Mean Number Of Antibiotics Research Articles

Impact of COVID-19 Related Restrictions on Infections in Children with Cancer or after Hematopoietic SCT.

Infections are a major concern for immunocompromised children. We investigated whether non-pharmaceutical interventions (NPIs) implemented in the general population during the coronavirus disease 2019 (COVID-19) pandemic in Germany had an impact on frequency, type and severity of infections in these patients. We analyzed all admissions to the clinic of pediatric hematology, oncology and stem cell transplantation (SCT) with (suspected) infection or fever of unknown origin (FUO) from 2018 to 2021. We compared a 27-month period before NPIs (Pre-COVID: 01/2018-03/2020; 1041 cases) with a 12-month period with underlying NPIs (COVID: 04/2020-03/2021; 420 cases). During the COVID period the number of in-patient stays with FUO or infections decreased (38,6 cases/month vs. 35,0 cases/month), the median duration of hospital stays was longer (8 d (CI95: 7-8 d) vs. 9 d (CI95: 8-10 d) P=0,02)), the mean number of antibiotics per case increased (2,1 (CI95: 2,0-2,2) vs. 2,5 (CI95: 2,3-2,7); P=0,003)) and a substantial reduction of viral respiratory and gastrointestinal infections per case was seen (0,24 vs. 0,13; P<0,001). Notably, there was no detection of respiratory syncytial virus, influenza and norovirus, between May 2020 and March 2021. Based on need of intensive care measures and further parameters we conclude that severe (bacterial) infections were not significantly reduced by NPIs. Introduction of NPIs in the general population during the COVID-pandemic substantially reduced viral respiratory and gastrointestinal infections in immunocompromised patients, while severe (bacterial) infections were not prevented.

E-Learning versus Face-to-Face Methodology for Learning Antimicrobial Resistance and Prescription Practice in a Tertiary Hospital of a Middle-Income Country.

Antimicrobial resistance is a growing health problem worldwide. One strategy to face this problem in a reasonable way is training health personnel for the rational use of antimicrobials. There are some difficulties associated with medical staff to receiving training with E-learning education, but there is a lack of studies and insufficient evidence of the effectiveness of this method compared to face-to-face learning. An educational intervention on antimicrobial resistance (AMR) and antimicrobial prescription practice (APP) was designed and implemented using two approaches: face-to-face and E-learning among physicians of the intensive care unit (ICU) and internal medicine ward (IMW) at Eugenio Espejo Hospital in Quito. Modalities of interventions were compared to propose a strategy of continuous professional development (CPD) for all hospital staff. An interventional study was proposed using a quasi-experimental approach that included 91 physicians, of which 49 belong to the IMW and 42 to the ICU. All of them received training on AMR-half in a face-to-face mode and the other half in an asynchronous E-learning mode. They then all participated on APP training but with switched groups; those who previously participated in the face-to-face experience participated in an E-learning module and vice-versa. We evaluated self-perception about basic knowledge, attitudes and referred practices towards AMR and APP before and after the intervention. A review of medical records was conducted before and after training by checking antimicrobial prescriptions for all patients in the ICU and IMW with bacteremia, urinary tract infection (UTI), pneumonia, and skin and soft tissue infection. The study received IRB clearance, and we used SPSS for statistical analysis. No statistically significant difference was observed between the E-learning and the face-to-face methodology for AMR and APP. Both methodologies improved knowledge, attitudes and referred practices. In the case of E-learning, there was a self-perception of improved attitudes (p &lt; 0.05) and practices (p &lt; 0.001) for both AMR and APP. In face-to-face, there was a perception of improvement only in attitudes (p &lt; 0.001) for APP. In clinical practice, the use of antimicrobials significantly improved in all domains after training, including empirical and targeted treatment of bacteremia and pneumonia (p &lt; 0.001) and targeted treatment of UTI (p &lt; 0.05). For the empirical treatment of pneumonia, the mean number of antibiotics was reduced from 1.87 before to 1.05 after the intervention (p = 0.003), whereas in the targeted management of bacteremia, the number of antibiotics was reduced from 2.19 to 1.53 (p = 0.010). There was no statistically significant difference between the effect of E-learning and face-to-face strategy in terms of teaching AMR and APP. Adequate self-reported attitudes and practices in E-learning exceed those of the face-to-face approach. The empiric and targeted use of antimicrobials improved in all reviewed cases, and we observed an overall decrease in antibiotic use. Satisfaction with training was high for both methods, and participants valued the flexibility and accessibility of E-learning.

