to determine the most cost-effective antibiotic treatment for patients with acute (RSA) and chronic rhinosinusitis (RSC) that is available at the Mexican Institute of Social Security (IMSS). METHODS: Cost-effectiveness analysis of RSA and RSC treatment from an institutional perspective. Effectiveness outcome was defined as the percentage of cure. A decision tree with a Bayesian approach included the following therapeutic alternatives: ciprofloxacin, gatifloxacin, trimetoprim/sulfametoxazol (TMP/SMX), amoxicilin/clavulanic acid (AAC) and clindamicin. RESULTS: Treatment for RSA with AAC showed a mean cost per cured patient of $ 878 pesos. The remaining antibiotics had a higher cost per unit of success, and therefore the results showed that AAC was the best alternative considering this criterion. The therapy that showed a larger percentage of cured patients in RSC was clindamicin; however, the therapeutic alternative with the lowest cost per successful unit was the one based on ciprofloxacin, which dominates gatifloxacin and AAC. CONCLUSIONS: The most cost-effective alternative in the antibiotic treatment of patients with RSA was ACC while for RSC it was ciprofloxacin; sensitivity analysis showed the strength of the base study results.

Nosocomial pneumonia: third-group chinolone versus clindamycin/ceftriaxone in modulation of the acute phase reaction and outcome and cost efficacy.

The effect of a third-group chinolone and clindamycin/ceftriaxone regarding outcome of patients with nosocomial pneumonia (NP) and modulation of the acute phase reaction as measured by immunologic parameters were studied in a prospective randomized trial on a surgical intensive care unit (ICU), as well as a comparison of therapy costs. Determination in 18 patients of serum tumor necrosis factor (TNF)-alpha, interleukin (IL)-6, procalcitonin, and endotoxin levels and assessment of clinical outcome of NP were followed by the calculation of therapy costs. Decline in all immunologic parameters between the first and last measurement of each patient was slightly greater for clindamycin patients but statistically significant only for TNF-alpha. One-day therapy costs were 63.5 Euro (chinolone) versus 86.9 Euro (clindamycin/ceftriaxone). There was no difference in the outcome of NP treated with either a third-group chinolone or clindamycin/ceftriaxone.