Management in the emergency room of patients requiring hospital treatment of community-acquired pneumonia / Manejo en la sala de urgencias de pacientes con neumonía adquirida en la comunidad que requieren tratamiento hospitalario

Introduction. To identify factors influencing decisions ininitial management of community-acquired pneumonia(CAP) admitted to hospital through Emergency departments.Methods. Records of CAP adult patients admitted to 24Spanish hospitals in January-Mars 2003 were reviewed. Patientssent for ambulatory treatment were excluded.Results. 341 patients (67.0 ± 24.6 years; 65.3 % males)were included; 39 % were taking antibiotics at attendance.PSI was (% patients): I-II (19.7 %), III (14.7 %), and IV-V(65.6 %). Comorbidities were: COPD (37.2 %), heart disease(24.6 %), hypertension (17 %), diabetes mellitus (10.8 %),and malignancies (10 %). Pneumococcal/Legionella urinaryantigens were performed in 34.0 %/42.2 % patients. Fewer(p ≤ 0.006) rapid tests were performed in class IV-V(p = 0.001), with higher (p ≤ 0.01) pneumococcal positiveresults in class V. Initial treatment was fluoroquinolone(37.5 %), beta-lactam + macrolide (26.4 %), beta-lactam(22.9 %), macrolide (4.7 %), and others (8.5 %). Patients referredto Internal Medicine had higher heart disease(p = 0.06) and hypertension (p = 0.001) as comorbidity thanthose at Short-Stay Units or Pneumology. COPD patientswere equally distributed between Internal Medicine andPneumology, with differences vs. Short-Stay Units.Conclusions. Rapid diagnostic tests were underused,maybe due to broad empirical treatments covering drug-resistantpneumococci and L. pneumophila (regardless PSI andcomorbidity). Presence of comorbidities or positive resultsin rapid diagnostic tests seems to influence the medicalward to which the patient is referred to, but not initialtreatment (AU)

Introducción. Identificación de los factores que influyenen el manejo inicial de los pacientes con neumoníaadquirida en la comunidad (NAC) ingresados en el hospitala través de los Servicios de Urgencias.Material y métodos. Se revisaron los registros de pacientesadultos con NAC admitidos en 24 hospitales españolesen el período comprendido entre los meses deenero-marzo de 2003. Los pacientes remitidos para tratamientoambulatorio fueron excluidos.Resultados. Se incluyeron 341 pacientes (67,0 ± 24,6años; 65,3 % varones). El 39 % estaba tomando antibióticosen el momento de atención en Urgencias. El grado deFine de los pacientes fue (% pacientes): I-II (19,7 %),III (14,7 %), y IV-V (65,6 %). Las comorbilidades fueron:EPOC (37,2 %), enfermedad coronaria (24,6 %), hipertensión(17 %), diabetes mellitus (10,8 %) y neoplasia (10 %). Lostests de antígenos urinarios de neumococo y Legionellafueron realizados en 34,0 % y 42,2 % pacientes respectivamente.En las clases IV-V (p ≤ 0,006) se realizaron menostests rápidos, con mayor número de resultados positivospara neumococos (p ≤ 0,01) en la clase V. El tratamientoinicial fue fluoroquinolonas (37,5 %), betalactámico +macrólido(26,4 %), betalactámico (22,9 %), macrólido (4,7 %),y otros (8,5 %). Los pacientes ingresados en Medicina Internatenían una mayor incidencia de enfermedad cardiaca(p = 0,06) e hipertensión (p = 0,001) como comorbilidadque aquellos ingresados en Neumología o en Unidades deCorta Estancia. Los pacientes con EPOC fueron igualmentedistribuidos entre Medicina Interna y Neumología, con diferenciasrespecto a las Unidades de Corta Estancia.Conclusiones. Los tests diagnósticos rápidos fueron infrautilizados,debido posiblemente a la amplia cobertura delos tratamientos empíricos cubriendo neumococo resistente yL. pneumophila (independientemente del Fine y la comorbilidad) (AU)

Has the licensing of respiratory quinolones for adults and the 7-valent pneumococcal conjugate vaccine (PCV-7) for children had herd effects with respect to antimicrobial non-susceptibility in invasive Streptococcus pneumoniae?