An Evaluation of Antibiotic Prescribing Practices in a Rural Refugee Settlement District in Uganda.

Ensuring access to effective antibiotics and rational prescribing of antibiotics are critical in reducing antibiotic resistance. In this study, we evaluated antibiotic prescribing practices in a rural district in Uganda. It was a cross-sectional study that involved a retrospective review of 500 outpatient prescriptions from five health facilities. The prescriptions were systematically sampled. World Health Organization core medicine use prescribing and facility indicators were used. Percentage of encounters with one or more antibiotics prescribed was 23% (10,402/45,160). The mean number of antibiotics per prescription was 1.3 (669/500). About 27% (133/500) of the diagnoses and 42% (155/367) of the prescriptions were noncompliant with the national treatment guidelines. Prescribing antibiotics for nonbacterial infections such as malaria 32% (50/156) and noninfectious conditions such as dysmenorrhea and lumbago 15% (23/156) and nonspecific diagnosis such as respiratory tract infection 40% (59/133) were considered noncompliant with the guidelines. On average, 68% (51/75) of the antibiotics were available on the day of the visit. Inappropriate prescribing practices included excessive use of antibiotics and failure to diagnose and prescribe in compliance with treatment guidelines. There is a need to strengthen antibiotic use in the health facilities through setting up stewardship programs and interventions to promote adherence to national treatment guidelines.

Antibiotic stewardship initiative in a Medicine unit of a tertiary care teaching hospital in India: A pilot study

Background & objectives:The models for implementation of antibiotic stewardship programme (ASP) in the acute care settings of developing countries are lacking. In most of the hospitals, patient turnover is high and a proper system for recording antibiotic-related information and tracking hospital-acquired infections is not in place. This pilot study was conducted in a tertiary care teaching hospital in north India to assess the feasibility of implementation of an ASP in a Medicine unit and to evaluate the effect of implementation as per the criteria applicable in this set up.Methods:A pre-post-quasi-experimental non-randomized study was conducted in two phases. In the first phase, current practices in the Medicine wards were observed. In the second phase, the ASP was implemented in a single Medicine unit, along with prospective audit and feedback, tracking of the process, as well as outcome measures. Patient risk stratification, blood culture on day one, day 3 bundle, dose optimization, de-escalation and intravenous to oral conversion of antibiotics were the key elements focused upon.Results:There was a significant improvement in the appropriateness of antibiotic prescription (66 vs. 86%, P<0.001) and reduction in the mean number of antibiotics used per person (4.41 vs. 3.86, P<0.05) along with decrease in the duration of hospital stay (17 vs. 14 days, P<0.05). There was a significant improvement in sending of blood cultures on day one during the stewardship phase (P<0.001).Interpretation & conclusions:The ASP approach used in our pilot study may be feasible and beneficial. However, it needs further confirmation in other settings and on a large scale.

