Commencement Of Antibiotic Therapy Research Articles

English

The study determined the frequency of extended-spectrum beta-lactamase-producing Escherichia coli (ESBL-PEc) in HIV-infected individuals with urinary tract infections (UTIs) attending Federal Teaching Hospital Abakaliki (FETHA II), and the responses of these bacterial pathogens to colistin, cephalosporins, aminoglycosides, fluoroquinolones, and ertapenem. Exactly 200 urine samples (mid-stream) were collected from HIV-infected individuals. Standard microbiological techniques were used to characterize bacterial isolates. Phenotypic screening for the production of ESBLs was done by double disc synergy test. Antibiotic susceptibility study was carried out by the Kirby-Bauer disc diffusion technique. Results showed the presence of ESBL-PEc in the urine samples of HIV-infected individuals. ESBL-PEc were highly resistant to gentamycin (85%), ofloxacin (75%), ciprofloxacin (75%), nalidixic acid (70%), tobramycin (65%), kanamycin (64.3%), and norfloxacin (60%), but susceptible to ertapenem (60%) and amikacin (57.1%). The ESBL-PEc isolates were multidrug-resistant. Average multiple antibiotic resistance indices (MARI) value of isolates was 0.8, further depicting misuse/abuse of these antibiotic classes in our study area. Thus, it is pertinent to carry out antibiotic susceptibility testing before the commencement of antibiotic therapy, especially in HIV-positive patients with UTIs so as to attain effective treatment regimens and reduce the incidence of antibiotic resistance in healthcare settings.   Key words: Escherichia coli, extended-spectrum beta-lactamase (ESBL), multidrug resistance, antibiotics, urinary tract infections (UTI), human immunodeficiency virus (HIV) patients.

1351 Primary Pituitary Abscess Presenting as An Isolated Bitemporal Hemianopia

Abstract Pituitary abscesses are rare yet life-threatening entities. Most common presenting features are headache, hypopituitarism, and visual changes. Majority of patients are found to have a predisposing risk factor, such as a pre-existing pituitary lesion, recent pituitary surgery or irradiation, or a primary source of infection. We present the case of a 53-year-old male with a spontaneous pituitary abscess, who presented with an isolated bitemporal hemianopia, but was otherwise asymptomatic with no known risk factors. Magnetic resonance imaging showed a sellar and suprasellar mass, thought to be a pituitary macroadenoma. He underwent endoscopic transsphenoidal adenectomy and cystic fluid was seen intraoperatively. Microbiology analysis showed Staphylococcus Aureus, and a course of intravenous ceftriaxone was commenced. Histopathology reported no evidence of adenoma and impression was of a pituitary abscess. Following transsphenoidal resection and commencement of antibiotic therapy, the bitemporal hemianopia resolved. We therefore report a rare case of primary pituitary abscess and emphasise the importance of including this condition as a differential diagnosis in any patient with a visual deficit or new pituitary lesion.

Nephrotoxicity of concomitant piperacillin/tazobactam and teicoplanin compared with monotherapy.

ObjectivesPiperacillin/tazobactam combined with vancomycin has been associated with a decline in renal function when compared with monotherapy. Teicoplanin is a glycopeptide similar to vancomycin. We investigated whether piperacillin/tazobactam combined with teicoplanin is associated with a decline in renal function as well.MethodsWe conducted a single-centre retrospective cohort study with data from our electronic health records from 9 August 2013 to 15 November 2019, including all adult patients that received either piperacillin/tazobactam, teicoplanin or piperacillin/tazobactam + teicoplanin. The incidence of acute kidney injury (AKI) at 48–72 h served as the primary outcome, whereas change in serum creatinine served as a secondary outcome.ResultsOf the 4202 included patients, 3188 (75.9%) received piperacillin/tazobactam, 791 (18.8%) received teicoplanin and 223 (5.3%) received piperacillin/tazobactam + teicoplanin. The incidence of AKI at 48–72 h after commencement of antibiotic therapy was 5.4% for piperacillin/tazobactam, 3.4% for teicoplanin and 11.7% for piperacillin/tazobactam + teicoplanin (P < 0.001). However, mean serum creatinine at 48–72 h was slightly higher in the piperacillin/tazobactam + teicoplanin group therapy compared with baseline [+1.61% (95% CI –2.25 to 5.70)], indicating a slight decrease in renal function, and decreased for piperacillin/tazobactam [–1.98% (95% CI –2.73 to –1.22)] and teicoplanin [–8.01% (95% CI –9.54 to –6.45)]. After correcting for significant confounders in a multivariate linear regression analysis, these patterns remained.ConclusionsOur study suggests that piperacillin/tazobactam + teicoplanin is associated with a higher prevalence of AKI compared with monotherapy. However, as the overall decline in renal function with piperacillin/tazobactam + teicoplanin is very small, its clinical relevance is likely limited. Therefore, piperacillin/tazobactam + teicoplanin can probably be safely combined.