OBJECTIVES: The aim of the study was to analyse the evolution of antibiotic non-susceptibility in Spanish invasive Streptococcus pneumoniae after licensure of respiratory-quinolones for adults and 7-valent pneumococcal conjugate vaccine (PCV-7) for immunization of children. METHODS: All invasive pneumococci received in the Reference Laboratory (January 2000-August 2007; n = 12 957 isolates) were serotyped, and susceptibility to penicillin/erythromycin/levofloxacin was determined. Antibiotic consumption and PCV-7 doses/year were provided by IMS and the manufacturer, respectively. RESULTS: In 2000-07, PCV-7 distribution (doses/1000 inhabitants

Influence of penicillin/amoxicillin non-susceptibility on the activity of third-generation cephalosporins against Streptococcus pneumoniae.

To study the influence of penicillin/amoxicillin non-susceptibility on the activity of third-generation cephalosporins, 430 consecutive penicillin non-susceptible Streptococcus pneumoniae 2007 isolates received in the Spanish Reference Pneumococcal Laboratory were tested. For comparative purposes, 625 penicillin-susceptible 2007 isolates were also tested. Susceptibility was determined by agar dilution using Mueller-Hinton agar supplemented with 5% sheep blood. Penicillin-susceptible strains were susceptible to amoxicillin, cefotaxime and ceftriaxone, 99.8% to cefpodoxime and 99.5% to cefdinir, and were inhibited by 0.12 microg/ml of cefditoren and 4 microg/ml of cefixime. Penicillin-intermediate strains were susceptible to cefotaxime and ceftriaxone, with <50% susceptibility to cefdinir and cefpodoxime. The MIC(50) and MIC(90) values of cefditoren were 0.25 microg/ml and 0.5 microg/ml, respectively, whereas cefixime exhibited only marginal activity (MIC(90)=16 microg/ml). Penicillin-resistant strains were resistant to cefdinir and cefpodoxime, with 74.8% and 94.1% susceptibility to cefotaxime and ceftriaxone, respectively. Cefditoren MIC(50)/MIC(90) (0.5/1 microg/ml) were lower than cefotaxime and ceftriaxone. Among amoxicillin non-susceptible strains, susceptibility to cefdinir and cefpodoxime was <10%, and susceptibility to cefotaxime decreased from 87.9% in the intermediate category to 63.0% in the resistant group. Cefditoren MIC(50)/MIC(90) (0.5/1 microg/ml) were lower than cefotaxime. In conclusion, the activity of cefixime, cefdinir and cefpodoxime was highly affected by penicillin/amoxicillin non-susceptibility, while parenteral third-generation cephalosporins exhibited higher intrinsic activity (MIC(90)=1 microg/ml for penicillin-resistant and 2 microg/ml for amoxicillin-resistant strains). Cefditoren exhibited one-dilution lower MIC(90) values for these strains, even against those of the most troublesome serotypes.

Odontogenic bacteria in periodontal disease and resistance patterns to common antibiotics used as treatment and prophylaxis in odontology in Spain.

Resistance in streptococci or Gram-negative bacteria is associated with antibiotic consumption. Scarce information exists on the antibiotic susceptibility of bacterial isolates from patients with periodontitis in countries with high antibiotic consumption, as this is an area in which microbiological testing is not performed in daily practice. The present study was undertaken to explore the susceptibility of bacterial isolates in periodontitis to antibiotics prescribed in odontology in Spain as treatment for local infections or prophylaxis for distant focal infections. Periodontal samples were prospectively collected in 48 patients classified by pocket depth of <4 mm and >or=4 mm. Species were identified by culture, selecting the five most frequent morphotypes per sample, and polymerase chain reaction (PCR). Susceptibility was determined by E-test. A total of 261 isolates were identified: 72.9% patients had Streptococcus oralis; 70.8% Streptococcus mitis; 60.4% Prevotella buccae; 39.6% Prevotella denticola; 37.5% Fusobacterium nucleatum; 35.4% Prevotella intermedia; 25% Capnocytophaga spp.; 23% Veillonella spp.; 22.9% Prevotella melaninogenica and Streptococcus sanguis; and <20% other species. Streptococcus viridans resistance rates were 0% for amoxicillin, approximately 10% for clindamycin, 9-22% for tetracycline, and for azithromycin ranged from 18.2% for S. sanguis to 47.7% for S. mitis. Prevotella isolates were susceptible to amoxicillin-clavulanic acid, with amoxicillin resistance ranging from 17.1% in P. buccae to 26.3% in P. denticola. Metronidazole resistance was <6% in all Prevotella species, while clindamycin resistance ranged from 0 to 21.1%. beta-Lactamase production was positive in 54.1% Prevotella spp., 38.9% F. nucleatum, 30% Capnocytophaga spp., and 10% Veillonella spp. In this study, amoxicillin-clavulanic acid was the most active antibiotic against all species tested, followed by metronidazole in the case of anaerobes.