MP69-16 CHARACTERISTICS AND MORBIDITY OF BACTEREMIA OF UROLOGIC ORIGIN IN THE PEDIATRIC PATIENT

You have accessJournal of UrologyPediatrics: Urinary Tract Infection & Vesicoureteral Reflux1 Apr 2018MP69-16 CHARACTERISTICS AND MORBIDITY OF BACTEREMIA OF UROLOGIC ORIGIN IN THE PEDIATRIC PATIENT Jesse Jacobs, Kevin Ginsburg, Kahlil Saad, and George Steinhardt Jesse JacobsJesse Jacobs More articles by this author , Kevin GinsburgKevin Ginsburg More articles by this author , Kahlil SaadKahlil Saad More articles by this author , and George SteinhardtGeorge Steinhardt More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2240AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Bacteremia of urologic origin (BUO) is a common cause of sepsis in the adult population causing significant morbidity and mortality. We sought to review patient characteristics and morbidity of pediatric patients presenting with BUO. METHODS We retrospectively reviewed cases of pediatric patients with BUO at the Helen DeVos Children′s Hospital from 2010 to 2015. Study sample was obtained using combinations of the ICD-9 diagnostic code 599.0 (urinary tract infection, UTI), with 790.7 (bacteremia), 995.92 (severe sepsis), 995.91 (sepsis), and 591.10 (acute pyelonephritis). The electronic medical recorded was reviewed for relevant laboratory and clinic parameters. BUO was present if blood and urine cultures grew the same organism. If discordance between the blood and urine cultures existed, or the blood culture was negative, the patient was considered to have clinical pyelonephritis (CP). Neonatal patients were excluded. RESULTS We identified 121 pediatric patients with diagnosis codes consistent with BUO. Upon review of the chart, 87 patients met criteria for CP or BUO. Most patients were female (74.7%) with a median age of 3.0 years (IQR 0.25-10.0). Forty-four patients (50.6%) were classified as having BUO. Patients with underlying genitourinary (GU) structural abnormalities had similar proportions with BUO compared to children without GU abnormalities (53.8% vs 47.9%, p=0.668). E. coli was the causative agent in the majority of cases of CP (76.7%) and BUO (70.5%) p=0.628. There was a significant difference in mean length of intravenous antibiotic use in patients with BUO compared to CP (7.7 vs 5.1 days, p=0.023) and in the mean number of antibiotics used to treat the infection (1.9 vs 1.4, p=0.003). In the 44 children with BUO, children with GU structural abnormalities tended to be younger (2.6 vs 5.8 years), although this difference was not statistically significant (p=0.07). There was no difference in age, gender, length of stay (LOS), antibiotic usage, or rates of BUO compared to CP in patients diagnosed with a GU structural abnormality prior to admission, compared to those diagnosed during or after admission. CONCLUSIONS BUO in the pediatric patient is relatively rare, with only 44 cases across our 5-year study period. Underlying structural GU abnormalities did not significantly increase the risk for BUO compared to clinical pyelonephritis. Although LOS and other morbidity were similar, patients with BUO tended to be younger and require more IV antibiotic therapy. Further studies into the impact of GU structural abnormalities on the development of BUO is warranted. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e932 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Jesse Jacobs More articles by this author Kevin Ginsburg More articles by this author Kahlil Saad More articles by this author George Steinhardt More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Clinical characteristics of patients with lower limb cellulitis and antibiotic usage in Hospital Kuala Lumpur: a 7-year retrospective study.

Cellulitis commonly involved lower limbs. This study was carried out to determine the demography, clinical characteristics, risk factors, microbiological aspects, and antibiotics usage in this group of patients in Hospital Kuala Lumpur. A total of one hundred and twenty four patients with lower limb cellulitis treated in the Department of Dermatology, Hospital Kuala Lumpur, between January 2008 and May 2013 were included in this study. There were 70 male and 54 female patients, aged between 13 and 87 years (mean 57.23±12.854). Thirty-one of them (25%) had recurrent cellulitis. Fifty-seven (46%) had fever at presentation, 55 (44.4%) had bullous cellulitis. The top risk factors identified were toe web intertrigo (n = 79, 63.7%), hypertension (n=76, 61.3%), obesity (n = 55, 44.4%), and diabetes (n = 55, 44.4%). However, only toe web intertrigo (p= 0.003), peripheral vascular disease (p = 0.01), and varicose veins (p = 0.02) were significantly higher in recurrent cellulitis. Thirty patients (24.2%) were complicated with lipodermatosclerosis, and six (4.8%) had lymphostasis verrucosa cutis. Skin swab cultures were positive in 54 (43.5%) patients, and Pseudomonas sp. was the most frequently identified organism. Mean number of antibiotics given for one episode of cellulitis was1.7±1. The antibiotics most given were cloxacillin (n=57, 46%) and other penicillins (n= 71, 57%), followed by cephalosporins (n = 40, 32%). Identifying clinical characteristics of those at risk may help to prevent recurrence of cellulitis and long-term complications.

