Nonadherence to treatment recommendations is a factor contributing to the clinical failure of daptomycin: Cohort study in Brazil

To evaluate the clinical outcomes of daptomycin therapy and adherence to treatment recommendations, a retrospective cohort study was conducted with patients that received daptomycin during the period of the study. The adherence and nonadherence to clinical guidelines were assessed through organism identification, dose and time of treatment, management of bacteremia, and vancomycin treatment failure. A multiple logistic regression model analyzed the association between independent variables and clinical success (dependent variable), considering 5% of statistical significance. The study presented 52 patients who received daptomycin for the treatment of bacteremia (21.1%) or infections (osteomyelitis [63.5%], synovial fluid [15.4%]). Most patients (86.5%) received daptomycin as the second line of treatment, and 51.9% achieved clinical success. The patients had a better chance of clinical success when they followed the guideline indications (OR = 16.86; 95% CI = 1.45-195.88) and the medication was prescribed by a specialist in infectious diseases (OR = 4.84; 95% CI = 1.11-21.09). The study demonstrated lower clinical success than that described in the literature because of patients who were not eligible according to the clinical guidelines. Adherence to recommendations and appropriate prescription of reserve antibiotics is important in limiting early resistance, and avoiding clinical failure and unnecessary expenditure.

Surveillance of multidrug-resistant bacteria in pediatric and neonatal intensive care units in Rio de Janeiro State, Brazil.

INTRODUCTION: Multi-drug-resistant bacteria surveillance (MDR) systems are used to identify the epidemiology of MDR bacteria in neonates and children. This study aimed to describe the patterns by which MDR bacteria colonize and infect neonatal (NICU) and pediatric intensive care unit (PICU) patients in the state of Rio de Janeiro State, Brazil. METHODS: A cross-sectional survey was performed using electronic data on NICU and PICU patients reported to the Rio de Janeiro State MDR bacteria surveillance system. All healthcare institutions that reported at least one case during the study period were included. RESULTS: Between 2014 and 2017, 10,210 MDR bacteria cases, including 9261 colonizations and 949 infections, were reported. Among the colonizations, 5379 occurred in NICUs and 3882 in PICUs, while 405 infections occurred in NICUs and 544 in PICUs. ESBL producing Klebsiella sp and E. coli were the most reported colonization-causing agents in NICUs (1983/5379, 36.9%) and PICUs (1494/3882; 38.5%). The main causing bacteria reported in catheter-associated bloodstream infection (CLABSI), ventilator associated pneumonia, and catheter-associated urinary tract infection in NICUs were Klebsiella sp and E.coli (56/156, 35.9%), carbapenem-resistant Gram-negative bacteria (CRGNB) (22/65, 33.9%), and CRGNB (11/36, 30.6%) respectively, while in PICUs, they were MRSA (53/169, 31.4%), CRGNB (50/87, 57.4%), Klebsiella sp and E.coli (18/52, 34.6%), respectively. CONCLUSIONS: MDR Gram-negative bacteria (ESBL producers and carbapenem-resistant bacteria) were the most reported agents among MDR bacteria reported to Rio de Janeiro surveillance system. Except for CLABSI in children, they caused all device-associated infections in NICUs and PICUs.

Surveillance of multidrug-resistant bacteria in pediatric and neonatal intensive care units in Rio de Janeiro State, Brazil

Abstract INTRODUCTION: Multi-drug-resistant bacteria surveillance (MDR) systems are used to identify the epidemiology of MDR bacteria in neonates and children. This study aimed to describe the patterns by which MDR bacteria colonize and infect neonatal (NICU) and pediatric intensive care unit (PICU) patients in the state of Rio de Janeiro State, Brazil. METHODS A cross-sectional survey was performed using electronic data on NICU and PICU patients reported to the Rio de Janeiro State MDR bacteria surveillance system. All healthcare institutions that reported at least one case during the study period were included. RESULTS Between 2014 and 2017, 10,210 MDR bacteria cases, including 9261 colonizations and 949 infections, were reported. Among the colonizations, 5379 occurred in NICUs and 3882 in PICUs, while 405 infections occurred in NICUs and 544 in PICUs. ESBL producing Klebsiella sp and E. coli were the most reported colonization-causing agents in NICUs (1983/5379, 36.9%) and PICUs (1494/3882; 38.5%). The main causing bacteria reported in catheter-associated bloodstream infection (CLABSI), ventilator associated pneumonia, and catheter-associated urinary tract infection in NICUs were Klebsiella sp and E.coli (56/156, 35.9%), carbapenem-resistant Gram-negative bacteria (CRGNB) (22/65, 33.9%), and CRGNB (11/36, 30.6%) respectively, while in PICUs, they were MRSA (53/169, 31.4%), CRGNB (50/87, 57.4%), Klebsiella sp and E.coli (18/52, 34.6%), respectively. CONCLUSIONS MDR Gram-negative bacteria (ESBL producers and carbapenem-resistant bacteria) were the most reported agents among MDR bacteria reported to Rio de Janeiro surveillance system. Except for CLABSI in children, they caused all device-associated infections in NICUs and PICUs.