Odontogenic bacteria in periodontal disease and resistance patterns to common antibiotics used as treatment and prophylaxis in odontology in Spain

La resistencia de los estreptococos o de las bacterias gramnegativas se asocia al consumo antibiótico, pero existe escasa información sobre la sensibilidad de los aislamientos de pacientes con periodontitis en los países con alto consumo de antibióticos, como es España; datos que pueden ser importantes cuando en la práctica diaria no se realizan determinaciones microbiológicas. En este estudio se analiza la sensibilidad de aislamientos de periodontitis a los antibióticos prescritos habitualmente en España en odontología para el tratamiento de infecciones locales o la profilaxis de infecciones a distancia. Se tomaron de forma prospectiva muestras periodontales de 48 pacientes clasificados, según la profundidad de la bolsa, en dos grupos: <4 mm y ≥ 4 mm. La identificación de las especies se realizó por PCR y por cultivo, seleccionando los cinco morfotipos más frecuentes en cada muestra. La sensibilidad antibiótica se determinó por E-test®. Se identificaron 261 cepas. El 72,9% de los pacientes presentaron Streptococcus oralis, el 70,8% Streptococcus mitis, el 60,4% Prevotella buccae, el 39,6% Prevotella denticola, el 37,5% Fusobacterium nucleatum, el 35,4% Prevotella intermedia, el 25% Capnocytophaga spp., el 23% Veillonella spp., el 22,9% Prevotella melaninogenica y Streptococcus sanguis, y <20% otras especies. Las tasas de resistencia de S. viridans fueron 0% a la amoxicilina, ≈10% a la clindamicina y 9% a 22% a la tetraciclina; se halló resistencia a la azitromicina entre el 18,2% de S. sanguis y el 47,7% de S. mitis. Los aislamientos de Prevotella fueron sensibles a la amoxicilina-ácido clavulánico. La resistencia a la amoxicilina osciló entre el 17,1% de P. buccae y el 26,3% de P. denticola. La resistencia al metronidazol fue <6% en las especies de Prevotella, mientras que a la clindamicina osciló entre un 0% y un 21,1%. El 54,1% de Prevotella spp., el 38,9% de F. nucleatum, el 30% de Capnocytophaga spp. y el 10% de Veillonella spp. eran productores de betalactamasas. Amoxicilina-ácido clavulánico fue el antibiótico más activo frente a todas las especies aisladas, seguido del metronidazol en el caso de los anaerobios

Resistance in streptococci or Gram-negative bacteria is associated with antibiotic consumption. Scarce information exists on the antibiotic susceptibility of bacterial isolates from patients with periodontitis in countries with high antibiotic consumption, as this is an area in which microbiological testing is not performed in daily practice. The present study was undertaken to explore the susceptibility of bacterial isolates in periodontitis to antibiotics prescribed in odontology in Spain as treatment for local infections or prophylaxis for distant focal infections. Periodontal samples were prospectively collected in 48 patients classified by pocket depth of <4 mm and ≥ 4 mm. Species were identified by culture, selecting the five most frequent morphotypes per sample, and polymerase chain reaction (PCR). Susceptibility was determined by E-test®. A total of 261 isolates were identified: 72.9% patients had Streptococcus oralis; 70.8% Streptococcus mitis; 60.4% Prevotella buccae; 39.6% Prevotella denticola; 37.5% Fusobacterium nucleatum; 35.4% Prevotella intermedia; 25% Capnocytophaga spp.; 23% Veillonella spp.; 22.9% Prevotella melaninogenica and Streptococcus sanguis; and <20% other species. Streptococcus viridans resistance rates were 0% for amoxicillin, ≈10% for clindamycin, 9-22% for tetracycline, and for azithromycin ranged from 18.2% for S. sanguis to 47.7% for S. mitis. Prevotella isolates were susceptible to amoxicillin-clavulanic acid, with amoxicillin resistance ranging from 17.1% in P. buccae to 26.3% in P. denticola. Metronidazole resistance was <6% in all Prevotella species, while clindamycin resistance ranged from 0 to 21.1%. β-Lactamase production was positive in 54.1% Prevotella spp., 38.9% F. nucleatum, 30% Capnocytophaga spp., and 10% Veillonella spp. In this study, amoxicillin-clavulanic acid was the most active antibiotic against all species tested, followed by metronidazole in the case of anaerobes

In vivo activity of gemifloxacin, moxifloxacin and levofloxacin against pneumococci with gyrA and parC point mutations in a sepsis mouse model measured with the all or nothing mortality end-point.