Pharmacist interventions for prophylactic antibiotic use in urological inpatients undergoing clean or clean-contaminated operations in a Chinese hospital.

ObjectivesTo evaluate the impact and cost-benefit value of pharmacist interventions for prophylactic antibiotic use in surgical patients undergoing clean or clean-contaminated operations.MethodsA pre-to-post intervention study was performed in the Department of Urological Surgery of a tertiary hospital. Patients admitted from January through June 2011, undergoing clean or clean-contaminated surgery, served as the pre-intervention group; patients admitted from January through June 2012 formed the post-intervention group. Pharmacist interventions were performed for the surgeries in the post-intervention group. The criteria for the rational use of antibiotic prophylaxis were established by the hospital administration. The pharmacist interventions included real-time monitoring of medical records and controlling of the prescriptions of prophylactic antibiotics against the criteria. The pre- and post-intervention groups were then compared to evaluate the outcomes of the pharmacist interventions. A cost-benefit analysis was performed to determine the economic effects of implementing the pharmacist intervention on preoperative antibiotic prophylaxis.ResultsAfter the pharmacist intervention, a significant decrease was found in the rate of no indications for prophylactic antibiotic use (p = 0.004), the rate of broad-spectrum antibiotic use (p<0.001), the rate of drug replacement (p<0.001) and the rate of prolonged duration of prophylaxis (p<0.001). Significant reductions were observed in the mean antibiotic cost (p<0.001), the mean duration of antibiotic prophylaxis (p<0.001) and the mean number of antibiotics used (p<0.001). A significant increase was observed in the rate of correct choice of antibiotics (p<0.001). The ratio of the net mean cost savings for antibiotics to the mean cost of pharmacist time was approximately 18.79∶1.ConclusionReal-time interventions provided by a clinical pharmacist promoted rational use of prophylactic antibiotics, with a significant reduction in antibiotic costs, thus leading to favorable economic outcomes.

BAY41-6551 achieves bactericidal tracheal aspirate amikacin concentrations in mechanically ventilated patients with Gram-negative pneumonia

To conduct a multicenter, randomized, placebo-controlled, double-blind, phase II study of BAY41-6551 (NCT01004445), an investigational drug-device combination of amikacin, formulated for inhalation, and a proprietary Pulmonary Drug Delivery System, for the treatment of Gram-negative pneumonia in mechanically ventilated patients. Sixty-nine mechanically ventilated patients with Gram-negative pneumonia, a clinical pulmonary infection score ≥6, at risk for multidrug-resistant organisms, were randomized to BAY41-6551 400mg every 12h (q12h), 400mg every 24h (q24h) with aerosol placebo, or placebo q12h for 7-14days, plus standard intravenous antibiotics. The combined primary endpoint was a tracheal aspirate amikacin maximum concentration ≥6,400μg/mL (25×256μg/mL reference minimum inhibitory concentration) and a ratio of area under the aspirate concentration-time curve (0-24h) to minimum inhibitory concentration ≥100 on day 1. The primary endpoint was achieved in 50% (6/12) and 16.7% (3/18) of patients in the q12h and q24h groups, respectively. Clinical cure rates, in the 48 patients getting ≥7days of therapy, were 93.8% (15/16), 75.0% (12/16), and 87.5% (14/16) in the q12h, q24h, and placebo groups, respectively (p=0.467). By the end of aerosol therapy, the mean number of antibiotics per patient per day was 0.9 in the q12h, 1.3 in the q24h, and 1.9 in the placebo groups, respectively (p=0.02 for difference between groups). BAY41-6551 was well tolerated and attributed to two adverse events in one patient (mild bronchospasm). BAY41-6551 400mg q12h warrants further clinical evaluation.