1357. Mycobacterium abscessus Native Tricuspid Valve Endocarditis. Is a 6-Week Course of Combination Antibiotic Therapy Enough?

BackgroundInfective endocarditis of the native heart valves due to M. abscessus has been reported in individuals who inject drugs. Only one case thus far has been reported with survival beyond 4 months after completion of antibiotic therapy. 24-year-old Caucasian woman with a history of intravenous drug use presented with intermittent fevers for 3–4 months. She was having chills, night sweats, and productive cough. She acknowledged using intravenous cocaine and heroin every few days after being discharged from our hospital 6 months previously when she was treated for tricuspid valve endocarditis. Chest radiograph demonstrated right lower lobe airspace disease suggestive of pneumonia. Three days later her blood cultures grew acid-fast bacilli, later identified as M. abscessus.MethodsShe was empirically treated with azithromycin, amikacin, and imipenem. Transthoracic and transesophageal echocardiograms were suggestive of tricuspid valve endocarditis. CT angiogram of the chest showed filling defects within several large right lower lobe pulmonary arteries and dense right lower lobe consolidation with pleural effusion. The patient underwent bronchoscopy with bronchoalveolar lavage (BAL) and therapeutic thoracoscopy with drainage and thoracostomy tube placement. BAL cultures also grew AFB. Multiple sets of blood cultures drawn after commencement of antibiotic therapy during the hospital course were negative. Drug susceptibilities were available 3 weeks later. The isolate was susceptible to amikacin. Linezolid, imipenem, and cefoxitin exhibited intermediate activity, and TMP/SMX, ciprofloxacin, moxifloxacin, doxycycline, minocycline, and clarithromycin were reported resistant. Inducible erm gene was present. Azithromycin and linezolid were discontinued and tigecycline was added.ResultsPatient completed 6 weeks of antibiotics from the day of the first negative blood culture. Repeat TTE 1 month after completion of therapy revealed a decrease in tricuspid valve vegetation. Blood culture done 3 months later was sterile. AFB blood cultures done a year later did not report any growth.ConclusionThis case opens a debate, if in a selected group of patients, a short course of combination antibiotic therapy is enough to obtain cure. This will require further analysis. Disclosures All authors: No reported disclosures.

The Pre - Eminence of Staphylococcus Aureus as The Causative Agent in Superficial Lesions, Aspirates And Secretions at a Tertiary Health Care Institution in Nigeria

A range of infections is caused by Staphylococcal organisms prominent among them are nosocomial superficial infections manifesting as abscesses, furuncles, and wound infections. The study objective is to determine the degree to which Staphylococcus aureus is a cause of such lesions in a tertiary health care institution in Nigeria. The study which was prospective and cross-sectional involved participants who were patients seen at the various facilities in a tertiary healthcare institution. There were 832 patients made up of 336 (40.3%) males, 201 (24.2%) females and 295 (35.5%) children. Specimens, which were consecutively obtained, consisted of swabs from wounds, burns, abscesses, aspirates and secretions. Specimens were collected for culture and sensitivity before commencement of antibiotic therapy. The major isolated organism was Staphylococcus aureus . Others were Pseudomonas aeruginosa, Klebsiella pneumoniae, Proteus mirabilis, Proteus vulgaris Proteus rettgerri, Alkaligenes faecalis, Acinetobacter calcoaceticus and Candida albican s. Six specimens did not yield growth. The in-vitro susceptibility of Staphylococcus aureus to ofloxacin, ceftazidime ,amoxicillin clavulanate and gentamycin was impressive While susceptibility to ceftriazone, cloxacillin, oxacillin and lincomycin was low. The organism was moderately susceptible to cefuroxime and 72.8% to vancomycin. The growing resistance of Staphylococcus aureus to many antimicrobial agents and especially to the penicillins and the cephalosporins is a cause for concern. Some measures were suggested for the control of Staphylococcus aureus infections. Keywords : staphylococcus aureus, superficial lesions, antibiotics

