Assessment of the impact of clinical recommendations on antibiotic use for CAP and HCAP: results from an implementation program in an Academic Hospital.

BACKGROUND: Local guidelines and recommendations to treat common infectious diseases are a cornerstone of most Antimicrobial Stewardship programs. The evaluation of the adherence to guidelines is an effective quality measure of the programs themselves; the proposed evaluation model aimed at examining antibiotic treatment for pneumonia. STUDY DESIGN: A retrospective pre-post intervention study was conducted in a North-Eastern Italian Academic Hospital. METHODS: 231 patients with Community-Acquired Pneumonia and 95 with Healthcare-Associated Pneumonia were divided into pre- and post-intervention groups (188 and 138, respectively). A course and a pocket summary of Pneumonia Regional Recommendations were the stewardship activities adopted. The compliance degree of prescriptions with Regional Recommendations was tested for drug(s), dosage and duration of treatment in both groups for Community-Acquired and Healthcare-Associated Pneumonia and a comparison with International guidelines was performed. RESULTS: A significant improvement in the compliance with Regional Recommendations for the variable drug emerged for Community-Acquired (38.8% vs 52.2%), but not for Healthcare-Associated Pneumonia; no significant variation in compliance was registered for dosage and duration of treatment. The significant decrease in consumption of levofloxacin showed the positive impact of the Regional Antimicrobial Stewardship programs. A high level of adherence to International Guidelines for the variable drug for Community-Acquired Pneumonia was found in both groups (75.5% and 77.2%, respectively). CONCLUSIONS: Our study highlighted that room for improvement in antibiotic prescription in Community-Acquired and Healthcare-Associated Pneumonia currently remains. New strategies for a better use of the adopted tools and definition of new antimicrobial stewardship initiatives are needed to improve compliance to Regional Recommendations.

Inhibition of human cytomegalovirus replication in a human retinal epithelial cell model by antisense oligonucleotides.

PURPOSE: The antiviral activity of first and second generation antisense oligonucleotides on human cytomegalovirus (CMV) replication was evaluated in two cell systems, the traditional system on human fibroblasts and on human retinal pigment epithelial (HRPE) cell culture system. METHODS: To evaluate CMV replication strategies within the retina, an HRPE cell system permissive to CMV replication was developed. In this study, the antiviral activity of the antisense oligonucleotides, ISIS 2922 (Vitraven) and ISIS 13312, was evaluated in the traditional fibroblast antiviral assay and in the HRPE cell system. Antiviral activity was measured by evaluating inhibition of virus induced cytopathic effect, virus plaque formation, and virus gene expression. RESULTS: Both oligonucleotides produced concentration-dependent inhibition of CMV cytopathic effect and CMV plaque formation in both human RPE cells and a human fibroblast cell line, MRC-5. The oligonucleotide, ISIS 2922, demonstrated a mean 50% inhibitory concentration (IC(50)) of 0.04 and 0.24 microM in HRPE and MRC-5 cells, respectively. The second-generation oligonucleotide, ISIS 13312, yielded similar results with IC(50) levels of 0.05 and 0.3 microM in HRPE and MRC-5 cells, respectively. Similar findings were obtained with a CMV clinical isolate. In addition, initiation of effective oligonucleotide treatment could be introduced 6 days after CMV infection in HRPE cells, whereas, in the fibroblast cell line, oligonucleotide treatment was only effective up to 3 days after infection. Semiquantitative RT-PCR analysis demonstrated significant inhibition of CMV intermediate early and late mRNAs by both oligonucleotides. CONCLUSIONS: These studies demonstrate that HRPE cells were significantly more sensitive than fibroblasts to the antiviral actions of ISIS 2922 and ISIS 13312. Moreover, the data indicate that the anti-CMV potency of the two oligonucleotides was similar. The enhanced potency of these oligonucleotides in HRPE cells may be associated with a delay in viral gene transcription and slow viral replication and spread in these cells.

Comparison of the toxicity profiles of ISIS 1082 and ISIS 2105, phosphorothioate oligonucleotides, following subacute intradermal administration in Sprague-Dawley rats.

