Local Antimicrobial Resistance Patterns Research Articles

Changing antibiotic prophylaxis for transrectal ultrasound‐guided prostate biopsies: are we putting our patients at risk?

To evaluate whether changing antibiotic prophylaxis from quinolone to penicillin antibiotics has affected infectious complication rates in those men undergoing transrectal ultrasound-guided prostate biopsy (TRUSgpb). This interventional study was designed to determine whether changing antibiotic prophylaxis had any bearing on developing serious infectious complications after taking TRUSgpb. As a secondary aim, we also investigated Clostridium difficile (C. difficile) rates in the same groups of men undergoing TRUSgpb. Men historically received ciprofloxacin 500 mg orally 1 h before their procedure followed by a 3-day course of 500 mg given twice daily (group A). Due to increasing local patterns of antimicrobial resistance to quinolones and concerns regarding potential antibiotic induced C. difficile infection, antibiotic prophylaxis was changed to a penicillin-based regimen comprising of co-amoxiclav 625 mg given orally 1 h before TRUSgpb followed by a three times daily course for 3 days (group B). Excluded from the study were those men given an alternative antibiotic prophylaxis than those given within the two distinct groups due to reasons of previous hypersensitivity reactions and/or clinical decision by the attending Urologist. Comparisons were made between the groups using two-tailed Fisher's exact tests. In all, 119 and 110 men were identified in groups A and B, respectively. Two men in group A (1.68%) developed sepsis after TRUSgpb requiring hospital admission and intravenous antibiotic treatment. The sepsis rate in group B was significantly higher than that of group A (eight of 110, 7.27%; P = 0.036). Escherichia coli was the only organism isolated from our cohort of patients. There were no incidences of C. difficile infections in either antibiotic prophylaxis groups. Ciprofloxacin appears to provide superior prophylaxis than co-amoxiclav in men undergoing TRUSgpb and was not associated with an increased risk of quinolone induced C. difficile infections. Changing antibiotic prophylaxis from a quinolone-based regime may therefore be putting our patients at an increased risk of serious infectious complications after TRUSgpb.

Hospital-acquired pneumonia in the 21st century: a review of existing treatment options and their impact on patient care

Hospital-acquired pneumonia is a common nosocomial infection, with significant morbidity and mortality, and represents a major therapeutic challenge to clinicians. The therapeutic approach must be patient-oriented and institution-specific. The specific risk factors of each patient, such as previous antibiotic exposure, underlying diseases, length of hospital stay and the local patterns of antimicrobial resistance, should guide physicians in their decision of the initial optimal empirical therapy. Delays in the initiation or inappropriate/inadequate initial therapy are related to increased mortality and worse outcomes. In responding patients, as soon as culture data are available, efforts should be made to change the initial broad spectrum antibiotic regimen to a more targeted one (de-escalation). The optimal duration of treatment is a matter of debate, but courses longer than 1 week are rarely justified.

Management of acute bacterial rhinosinusitis: current issues and future perspectives

Acute bacterial rhinosinusitis (ABRS), which manifests as an inflammation of at least one of the paranasal sinuses, is a major public health issue in developed countries. Diagnosis and treatment of ABRS can pose significant challenges in clinical practice, including difficulty in differentiation between viral and bacterial infection and a lack of simple, reliable and convenient methods for definitive diagnosis. Treatment choice is also a challenge because a decision is typically made empirically; therefore, the selection of therapy should be based on knowledge of local patterns of antimicrobial resistance, spectrum of activity against the most common ABRS pathogens (including those that are resistant to penicillins and macrolides) and pharmacodynamic potency. Current guidelines for diagnosis and treatment of ABRS in various countries share some similarities but also have important differences. Criteria for making the clinical diagnosis of sinusitis vary only slightly from country to country, while recommendations of therapy reflect the local impact of bacterial resistance.