Clinical impact of reducing routine susceptibility testing in chronic Pseudomonas aeruginosa infections in cystic fibrosis

BACKGROUND Susceptibility testing results are not predictive of clinical response to antibiotic therapy in chronic Pseudomonas aeruginosa infections in cystic fibrosis (CF). We assessed the impact of reducing the number of routine susceptibility tests performed on clinical outcome in these cases. METHODS In June 2006, we introduced a protocol whereby susceptibility tests of P. aeruginosa isolates obtained from respiratory samples of people with CF were limited to those taken at the commencement of antibiotic therapy, when there was evidence of clinical failure or routinely if not tested in the previous 3 months. At all other times, isolates were identified and reported as normal but P. aeruginosa isolates were not subjected to susceptibility testing. RESULTS Over a 6 month period, P. aeruginosa was isolated on at least one occasion from 193 patients attending the Adult Cystic Fibrosis Unit. In this period, we reduced the number of routine susceptibility tests by 56% (from a projected 2231 tests on 872 samples to an actual 972 tests on 427 samples). We assessed the response to courses of intravenous antibiotic treatment administered during the 6 month study period in 2006 and for courses administered in the same patients during the same calendar months in 2005. No significant differences in median change of FEV1, FVC, C-reactive protein (CRP), white cell count, weight or duration of intravenous antibiotics were observed. The projected savings of this intervention were 3500 euros in consumables and 170 h (costed at 6500 euros) of laboratory staff time per annum, a total annual saving of 10,000 euros (6500 pounds sterling). CONCLUSIONS For CF units sending regular, routine sputum samples, a reduction in the number of susceptibility tests performed in cases of chronic P. aeruginosa infection can be carried out without impacting on short-term clinical outcomes.

Case report: brain and liver abscesses caused by oral infection with Streptococcus intermedius

Organ abscesses are a rare and life-threatening complication mostly of hematogenously disseminated infections. We report a case of brain and liver abscesses. Identification of the lesions was made by contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI), respectively. An oral examination comprised an oral focus of infection. Streptococcus intermedius was isolated from oral smear, liver and ventricular drainage, and blood sample. After the commencement of antibiotic therapy, drainage of abscesses and oral rehabilitation, complete recovery was noted.

Bilateral plantar tendinitis during levofloxacin therapy

A 51-year-old woman was referred with suspicion of deep vein thrombosis 8 days after successful aorto-coronary bypass surgery. On clinical examination a mild swelling of the calves with little pitting oedema were found. Plantar tendons on both feet were crepitating, rough and hurtful under palpation. On complete compression ultrasound (CCUS) proximal or distal deep vein thrombosis were excluded, but features of plantar tendinitis including oedema surrounding the plantar tendons of D II–IV on both feet were detected. The patient had been on antibiotics since the day of surgery which had been changed from intravenous cefuroxim to oral levofloxacin 2 days prior to the onset of symptoms. Concomitant medication consisting of metoprolol, ramipril, simvastatin, acetylsalicylic acid, clopidogrel, hydrochlorothiazid, esomeprazol and paracetamol had not been changed. Since no trauma was reported, mobilization had so far progressed without problems and symptoms occurred simultaneously on both feet, levofloxacin was considered to be the most probable cause of the bilateral plantar tendinitis. Levofloxacin was discontinued and bed rest and cryotherapy were administered for 2 days. Symptoms completely subsided without further treatment within 2 days and the patient was discharged. To our knowledge, no cases of bilateral plantar tendinitis associated with levofloxacin therapy have previously been reported, but there are an increasing number of reports associating tendinitis or ruptures of the Achilles tendon and very rarely hand or shoulder tendons with fluoroquinolone treatment [1–4]. Symptoms typically start within a few days after commencement of antibiotic therapy [1, 2], which has been confirmed in an animal experiment, showing degenerative alterations of tenocytes after 3 days of fluoroquinolone therapy [5]. Elderly patients [3, 6] and patients with concomitant corticoid therapy [1, 3] seem to be at increased risk. The pathophysiology of fluoroquinolone-induced tenocyte degeneration involves changes in receptor and signalling proteins as well as apoptosis [7] and may be accelerated by magnesium deficiency [5, 8]. Physicians should be aware of early symptoms of any tendinitis under fluoroquinolone therapy. Withdrawal of fluoroquinolones and symptomatic therapy should start immediately and lead to an improvement of symptoms within a few days. For patients at risk, alternative antibiotic agents should be considered.

