Antibiotic regimens utilization in treating community acquired pneumonia of a government practice setting: a prospective observational study in medical inpatients

Background: Pneumonia is a lower respiratory tract infection characterized by inflammation of lung tissue accompanied by infiltration of alveoli and bronchioles. Most common type is community acquired pneumonia (CAP). Initial therapy is usually empirical that is designed to treat various pathogens. In CAP cases, antibiotic therapy should begin at the earliest. The objectives of the study include to identify most common causative micro-organisms, to assess risk of developing CAP in patients having co-morbidities, to identify most commonly prescribed antibiotic regimen.Methods: A prospective observational study was conducted for period of 6 months at RIMS, Kadapa. 120 patients were recruited based on inclusion criteria. Treatment was given according to Infectious Diseases Society of America and American Thoracic Society guidelines.Results: In a total of 120 patients, 77 were males and 43 were females. 69 patients belong to 46-55 & above age groups. 84 patients had social habits and 36 patients are without social habits. Patients with single lobe infiltrations are 105 and patients with multiple lobe infiltrations are 15. In our study, streptococcus pneumoniae and pseudomonas aeruginosa were the most common isolated organisms. Monotherapy was given for 7 patients, dual therapy for 97 patients and triple therapy for 16 patients. 33 patients received ceftriaxone (CEF) and augmentin (AUG), 29 patients received CEF and azithromycin (AZI), 7 patients received levofloxacin (LEV), 25 patients received CEF and LEV, 10 patients received CEF and ciprofloxacin (CIP) and 16 patients received CEF, AUG and AZI. 100 patients had less than 8 days of hospital stay.Conclusions: Research study concluded that ? lactum antibiotics were the most commonly prescribed class. CEF and AUG was highly recommended drug regimen.

Strive to Improve the Eradication Rate of Helicobacter pylori / 胃肠病学

As the awareness of the harmfulness of Helicobacter pylori (Hp) infection increases, the indications for Hp eradication continue to expand. "Kyoto Global Consensus Report on Helicobacter pylori Gastritis" puts forward "Hp infected individuals should be offered eradication therapy, unless there are competing considerations" and the statement has been accepted by more and more scholars. In our country, "the confirmed Hp infection" has been listed as an indication for eradication. However, as the antibiotic resistance rate of Hp increases, the eradication rate of Hp is gradually decreasing, and the proportion of people who has failed multiple treatments is increasing. This article was specially written for helping the clinicians to improve the eradication rate of Hp infection.

Antibiotic sensitivity profile of Klebsiella isolates and it’s impact on clinical outcome

Background: Antimicrobials are the greatest discovery of the twentieth century. To limit the emergence and spread of resistance, antibiotic therapy should be adjusted according to the results of microbiological culture. Klebsiella isolates causes various types of infections and the incidence of antibiotic resistance is also high in Klebsiella infections. So, Authors plan this study to analyze how the results of microbiological cultures influence the antibiotic use in the treatment of Klebsiella infections.Methods: It is a record based observational prospective study which assessed the impact of Klebsiella positive culture results on antibiotic prescribing pattern and its impact on clinical outcome. Patients with empirical antibiotic therapy and Klebsiella positive were included and patients with inadequate data were excluded in this study and the data were recorded. Recorded data were entered and analyzed in Microsoft Office Excel-2013. Unpaired student t-test was used to compare the mean duration of hospital stay using Past software (version 3.20).Results: There were total 400 patients in our study. Amikacin was the most common drug (n=202) used as empirical therapy. Empirical antibiotic therapy was changed in 161(40.25%) patients. Meropenem was the most commonly used definitive drug. Mean duration of hospital stay is less in empirical sensitive antibiotic therapy as compared to empirical resistance antibiotic therapy having p value <0.0001 which shows significant difference between two groups showing better clinical outcome.Conclusion: Initial empirical therapy with broad-spectrum antimicrobials is a treatment strategy for severe Klebsiella infections.

Bacteriological Profile and Antibiogram of Bloodstream Infection in a Tertiary Care Hospital, India

Purpose: Blood stream infections (BSIs) are an importantcause of morbidity and mortality worldwide. Continuous orintermittent presence of microorganisms in the circulating bloodis a danger to every organ in the body. BSIs range from selflimiting infections to life threatening sepsis requiring rapid andaggressive antimicrobial treatment.[1] Culture of blood is a vitaltool to diagnose such infections. Antibiotic susceptibilitypatterns help in rationalizing therapy.Objective: The objective of this study was to determine thebacteriological profile and their antibiotic sensitivity patterns ofisolates from blood stream infections.Materials and Methods: This is a retrospective studyconducted from February 2018 to January 2019 at a tertiarycare hospital, RIMS, India. Blood samples were asepticallycollected and incubated in BD Bactec system, a fullyautomated blood culture system for detection of aerobic growthand incubated for 7 days at 37°C. Identification of microbialgrowth was done by standard methods (biochemical tests) andantibiotic sensitivity test was carried out by Kirby-Baur discdiffusion method as per Clinical Laboratory Standards Instituteguidelines (CLSI guidelines).Results: A total of 82 (28%) pathogens were isolated from 289bacteremia suspect patient blood specimens. Gram‑positivecocci (65.85%) were predominant organisms recoveredfollowed by Gram‑negative bacilli (34.15%). Staphylococcusaureus, Klebsiella spp and CoNS, were the primary pathogensisolated. Staphylococcus aureus (48%) was the predominantamong all. Glycopeptides, aminoglycosides, and carbapenems,were the most effective drugs for treating bacteremia.Conclusions: Early diagnosis and appropriate antimicrobialtreatment is the basis for the successful treatment of sepsis.The understanding of local bacteriological profile andantimicrobial susceptibility patterns may help the clinician inrationalizing the empirical treatment strategies.