The systemic toxicity of two phosphorothioate oligonucleotides specific for herpes simplex viruses (ISIS 1082) and human papiloma virus (ISIS 2105) were evaluated following repeated intradermal injections of vehicle control, 0.33, 2.17, or 21.7 mg/kg daily to Sprague-Dawley rats (10/sex/group) for 14 days. Animals were sacrificed 1 day after the last dose, except for a portion of the ISIS 1082-treated animals (5/sex/group) which were maintained for an additional 14-day recovery period. The profile of alterations noted for both compounds was very similar. Other than local signs of irritation at the site of injection, there were no clinical signs of toxicity or treatment-related mortality, but there was a slight decrease in body weight gain for the 21.7 mg/kg dose groups. Alterations in hematology parameters included dose-dependent thrombocytopenia and anemia. Alterations in serum chemistry parameters were suggestive of mild alterations in hepatic metabolism, with increases in liver transaminases and bilirubin, along with decreases in albumin and cholesterol. Both spleen and liver weights were significantly elevated in a dose-dependent fashion. Histopathological alterations noted in liver, kidney, lung, injection site skin, and spleen were characterized as perivascular and interstitial infiltrates of macrophages and monocytes. Additional microscopic alterations in the spleen included mild lymphoid hyperplasia (seen in lymph nodes as well), and extramedullary hematopoiesis. Treatment-related cytopenias were likely related to mild, focal hypocellularity in the bone marrow. Alterations in ISIS 1082-treated animals were only partially reversed following the 14-day treatment-free period. In conclusion, repeated intradermal administration of ISIS 1082 and ISIS 2105 produced a similar spectrum of toxicities, with liver, kidney, spleen, and bone marrow being identified as target tissues.

A pharmacokinetic evaluation of 14C-labeled afovirsen sodium in patients with genital warts.

Afovirsen sodium is a 20-mer phosphorothioate oligonucleotide designed to be complementary to the messenger ribonucleic acid sequence for the translation initiation codon of the E2 protein vital to replication of human papillomaviruses types 6 and 11. 14C-Labeled afovirsen was given as a single-dose intradermal injection in each of four warts of five patients to determine the time-dependent changes in concentration of intact afovirsen in genital warts and to determine the systemic absorption and elimination of radiolabeled compound. Intact afovirsen in genital warts was determined by high pressure liquid chromatography analysis of protease K digested extracts. Intact afovirsen was present in wart tissue for at least 72 hours at concentrations several times in excess of the estimated minimal inhibitory concentration of 1 mumol/L. Absorption of radiolabeled afovirsen from the injection site was rapid, with a peak plasma concentration achieved within 1 hour. Clearance of afovirsen was primarily attributable to slow metabolism, with about 30% of the radiolabel eliminated as 14C-CO2 in expired air over a 6-day period after dosing. Radioactivity eliminated in urine represented metabolites of afovirsen. From the clinical pharmacokinetic data presented here and from previously published pharmacokinetic data in rats, the disposition of afovirsen in humans appears to be relatively similar to that in rats. These data suggest that once or twice weekly dosing regimen in the clinic may be appropriate.

Altered actin and immunoglobulin C mu expression in nitrogen mustard-resistant human Burkitt lymphoma cells.

Raji-HN2 is a B cell lymphoma (Burkitt lymphoma) line that was made resistant to nitrogen mustard. The drug-resistant phenotype was accompanied by changes in gene expression. The expression of four unrelated genes was examined by Northern blot analysis. Raji-HN2 cells were found to contain about twice the number of actin mRNA found in Raji cells. Both cell lines were found to contain equivalent amounts of beta 2-microglobulin, c-myc oncogene, and immunoglobulin C mu mRNAs. The C mu mRNA was, however, larger in size in Raji-HN2 cells. Alterations in actin and C mu mRNAs in Raji-HN2 cells were not due to gene amplification or rearrangement because Southern blot analysis revealed no changes in the genomic organization of these genes. The increased actin mRNA content was correlated with an increased actin content of Raji-HN2 cells. The F-actin (stained with 7-nitrobenz-2-oxa-1,3-diazolylphallacidin) content of single cells was quantitated in a meridian interactive laser cytometer. Raji-HN2 cells contained about twice the amount of F-actin present in the parental Raji cells. Similar results were obtained when large populations, 10(6) cells each, were examined in a flow cytometer.