The Importance of De-escalating Antimicrobial Therapy in Patients with Ventilator-Associated Pneumonia

The management of ventilator-associated pneumonia (VAP) requires a strategy for antibiotic use that achieves prompt and accurate empirical therapy without overusing antibiotics. Although, efforts at better diagnosis and antibiotic restriction have been attempted, "de-escalation" may be a more useful and effective strategy, and one that can achieve these goals while improving patient outcomes. The centerpiece of this approach is to initiate empirical therapy with a broad-spectrum treatment regimen, based on knowledge of local patterns of microbiology and antimicrobial resistance. Prior to therapy, patients require collection of a lower respiratory tract sample for culture. After 2 to 3 days, the clinical course can be assessed and the culture data reviewed, and in responding patients, efforts can be made to change the initial broad-spectrum therapy. This de-escalation can involve focusing to a more narrow spectrum agent, reducing the number of antibiotics, stopping therapy altogether in patients not likely to have infection, and making efforts to reduce duration of therapy. When this strategy has been used, outcomes such as the frequency of secondary infection, antimicrobial resistance, and mortality have improved. Additional information is needed to apply this approach more widely, especially in patients infected with multidrug-resistant organisms and in those with negative lower respiratory tract cultures.

Community-acquired pneumonia in children.

Community acquired pneumonia (CAP) is common in childhood. Viruses account for most cases of CAP during the first two years of life. After this period, bacteria such as Streptococcus pneumoniae, Mycoplasma pneumoniae and Chlamydia pneumoniae become more frequent. CAP symptoms are nonspecific in younger infants, but cough and tachypnea are usually present in older children. Chest x-ray is useful for confirming the diagnosis. Most children can be managed empirically with oral antibiotics as outpatients without specific laboratory investigations. Those with severe infections or with persistent or worsening symptoms need more intensive investigations and may need admission to hospital. The choice and dosage of antibiotics should be based on the age of the patient, severity of the pneumonia and knowledge of local antimicrobial resistance patterns. The Canadian Paediatric Society recommends the use of the heptavalent conjugate pneumococcal vaccine, which is efficacious in reducing chest x-ray positive pneumonia by up to 20%.

A 12-Month Review of Peritoneal Dialysis-Related Peritonitis in Western Australia: Is Empiric Vancomycin Still Indicated for Some Patients?

The International Society for Peritoneal Dialysis (ISPD) guidelines recommend empiric therapy with cefazolin and ceftazidime for peritoneal dialysis (PD)-related peritonitis. Empiric cefazolin therapy may have diminishing efficacy because of emerging methicillin resistance in gram-positive bacteria (GPB). Western Australia also has large numbers of Aboriginal and isolated regional patients, where giving these antimicrobials can be impractical. To evaluate, based on local antimicrobial resistance patterns, the feasibility of following ISPD guidelines in Western Australia and to identify any subgroups of PD peritonitis patients that may benefit from alternative empiric intraperitoneal antibiotics (e.g., vancomycin). Retrospective study of all PD peritonitis episodes in Western Australia from 1 February 2000 to 31 January 2001. Three adult tertiary referral university hospitals and their PD patients in metropolitan Perth and regional Western Australia. All adults on PD in Western Australia. Isolates and antibiograms were analyzed versus patient characteristics, including race and patient demographics. 293 patients (28% Aborigines, 32% regional patients) received PD. 145 episodes of PD peritonitis occurred during the study. The overall PD peritonitis rate was 1 episode/16 patient months, with Aborigines having 1 episode/10.5 patient months versus non-Aborigines having 1 episode/17 patient months (p < 0.001). 36% of isolates from PD peritonitis episodes were resistant to cefazolin or ceftazidime. 22% were methicillin-resistant GPB (MR-GPB) [18% coagulase-negative staphylococci (CoNS), 1.6% MR Staphylococcus aureus]; 2.5% were multidrug-resistant gram-negative bacteria (MDR-GNB); 5.7% were polymicrobial (MR-GPB and/or MDR-GNB); and 5.7% were fungal. 63% of CoNS were methicillin resistant. Non-Aboriginal patients yielded MR-GPB in 22% of isolates versus 23% in Aborigines (p = 0.9). Six of seven cases of fungal peritonitis occurred in Aboriginal patients (p < 0.001). In our study population the ISPD guidelines were appropriate for 64% of patients with PD peritonitis. We could not identify specific patient subgroups where empiric cefazolin use could be more effective. High proportions of MR-GPB PD peritonitis episodes, along with local factors, make empiric cefazolin unsuitable for many regional PD patients in Western Australia.