Typing of Propionibacterium acnes: a review of methods and comparative analysis.

Propionibacterium acnes is a major commensal of the human skin. However, it is also the pathogen responsible for acne vulgaris and other diseases, such as medical-device infections. Strains of Propionibacterium acnes have long been classified into several different types. Recently, typing systems for this bacterium have taken on an increased importance as different types of P. acnes have been found to be associated with different disease states, including acne. Genetic approaches based on individual or multiple genes have classified P. acnes into types, which have been supported by the sequencing of nearly 100 P. acnes genomes. These types have distinct genetic, transcriptomic and proteomic differences. Additionally, they may have different immune response profiles. Taken together, these factors may account for the different disease associations of P. acnes types.

[Enterococcal infections: from simple to most complex]. / Infections à entérocoques: du plus simple au plus complexe...

Enterococci are microorganisms with a remar- kable ability to adapt to their environment. Two species have a significant clinical implication, Enterococcus faecalis and Enterococcus faecium. The risk factors for colonization and infection must be recognized, including prior treatment with antibiotics such as cephalosporins or quinolones. Because of their native resistance to several classes of antibiotics and the increase of acquired resistance to penicillins, the initial empiric treatment of a severe infection in a patient at risk of enterococcal infection often includes a glycopeptide. A restriction in the empirical use of cephalosporins or quinolones and a targeted antibiotic therapy following receipt of the antibiogram are essential to prevent the emergence of enterococcal strains and especially vancomycin-resistant enterococci.

Treatment recommendations of hospital-acquired pneumonia in Asian countries: first consensus report by the Asian HAP Working Group.

Many different treatment options are available for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), which are important causes of morbidity and mortality. Although guidelines for the diagnosis and treatment of HAP and VAP have been published by various American and European societies, these guidelines may not be applicable in all respects to the diagnosis and treatment of HAP and VAP in Asian countries. In addition, clinical practice may vary among Asian countries, due to such factors as availability of specific antibiotics and formulations and their relative cost. In addition, and in particular, different epidemiologic, etiologic, and resistance patterns in Asian countries may affect treatment choices compared with those in Western countries. To address these issues, the Asian-Pacific Research Foundation for Infectious Diseases, together with the Asian Network for Surveillance of Resistant Pathogens, organized the Asian HAP Working Group to discuss current clinical practices and develop consensus treatment recommendations for HAP in Asian countries. The consensus treatment recommendations, summarized herein, represent the findings of an expert panel comprising 30 representatives from 10 Asian countries.

Discrimination between epidemic and non-epidemic glycopeptide-resistant E. faecium in a post-outbreak situation.

Vancomycin-resistant enterococci (VRE) have been isolated in increasing numbers. Hospital-adapted VRE exhibit relatively high pathogenicity by expressing factors like enterococcal surface protein (Esp), which facilitates epidemic spread. By contrast, 'community-acquired' VRE show low pathogenicity and non-epidemic features. In 2004 and 2005 an extended outbreak of VRE occurred at a university hospital in Southwestern Germany and an infection control programme was implemented to confine the outbreak. Pulsed-field gel electrophoresis (PFGE), esp PCR, multiple-locus variable number of tandem repeat analysis (MLVA), purK1 typing and multiple-locus sequence typing (MLST) were performed on representative VRE isolates. Twenty-six non-epidemic and two epidemic VRE types (MLST203, MLST280) were identified by PFGE. Seven of the non-outbreak VRE types were esp gene negative, whereas 19 non-outbreak and both epidemic VRE types were esp positive. Eight MLVA types were identified. MLVA type 1 included five PFGE types and MLVA type 159 included 16 PFGE types. Currently there is no efficient method available to identify non-epidemic VRE and avoid unnecessary isolation of patients. More than 50% non-epidemic clones were esp positive; nevertheless, esp PCR appears to be the most promising approach to identify non-epidemic VRE.