Factors Associated with Candidemia Caused by Non‐albicans CandidaSpecies VersusCandida albicansin the Intensive Care Unit

Candida albicans has been the most common cause of fungal bloodstream infections (BSIs) in intensive care units (ICUs); however, infections due to non-albicans Candida species have been increasing in prevalence. We examined factors associated with BSIs due to non-albicans Candida species, compared with C. albicans BSIs, in an ICU patient population. For our case-comparator study, we identified consecutive adult ICU patients with BSIs due to non-albicans Candida species or C. albicans at 2 tertiary care hospitals during the period 1995-2005. Data collected included demographic characteristics, comorbidities, exposure to antibiotics and antifungals, and ICU-related factors, such as total parenteral nutrition, blood product transfusions, invasive procedures, central venous catheter use, hemodialysis, and mechanical ventilation. We built a multivariable logistic regression model that identified variables that differentiate BSIs due to non-albicans Candida species from BSIs due to C. albicans. There were 67 patients with BSIs due to non-albicans Candida species and 79 patients with C. albicans BSIs. Variables were adjusted for time at risk. In multivariable models, factors associated with an increased risk of BSIs due to non-albicans Candida species, compared with C. albicans BSIs, included fluconazole exposure (odds ratio, 11.6; 95% confidence interval, 2.28-58.8), central venous catheter exposure (odds ratio, 1.95; 95% confidence interval, 1.10-3.47), and mean number of antibiotics per day (odds ratio, 2.31; 95% confidence interval, 0.71-7.54). Total parenteral nutrition exposure was associated with a decreased risk (odds ratio, 0.16; 95% confidence interval, 0.05-0.47) of BSIs due to non-albicans Candida species, compared with C. albicans BSIs. Duration of stay in the ICU was not significantly different between the 2 groups. Specific antibiotics, such as vancomycin and piperacillin-tazobactam, were not independently associated with BSI due to non-albicans Candida species. Receipt of fluconazole and central venous catheter exposure were associated with an increased risk of BSI due to non-albicans Candida species, and total parenteral nutrition was associated with a decreased risk of BSI due to non-albicans Candida species, compared with BSI due to C. albicans. Patients without characteristics of infection due to non-albicans Candida species might benefit from empirical antifungal therapy with fluconazole.

Prior Environmental Contamination Increases the Risk of Acquisition of Vancomycin-Resistant Enterococci

Patients colonized with vancomycin-resistant enterococci (VRE) frequently contaminate their environment, but the environmental role of VRE transmission remains controversial. During a 14-month study in 2 intensive care units, weekly environmental and twice-weekly patient surveillance cultures were obtained. VRE acquisition was defined as a positive culture result >48 h after admission. To determine risk factors for VRE acquisition, Cox proportional hazards models using time-dependent covariates for colonization pressure and antibiotic exposure were examined. Of 1330 intensive care unit admissions, 638 patients were at risk for acquisition, and 50 patients (8%) acquired VRE. Factors associated with VRE acquisition included average colonization pressure (hazard ratio [HR], 1.4 per 10% increase; 95% confidence interval [CI], 1.2-1.8), mean number of antibiotics (HR, 1.7 per additional antibiotic; 95% CI, 1.2-2.5), leukemia (HR, 3.1; 95% CI, 1.2-7.8), a VRE-colonized prior room occupant (HR, 3.1; 95% CI, 1.6-5.8), any VRE-colonized room occupants within the previous 2 weeks (HR, 2.5; 95% CI, 1.3-4.8), and previous positive room culture results (HR, 3.4; 95% CI, 1.2-9.6). In separate multivariable analyses, a VRE-colonized prior room occupant (HR, 3.8; 95% CI, 2.0-7.4), any VRE-colonized room occupants within the previous 2 weeks (HR, 2.7; 95% CI, 1.4-5.3), and previous positive room culture results (HR, 4.4; 95% CI, 1.5-12.8) remained independent predictors of VRE acquisition, adjusted for colonization pressure and antibiotic exposure. We found that prior room contamination, whether measured via environmental cultures or prior room occupancy by VRE-colonized patients, was highly predictive of VRE acquisition. Increased attention to environmental disinfection is warranted.