Nosocomial Pneumonia: More Than Just Ventilator-Associated.

We reviewed literature published from 1995 through 2000 on developments in ventilator-associated pneumonia. There is no gold standard with which to compare the accuracy of various invasive procedures performed for diagnosis. Moreover, leaders in the field are calling for an outcomes-based analysis to assess the utility of invasive procedures. Two things are clear: 1) adequate empiric therapy is beneficial, and 2) changes in therapy based on recovery of pathogens by invasive means do not affect outcome. Clinicians are urged to review local antimicrobial resistance patterns and to initiate empiric therapy on the basis of those data.

Community-Acquired Pneumonia

Community-Acquired Pneumonia

Guidelines and Critical Pathways for Severe Hospital-Acquired Pneumonia

Hospital-acquired pneumonia (HAP) is associated with high morbidity and mortality. Early, appropriate, and adequate empiric therapy can increase the chance of survival. In 1995, the American Thoracic Society provided guidelines for the initial treatment of immunocompetent HAP patients, which is one of the principal HAP management approaches available to physicians today. However, these guidelines have several important limitations, including a lack of recommendations for duration of therapy and no recognition of newer drugs such as cefepime, trovafloxacin, and meropenem. Furthermore, they fail to distinguish among similar compounds (ie, beta-lactam/beta-lactamase inhibitor combinations) or to recommend specific antibiotics. The clinician using these guidelines needs to address local patterns of antimicrobial resistance, especially in ICUs. Effective computerized antibiotic management programs that incorporate information on local patterns of antimicrobial resistance can assist physicians in empiric therapy decision making, improve patient quality of care, and reduce medical costs.

Antimicrobial Treatment Guidelines for Acute Bacterial Rhinosinusitis

Target population: Healthcare practitioners who treat upper respiratory infections in children and adults; secondarily, the patient population. Sponsoring organization: Sinus and Allergy Health Partnership, a not-for-profit organization created by the American Academy of Otolaryngic Allergy, the American Academy of Otolaryngology--Head and Neck Surgery, and the American Rhinologic Society. Type: Clinical treatment guideline based on analysis of pathogenesis, microbial isolates, local antimicrobial resistance patterns, age groups, history of previous antibiotic treatment, and mathematical modeling …

Anaesthesia and emerging infectious diseases.

New infectious diseases and microorganisms continue to be described. They may be blood- or arthropod-borne, or spread by the respiratory, sexual or faecal-oral route; in some cases, modes of transmission remain unknown or new ones have been described. Complex factors have contributed to the re-emergence of older pathogens in both developing and developed countries. Changes in medical and surgical practice have led to the frequent description of resistant gram-positive and negative bacteria, fungi and bacteria. Although many of the newly described agents may not be directly relevant to routine anaesthetic and intensive care practice, their impact on both patients and staff can be minimized by adherence to rational infection control guidelines, understanding of local disease and anti-microbial resistance patterns, sensible patient evaluation and access to expert advice. Given recent history, it can be expected that new microorganisms and clinical syndromes will continue to appear.

Therapeutic Concepts in Drug Prescribing for Respiratory Tract Infection

Respiratory tract infection (RTI) poses a serious threat to the health of patients in all age groups. Low birthweight, poor nutritional status, smoking, overcrowding and breathing polluted air may predispose one to the development of this disorder. While viruses are the main pathogens, different bacteria are involved in upper and lower RTI When identifying the offending bacterial pathogen, one must take into account local antimicrobial resistance patterns. Selection of an appropriate antibiotic requires consideration of pharmacokinetic and pharmacodynamic properties and antibacterial activity to ensure the use of drugs that will aid patient compliance with the prescribed regimen. Additional factors in the decision of which antimicrobial to use include in vitro susceptibility, proven efficacy in controlled clinical trials, low cost, safety and good oral absorption. In this regard, macrolides, particularly the newer agents such as roxithromycin, may be considered effective therapy in RTI.