[Chemotaxonomical methods in the diagnostics of clinical strains causing actinobacterial infections]. / Metody chemiotaksonomiczne w rozpoznawaniu zakazen wywolywanych przez aktynobakterie.

The application of polyphasic taxonomic studies to identify several strains of Actinobacteria is presented. These microorganisms cause opportunistic infections relatively often (especially in immunocompromised patients), but their proper classification is difficult and they may be mistaken with other similar taxa. The article involves some clinical isolates properly identified by extended analysis, including simplified chromatographic methods (TLC, GLC). These procedures helped to establish a chemotaxonomic profile based on the well-grounded detection of chemical compounds of the bacterial cell envelope. Several components are useful taxonomic markers: the main amino acids of murein, sugars, and fatty acids and polar lipids, mainly phospholipids and glycolipids. The chemotaxonomy of Actinobacteria is a part of the contemporary classification of these microorganisms and should be applied in reference laboratories to avoid or minimize diagnostic and therapeutic error.

Bacteriological study of diabetic foot infections.

AIMS: The polymicrobial nature of diabetic foot infection has been well documented in the literature. Patients with diabetic foot infection not exposed to antibiotics are not well studied before. The relative frequency of bacterial isolates cultured from community-acquired foot infections that are not exposed to antimicrobial agents for 30 days is studied. In addition, the bacterial comparative in vitro susceptibility to the commonly used antibacterial agents is assessed. METHODS: This is a prospective study in which the infected wounds of 86 consecutive diabetic patients seen in the diabetic foot clinic in Adan Teaching Hospital were cultured when visiting the clinic. The patients did not receive antimicrobial therapy 30 days prior to taking the cultures. The specimen was cultured using aerobic and anaerobic microbiological techniques. Isolates were tested for susceptibility to commonly used antimicrobial therapy. RESULT: Staphylococcus aureus was the most common isolate, being recovered from 38.4% of cases. Other organisms were Pseudomonas aeruginosa (17.5%) and Proteus mirabilis (18%), anaerobic gram-negative organisms (10.5%), mainly Bacteroides fragilis. Imipenem, meropenem, and cefepime were the most effective agents against gram-negative organisms. Vancomycin was the most effective against gram-positive organisms. CONCLUSION: S. aureus and P. aeruginosa were the most common causes of diabetic foot infections. Anaerobic organisms are still a common cause for infection, although the prevalence is less. These wounds may require use of combined antimicrobial therapy for initial management.

[Treatment of severe Gram-positive infections: current situation and new opportunities]. / Situation actuelle du traitement des infections sévères par germes à Gram positif et nouvelles opportunités.

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) INFECTIONS: A growing number of MRSA strains with an increased minimum inhibitory concentration (MIC) and intermediary susceptibility to glycopeptides (GISA) or vancomycin (VISA) are encountered in clinical practice. In patients on mechanical ventilation who develop acute pneumonia, it would appear appropriate to achieve a vancomycin concentration in serum and the lung 2 to 4 times above the MIC, while carefully monitoring the risk of toxicity. POSSIBLE SOLUTIONS: Better prevention of severe MRSA infections, a more rational use of glycopeptides, using a recycling scheme, i.e. altering prescriptions with antibiotics other than glycopeptides or using combinations. OTHER AGENTS CURRENTLY AVAILABLE: Several antibiotic classes can now be used to preserve the efficacy of glycopeptides: cotrimoxazole, quinupristine/dalfopristine and linezolide. Linezolide is the first compound of a new family of antibiotics called oxazolidinones which are active against aerobic and anaerobic Gram positive strains, particularly those exhibiting intermediary sensitivity or resistance to other antibiotics. Its pharmacokinetic properties are quite favorable. ANTIBIOTIC COMBINATIONS: In case of severe MRSA infection, antibiotics that can be combined with vancomycin include gentamycin, rifampicin, or fosfonycine. For GISA infections, vancomycin could be combined with a ss-lactam, or quinupristine/dalfopristine. Combination with linezolide appears to be antagonistic.

Nosocomial bloodstream infection in a neonatal intensive care unit of a medical center: a three-year review.