Clinico-epidemiological features of infections caused by CTX-M type extended spectrum beta lactamase-producing Escherichia coli in hospitalised patients

A review of medical records of 45 of 53 hospitalised patients with positive cultures for CTX-M type ESBL-producing Escherichia coli between 01 January and 31 May 2004 was conducted. The mean age of the population studied was 73.1 (+/-14.6) years and the majority (55.6%) had been under the care of the internal medicine or elderly care service. In the majority (77.8%) of instances the isolate was attributed to a clinical infection rather than colonisation and the commonest clinical specimen to yield the organism was urine, which was positive in 57.8% of patients. Acquisition of the organism was categorised as nosocomial in 68.9% of patients; in this subgroup, the median duration of inpatient stay prior to recovery of the organism was 24 (range 3-240) days. Haemodialysis-dependence was the most common of the comorbidities evaluated. The mean number of antibiotics prescribed per patient in the 30 days prior to first isolation of the organism was 1.7 (range 0-4). Furthermore, the mean number of antibiotic-days exposure per patient during this period was 13.9 (range 0-48). The most frequently received class of antibiotic was beta-lactam/beta-lactamase inhibitor combinations. Of 35 infections, 26 (74.2%) were successfully treated. Overall 12 patients with infection died (34.3%); attributable mortality was presumed in seven (20%).

Antibiotic medication and bacterial resistance to antibiotics: a survey of children in a Vietnamese community.

To investigate antibiotic use and antibiotic susceptibility of respiratory tract pathogens in children aged 1-5 years in Bavi, Vietnam. Nasopharynx and throat specimens were collected from 200 children from randomly selected households in a demographically defined population. Respiratory isolates were tested for antibiotic susceptibility according to the standard disk diffusion method. A questionnaire survey of carers elicited information on type of antibiotic used, duration of treatment, where the antibiotics had been purchased, type of treatment information retained by carers and episodes of illness preceding the study. 82% of the children had at least one symptom of acute respiratory tract infection (ARI) in the 4 weeks prior to the study, and of these 91% were treated with antibiotics. The most commonly used antibiotics were ampicillin (74%), penicillin (12%), amoxicillin (11%), erythromycin (5%), tetracycline (4%) and streptomycin (2%). Ampicillin was used for 3.3 days on average (SD:1.8) and penicillin for 2.6 days (SD:0.7). When deciding which antibiotic to use, 67% of the carers consulted the pharmacy seller, 11% decided themselves and 22% followed the doctor's prescription. The carrier rate of Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis was 50%, 39% and 17%, respectively. Isolates from 145 children were susceptibility tested, and 74% were found to carry resistant pathogens. Of the tested isolates, 90% of S. pneumoniae, 68% of H. influenzae and 74% of M. catarrhalis were resistant to at least one antibiotic. The mean number of antibiotics (susceptible strains excluded) to which resistance was found was 2.0 (SD:1.2), 2.5 (SD:1.8) and 2.1 (SD:0.9), respectively. S. pneumoniae and H. influenzae showed high resistance to tetracycline (88% and 32%, respectively), trimethoprim/sulphonamide (32% and 44%), and chloramphenicol (25% and 24%). 23% of S. pneumoniae were erythromycin-resistant and 18% of H. influenzae isolates were resistant to ampicillin. There was a significant difference in ampicillin and penicillin resistance between the group of children previously treated with beta lactam antibiotics and the group of children who did not receive antibiotics. As reported by the carers, children in Bavi are treated with antibiotics frequently. Most antibiotics were obtained without consulting a doctor. High levels of antibiotic resistance and high prevalence of multidrug-resistant strains were found among respiratory pathogens. The existence of a large reservoir of resistance genes among children in low-income countries represents a threat to the success of antibiotic therapy throughout the world. Multi-faceted programmes to improve rational use of antibiotics in Vietnam are urgently needed.