A dose-decreasing immunocompetent sepsis mouse model was used to evaluate the in vivo effect of levofloxacin, moxifloxacin and gemifloxacin, using a ciprofloxacin/levofloxacin susceptible serotype 6B strain (ciprofloxacin MIC: 1 mg/l) and two resistant serotype 14 and 19F strains with gyrA and parC point mutations (ciprofloxacin MICs of 32 and 64 mg/l, respectively). Significant higher in vivo activity was found for moxifloxacin and gemifloxacin than for levofloxacin against strains 1 and 2, and for gemifloxacin versus moxifloxacin or levofloxacin against strain 3. Gemifloxacin treatment resulted in 100% survival against strains 1 and 2(AUC0-24 h/MIC of 30 and 62) but against strain 3, survival was 60-80% (AUC0-24 h/MIC of 93). Similar AUC0-24 h/MIC values produced different therapeutic results suggesting that in vitro parameters other than the MIC could influence efficacy predictions based on in vitro susceptibility tests (MICs) or pharmacodynamic parameters (AUC0-24 h/MIC).

Beta-lactam modification of the bacteraemic profile and its relationship with mortality in a pneumococcal mouse sepsis model.

A sepsis BALB/c mice model was used to investigate the relationship between mortality and the bacteraemic profile produced by a serotype 6B Streptococcus pneumoniae clinical isolate (MIC/MBC of amoxicillin 4/4 mg/L and of cefotaxime 2/4 mg/L). Animals were treated subcutaneously with doses of amoxicillin or cefotaxime ranging from 6.25 to 50 mg/kg tds for 48 h, starting 1 h after intraperitoneal inoculation (2 x 10(7) cfu/mouse). Blood cultures were carried out daily over 15 days. A survival rate of 100% was obtained with amoxicillin 25 mg/kg and of 60% with cefotaxime 50 mg/kg. A statistically significant (P = 0.012) relationship was found between the maximum cfu/mL in blood and mortality. A maximum log cfu/mL of 6.5 was associated with an 84% probability of death.

In vitro bactericidal activity of peak serum concentrations of co-amoxiclav, amoxicillin and vancomycin against methicillin-resistant Staphylococcus aureus.

In order to explore the bactericidal activity of concentrations similar to the peak serum concentrations obtained after a single i.v. dose of 2,000/200 mg co-amoxiclav and 500 mg vancomycin, killing curves with co-amoxiclav (69/10 microg/ml), amoxicillin (69 microg/ml), clavulanic acid (10 microg/ml), and vancomycin (15 microg/ml) were performed against two isogenic (ss-lactamase positive and negative) methicillin-resistant Staphylococcus aureus strains in cation-supplemented Mueller-Hinton broth with 2% NaCl incubated at 35 degrees C. Colony counts were performed at 0, 1, 2, 3 and 4 hours in Mueller- Hinton plates supplemented with 4% NaCl and 25 microg/ml oxacillin to measure the resistant population. Similar initial inocula reductions were obtained for amoxicillin-clavulanic acid and vancomycin for both strains, and significant differences were found in comparison to the control. Clavulanic acid decreased the growth rate of the ss-lactamase negative strain when compared to control curves. The penicillin-binding protein 2a affinity of old ss-lactams in conjunction with clavulanic acid overcoming ss-lactamase resistance may explain these results.

Antimicrobial treatment of an experimental otitis media caused by a beta-lactamase positive isolate of Haemophilus influenzae.

A gerbil model of otitis media induced by a beta-lactamase producing and non-serotypeable isolate of Haemophilus influenzae was used to assess the in-vivo efficacy of co-amoxiclav and cefuroxime at low (5 mg/kg) and high (20 mg/kg) doses. The MIC of the antibiotics tested against the pathogen was 1 mg/L (1/0.5 mg/L for co-amoxiclav). The organism was inoculated (+/-10(6) cfu) by transbullar challenge directly in the middle ear and antibiotic treatment was commenced 2 h post-inoculation and continued at 8 h intervals for three doses. Only high dose co-amoxiclav significantly reduced the number of culture-positive specimens as compared with untreated animals or with other treatment groups (91.7% as compared with 36.7% for high dose cefuroxime). The results obtained in any treatment group were related to middle ear antibiotic level/MIC. Antibiotic concentrations in the middle ear 90 min after administration were about 10% of serum levels at 15 min, probably related to a slight inflammatory response. Only after high dose co-amoxiclav did the concentration in the middle ear exceed the MIC by a factor of four. In otitis media with effusion, if indicated, antibiotics active in vitro should be administered in high doses and, to avoid side effects, probably in short courses.