Vasopressin induces V1 receptors to activate phosphatidylinositol- and phosphatidylcholine-specific phospholipase C and stimulates the release of arachidonic acid by at least two pathways in the smooth muscle cell line, A-10.

The rat thoracic aortic smooth muscle cell line, A-10, expresses vasopressin receptors of the V1 subtype. Vasopressin treatment of these cells stimulated the release of arachidonic acid and the formation of diacylglycerol and phosphocholine. These responses to vasopressin were inhibited by the V1-specific antagonist SK&F 100273, indicating that these were receptor-mediated phenomena. The mechanisms by which V1 receptors mediate arachidonic acid release appeared to be unaffected by cycloheximide or actinomycin D, suggesting that the release is independent of protein and RNA synthesis. The V1 receptors also appeared to be coupled to a phospholipase C which can hydrolyze phosphatidylcholine, a possible source of the released arachidonic acid. Phosphocholine and diacylglycerol were also generated. The release of arachidonic acid, phosphocholine, or diacylglycerol was not affected by prior treatment of the cells with pertussis toxin (islet-activating protein). Thus, the release of these second messengers is not mediated by the guanine nucleotide-binding protein Gi or other pertussis toxin-sensitive substrates. We conclude that V1 receptors induce the release of arachidonic acid and the formation of diacylglycerol and phosphocholine via the activation of both a phosphatidylinositol- and phosphatidylcholine-specific phospholipase C.

Forskolin effects on frog and rabbit corneal epithelium ion transport.

The effects of forskolin on the electrophysiological parameters of the isolated corneal epithelium from bullfrog (Rana catesbeiana) were investigated. Forskolin stimulated the short-circuit current (SCC) and transepithelial potential difference (PDt), while reducing the transepithelial resistance. These effects were absent in Cl- -free bathing solutions. Furosemide, added either before or after forskolin, completely blocked the effects. Epinephrine and A23187, added after forskolin, produced only a small additional stimulation of the SCC. Propranolol neither blocked nor reduced the effect of forskolin. Forskolin increased the stroma to tear 36Cl flux by 61% and the tear to stroma 36Cl flux by 64%. Intracellular recordings showed that forskolin depolarized the potential difference across the apical membrane and reduced the apical/basolateral resistance ratio. Intracellular recordings in the isolated rabbit epithelium showed the same effects by forskolin except that there was only a brief stimulation of PDt, after which it stabilized slightly below the control level. These results are consistent with an increase in apical membrane permeability similar to that produced by adenosine 3',5'-cyclic monophosphate, epinephrine, and the Ca2+ ionophore A23187.

Na+-K+ ATPase distribution in frog and bovine lenses.

Na+-K+ ATPase activity was measured in the capsule-epithelium and decapsulated frog and bovine lens. The decapsulated lens contained approximately 20% of the whole lens activity in the frog and 30% in the bovine. These values were measured from the aqueous homogenate of the entire decapsulated lens, an approach which may have underestimated the activity by diluting the ouabain-sensitive component in the preparation. Subsequent determinations were done on separate portions of superficial (2 to 3 mm) anterior-equatorial, and posterior bovine cortex. The activities per gram of tissue were enriched with respect to the values for the entire decapsulated bovine lens. These activities were further enriched by a sucrose density gradient centrifugation. The anterior-equatorial cortical segment contained 1.6 times the activity found in the capsule-epithelium. The posterior cortex had a much smaller but statistically significant level of Na+-K+ ATPase. It is unlikely that the observed asymmetry of the anterior-equatorial segment with the posterior cortex is exclusively due to epithelial contamination for the result would require the adherence of 62% of the epithelium. Scanning electron micrographs of 6 decapsulated bovine lenses indicated an average contamination of about 9%. This asymmetry may have a physiological role in assisting the pump mechanism of the epithelium.