Molecular typing for investigating an outbreak of Candida krusei

Invasive infections due to Candida krusei are often observed in immunocompromised patients who have received prior therapy with fluconazole, although infection has also occurred in patients in the absence of this antifungal agent. From August 25 through September 19, 1995, we identified four patients with C. krusei fungemia on our hematology/oncology unit. Molecular typing of all the isolates was performed by restriction endonuclease analysis of genomic DNA using HinfI. A total of 7 patients found to be colonized or infected with C. krusei were matched with 14 controls. There was no difference between the cases and controls with respect to underlying disease, duration of hospitalization, or neutropenia. The numbers of days of hyperalimentation, corticosteroids, and antibiotics were similar between both groups. The mean number of antibiotics was greater in the cases versus controls (5.0 versus 2.5; p = .003). There was no difference with respect to total dose or duration of fluconazole administration. Molecular typing of the isolates revealed that four had identical DNA banding patterns, plus another two that differed by one band and were considered related. Three historical strains were unrelated. In conclusion, this report demonstrates that molecular typing can be used to define clonality and, thereby, support increased infection control practices to eliminate such outbreaks when evidence of clonal spread is present.

The Relationship Between Antecedent Antibiotic Use and Resistance to Extended-Spectrum Cephalosporins in Group I -Lactamase-Producing Organisms

Gram-negative pathogens are increasingly resistant to extended-spectrum cephalosporins (ESCs). Using a prospective, case-controlled observational study, we examined the prevalence and the risk factors for development of resistance to ESCs in group I beta-lactamase-producing organisms. Of the 386 isolates of Enterobacter species, Pseudomonas aeruginosa, Citrobacter species, and Serratia marsescens from 340 consecutive patients, 70 (18.1%) were resistant to ESCs; the highest rates of resistance were found among Citrobacter freundii (40.9%), Enterobacter cloacae (31.1%), and Enterobacter aerogenes isolates (18.9%). Patients' prior antibiotic use and the mean number of antibiotics used were significantly greater in association with resistant vs. susceptible isolates. Resistance was associated with prior use of ceftizoxime or cefotaxime (P = .008), ceftazidime (P = .004), and piperacillin (P = .001). Other antibiotics were not associated with resistance. Resistance was less frequent in patients receiving ESCs and an aminoglycoside. We conclude that prior use of ESCs is associated with the isolation of resistant group I beta-lactamase-producing organisms. Concomitant use of an aminoglycoside may decrease this risk.

Cellulitis: Treatment with Cefoxitin Compared with Multiple Antibiotic Therapy

Cefoxitin, a parenteral cephamycin beta-lactam antibiotic was prospectively evaluated as a single drug alternative in 31 children with cellulitis and the results of therapy were compared retrospectively with those from prevailing multiple antibiotic therapy for cellulitis in 56 children. Periorbital and lower extremity cellulitis accounted for more than 60% of the cases in both study groups. The most common bacterial agents included Haemophilus influenzae, Staphylococcus aureus, and group A beta-hemolytic Streptococcus. In as many as 50% of the cases, no etiologic agent could be found. In addition to blood cultures, cellulitis leading edge aspirate cultures were helpful in establishing the etiologic diagnosis. Of 52 patients sampled in the combined studies, 21% had positive aspirate cultures in the presence of negative blood cultures. The outcome and mean duration of hospital stay were similar in both groups. No severe adverse reactions were encountered. The mean number of antibiotics used in the retrospective study was three (range 1 to 7) whereas cefoxitin alone was used in the prospective study. All organisms isolated in the prospective study were susceptible to cefoxitin. Single antibiotic therapy with cefoxitin appears to be as safe and as effective in the treatment of cellulitis in children as multiple antibiotic therapy.