Antibiotic Sensitivity Patterns of Microbial Isolates from the Urine of Pregnant Women with Urinary Tract Infections

Context: Urinary tract infections are the most common bacterial infections during pregnancy. Though the causative organisms have remained essentially the same over time, they have become increasingly resistant to the usual antibiotics. Objective: To determine the current microbial isolates and their pattern of antibiotic sensitivity in pregnant women with urinary tract infection. Patients and Methods:This was a descriptive study done in the Obstetric Unit of the Obafemi Awolowo Unversity Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria. Midstream urine specimens of all pregnant women with features of urinary tract infection were collected and subjected to microscopy, culture and sensitivity before commencement of antibiotic therapy. Results: The incidence of urinary tract infection in pregnancy was 6.2%. The commonest organisms isolated were Escherichia coli (42.2%), Staphylococcus aureus (21.9%), Klebsiella spp (12.8%), unspecified coliform organisms (11.7%) and Streptococcus faecalis (4.2%). Nitrofurantoin (83.7%), gentamicin (61.2%) and pefloxacin (54.2%) were the only antibiotics to which at least 50% of the organisms isolated were sensitive. Conclusion: Gram-negative organisms remain the leading group of organisms infecting the urinary tract of pregnant women at Ile-Ife, Nigeria and they are generally sensitive to nitrofurantoin, gentamicin and pefloxacin. Key Words: Urinary Tract Infection, Pregnancy, Antibiotic Sensitivity [Trop J Obstet Gynaecol, 2003, 20: 113-115]

The role of antibiotics and chronic lung disease

SummarySputum purulence is highly suggestive of bacterial infection in the lower respiratory tract and is a prime indicator for the commencement of antibiotic therapy. The choice of an appropriate antimicrobial agent depends on a number of factors including local antibiotic sensitivity/resistance patterns, bioavailability of selected drugs and an understanding of the possible interaction between the chosen antibiotic and host defence mechanisms including neutrophils and cytokines.

Increasing urinary IL-6 levels announce kidney graft rejection*

Abstract Acute rejection (AR) is the recipient's inflammatory response to the grafted organ. Within the graft-infiltrating cells, a high ratio of IL-6 producing cells can be found, indicating local IL-6 production. Therefore, in cases of kidney transplantation, urinary (u) IL-6 should be detectable. In order to establish the dynamics and diagnostic relevance, uIL-6 levels were determined daily by Quantikine IL-6 immunoassay (R&D Systems, Minneapolis, Minn.) in 101 kidney graft recipients (n = 1915 urine samples) during their post-transplant hospital stay. Immunosuppression consisted of azathioprine, steroids, cyclosporine and an intraoperative high-dose single antithymocyte globulin (ATG)-Fresenius bolus (9 mg/kg). In all the uncomplicated courses (n = 31) mean uIL-6 level was determined, after a post-transplant peak of 174 pg/ml, to be between 4 and 8 pg/ml. In contrast, delayed graft function (n = 16) was always associated with very high uIL-6 levels (> 200 pg/ml), dropping down only with commencement of graft function. Steroid-sensitive AR (n = 14) was consistently associated with significantly increasing uIL-6 levels prior to antirejection therapy (from 23 to 82 pg/ml). In cases of steroid-resistant AR, following anti-rejection therapy with methylprednisolone (5 days 5 mg/kg), there was no obvious trend towards normalization, indicating the persistence of inflammation (mean uIL-6 peak prior to OKT3 or ATG therapy: 99 pg/ml). In addition, AR-associated uIL-6 levels were found to be of much greater diagnostic relevance than AR-associated serum IL-6 levels. In bacterial urinary tract infections (n = 20), increased uIL-6 levels (peak 53 pg/ml) coincided with the commencement of antibiotic therapy. In mild cytomegalovirus diseases (n = 8), the development of leukocytopenia was associated with a slight increase of uIL-6 (peak 26 pg/ml), showing graft involvement. All increased uIL-6 values returned towards baseline after successful treatment. Thus, uIL-6 provides information about the intragraft inflammatory situation. Its determination is simple, expressive, non-invasive and can be recommended.