Bloodstream infections are the most frequent nosocomial infections in neonatal intensive care units. This retrospective study surveyed the epidemiologic characteristics of nosocomial bloodstream infections which occurred in the neonatal intensive care unit from January 1, 1997 to December 31, 1999. The overall infection patient rate was 5.5% in the 3-year period, and the overall infection patient-day rate was 4.4 per 1000 patient-days. Low birth weight was a risk factor for bloodstream infections. The rate of infection for neonates with birth weight below 1000 g ranged from 36.6% to 45.8% (1997: 36.6%; 1998: 45.8% and 1999: 38.9%). The most common pathogens causing nosocomial bloodstream infection were: Staphylococcus aureus (18.5%) (with 92% oxacillin-resistant), Acinectobacter baumannii (16.3%), Klebsiella pneumoniae (11.9%), Escherichia coli (9.6%), and Pseudomonas aeruginosa (8.1%). The mortality due to nosocomial bloodstream infection was highest among gram-negative bacteria, especially with P. aeruginosa (45.5%). Therefore, surveillance of nosocomial bloodstream infection and successful strategies to decrease nosocomial bloodstream infection, such as infection control and optimal antibiotic use, are warranted.

Safety and efficacy of cefepime versus ceftazidime in the treatment of severe infections.

An open-label, randomized study was conducted to evaluate the safety and efficacy of cefepime versus ceftazidime in the treatment of severe bacterial infections, including septicemia, urinary tract infection, bacterial bronchitis, bacterial pneumonia, and intraabdominal infection. Fifty-two patients with severe infections were eligible and prospectively randomized to receive cefepime (26 patients) or ceftazidime (26 patients) during a 15-month period. Forty-two patients were evaluable (24 in the cefepime group and 18 in the ceftazidime group). Most (86%) of the patients had urinary tract infections and the most commonly isolated pathogen was Escherichia coli (79%). Satisfactory clinical response rates of 71% and 61%, and bacteriological eradication rates of 87.5% and 89% were achieved for the cefepime and ceftazidime groups, respectively. Two patients treated with cefepime died, one from superinfection and one from suspected paraneoplastic syndrome. Cultures of the blood obtained at entry into the study were positive in 19 (45%) of the 42 evaluable cases. In the cefepime group, a patient with Salmonella paratyphi A septicemia was cured, which has not been previously reported. Adverse effects attributable to therapy were minimal in both groups of patients, and none required discontinuation or dose reduction. In conclusion, these results suggest that cefepime is as efficacious and well tolerated as ceftazidime in the treatment of severe bacterial infections, such as septicemia, urinary tract infection, bacterial bronchitis, bacterial pneumonia, and intraabdominal infection.

[The clinico-microbiological and epidemiological aspects of hospital infections in a surgical clinic]. / Kliniko-mikrobiologicheskie i épidemiologicheskie aspekty gospital'nykh infektsii v khirurgicheskoi klinike.

Complex clinical and microbiological and epidemiological study of specificity of hospital infections was conducted in surgical clinics of Military and Medical Academy. Analysis of the materials obtained has permitted to develop the classification of agents of modern hospital surgical infections, to study the variety and specificity of forming of microorganism hospital strains. To optimize the system of sanitary and epidemiological inspection on hospital infections and to improve their prophylaxis it is proposed to introduce into the practice of bacteriological laboratories of military medical and prophylactic institutions the quantitative microbiological examinations of clinical material. Besides it is reasonable to have in the stuff of multipurpose military hospitals the post of hospital epidemiologist trained in the actual problems of clinical microbiology, hospital hygiene and surgical infection.

Enterococcus faecium in hospitals.

Most of the characteristics that have ensured the success of enterococci as nosocomial pathogens were described early in this century. Enterococcus faecium and Enterococcus faecalis, the enterococci most frequently isolated from clinical material, differ fundamentally. The intrinsic antimicrobial resistance of Enterococcus faecium, supplemented by acquired resistance mechanisms, can generate a glycopeptide-multiply-resistant nosocomial pathogen that survives on hands and in the environment, and has the potential for intra-hospital and inter-hospital spread. The use of terms such as 'an enterococcus', 'faecal streptococci' and 'group D streptococci' have hindered, and still hinder, our understanding of a species rapidly emerging as the most problematic of nosocomial pathogens.

Aerococcus-like organisms: use of antibiograms for diagnostic and taxonomic purposes.

Recently, some Aerococcus-like organisms (ALOs), isolated from urine and blood of elderly patients with urinary tract infection, have been described. In this study ALOs and related taxons were tested for susceptibility by agar diffusion and agar dilution methods to 15 selected antimicrobial agents for diagnostic and taxonomic considerations. ALOs were susceptible to a wide range of antimicrobials including beta-lactams, but resistant to aminoglycosides, sulphonamides, trimethoprim and nalidixic acid. By using tablets containing vancomycin, furazolidone and bacitracin, it was possible to separate ALOs from related taxons. Clustering based on antibiotic susceptibilities showed that there is little similarity between Aerococcus viridans and ALOs.