Increasing urinary IL-6 levels announce kidney graft rejection.

Acute rejection (AR) is the recipient's inflammatory response to the grafted organ. Within the graft-infiltrating cells, a high ratio of IL-6 producing cells can be found, indicating local IL-6 production. Therefore, in cases of kidney transplantation, urinary (u) IL-6 should be detectable. In order to establish the dynamics and diagnostic relevance, uIL-6 levels were determined daily by Quantikine IL-6 immunoassay (R & D Systems, Minneapolis, Minn.) in 101 kidney graft recipients (n = 1915 urine samples) during their post-transplant hospital stay. Immunosuppression consisted of azathioprine, steroids, cyclosporine and an intraoperative high-dose single antithymocyte globulin (ATG)-Fresenius bolus (9 mg/kg). In all the uncomplicated courses (n = 31) mean uIL-6 level was determined, after a post-transplant peak of 174 pg/ml, to be between 4 and 8 pg/ml. In contrast, delayed graft function (n = 16) was always associated with very high uIL-6 levels (> 200 pg/ml), dropping down only with commencement of graft function. Steroid-sensitive AR (n = 14) was consistently associated with significantly increasing uIL-6 levels prior to antirejection therapy (from 23 to 82 pg/ml). In cases of steroid-resistant AR, following antirejection therapy with methylprednisolone (5 days 5 mg/kg), there was no obvious trend towards normalization, indicating the persistence of inflammation (mean uIL-6 peak prior to OKT3 or ATG therapy: 99 pg/ml). In addition, AR-associated uIL-6 levels were found to be of much greater diagnostic relevance than AR-associated serum IL-6 levels. In bacterial urinary tract infections (n = 20), increased uIL-6 levels (peak 53 pg/ml) coincided with the commencement of antibiotic therapy. In mild cytomegalovirus diseases (n = 8), the development of leukocytopenia was associated with a slight increase of uIL-6 (peak 26 pg/ml), showing graft involvement. All increased uIL-6 values returned towards baseline after successful treatment. Thus, uIL-6 provides information about the intragraft inflammatory situation. Its determination is simple, expressive, non-invasive and can be recommended.

Tricuspid valve endocarditis on a healthy valve—potentially lethal in infants and young children

SummaryTricuspid valve endocarditis on a normal valve has been rarely documented in children. In all five previous cases the infecting organism was Staphylococcus aureus. We report five infants and children with tricuspid valve endocarditis, whose ages ranged from four months to four years. In all of them large vegetations were identified by two-dimensional echocardiography. Positive blood cultures were found in four of five patients. Staphylococcus aureus, Corynebacterium species, Haemophilus influenzae and Candida albicans were the respective isolates. There were three deaths, all relatively sudden, 10–33 days after commencement of antibiotic therapy. At the only post mortem carried out in the patient with Candida albicans endocarditis and Down syndrome, there were two large fungating masses straddling the tricuspid valve. They appeared to have obstructed the circulation. Microscopic examination of a lymph node and the thymus showed features consistent with an immune deficiency syndrome. One child has been lost to follow-up. In the remaining survivor, progressively severe tricuspid regurgitation with congestive cardiac failure, necessitated open heart surgery 13 months later. A homograft replacement of the destroyed septal leaflet was carried out. Tricuspid valve endocarditis in an infant or child is a serious and potentially lethal condition. Early surgical intervention to remove large obstructive vegetations appears to be warranted.