Neutropenia febril en niños con cáncer: manejo en el servicio de emergencias / Febrile neutropenia in cancer patients: management in the emergency room

Resumen La neutropenia febril es una condición que puede amenazar la vida y que requiere de atención inmediata, particularmente en pacientes en que la misma está asociada a tratamientos con quimioterapia. Estos pacientes tienen un riesgo mucho mayor de desarrollar enfermedades bacterianas, y en ellos, la fiebre puede ser el único indicador de enfermedad bacteriana grave. El manejo adecuado de la neutropenia febril da énfasis en la identificación pronta de los pacientes, estratificación del riesgo y antibioterapia iniciada durante los primeros 60 min del ingreso al servicio de emergencias. No todos los niños con neutropenia febril conllevan el mismo riesgo de morbi-mortalidad, por lo que en los últimos años se han hecho esfuerzos para distinguir entre pacientes de alto riesgo en quienes se recomienda el manejo hospitalario más agresivo. En pacientes que se clasifican como de bajo riesgo se puede considerar el manejo ambulatorio inicial o después de 72 h, mientras que en aquellos de alto riesgo se recomienda hospitalizar y manejar con antimicrobianos parenterales.

Febrile neutropenia is a life-threatening condition that requires immediate attention, especially in patients with chemotherapy-related neutropenia. Patients with febrile neutropenia have a much greater risk of developing bacterial disease, and fever may be the only indicator of severe bacterial infection. Adequate management of febrile neutropenia emphasizes early recognition of patients, risk stratification, and antibiotic therapy administration during the first 60 minutes of admission to an emergency room. Not all children with febrile neutropenia carry the same risk of morbidity and mortality, so in recent years, efforts have been made to distinguish between high-risk patients where more aggressive hospital management is required. In children classified as low-risk, outpatient management may be considered initially or after 72 hours, whilst high-risk patients should be hospitalized and managed with parenteral antibiotics.

Economic Evaluation of Caspofungin vs. Voriconazole in Initial Empirical Antifungal Therapy of Febrile Neutropenia / 中国药房

OBJECTIVE:To evaluate the economics of caspofungin vs. voriconazole in initial empirical antifungal therapy of fe-brile neutropenia(FN). METHODS:Based on two international multiple center clinical trials about caspofungin vs. voriconazole in initial empirical antifungal therapy of FN,combined with domestic clinical experts'opinions about drug selection,a decision tree model was developed. TreeAge Pro 2011 software was used to analyze the cost and effectiveness of 10-day therapy of caspofungin or voriconazole as initial empirical antifungal therapy. RESULTS:The direct medical cost of caspofungin group was lower than that of voriconazole group(52826.71 yuan vs. 58246.70 yuan). The success rate and survival rate were higher than voriconazole group(33.95% vs. 25.63%、92.36% vs. 91.87%). Whether the success rate or the survival rate of patients as the effect indicators, cost-effectiveness ratio of caspofungin group was lower than that of voriconazole group. Moreover,incremental cost effectiveness ra-tio and sensitivity analysis confirmed this conclusion. CONCLUSIONS:Caspofungin has more advantages than voriconazole in cost and effectiveness as initial empirical antifungal therapy in patients with FN.

Antimicrobial Therapy in Diabetic Foot Infections / 임상당뇨병

Treatment of diabetic foot infection remains a challenging issue to be solved. Bacterial species complicating diabetic foot ulcer differ from those of non-diabetic patients. Empirical antibiotic regimens are selected based on the severity and type of infection (acute infection versus chronic infection), which should always include coverage for aerobic Gram-positive cocci, especially Staphylococcus aureus. Narrow-spectrum antibiotic agents are considered for mild-to-moderate, recent infections, while broad-spectrum agents are usually required for severe, chronic infections, targeting both Gram-positive cocci and Gram-negative bacilli.

Antibacterial susceptibility patterns and cross-resistance of methicillin resistant and sensitive Staphyloccus aureus isolated from the hospitalized patients in Shiraz, Iran

Nosocomial infections caused by methicillin-resistant staphylococci (MRSA) pose a serious problem in many countries. This study aimed to determine the antibacterial susceptibility patterns of methicillin sensitive and resistant Staphylococcus aureus isolates from the hospitalized patients. Totally 356 isolates of Staphylococcus aureus (S. aureus) including 200, 137 and 19 corresponding to MSSA, MRSA, and intermediate MRSA strains, respectively were isolated. Antibacterial susceptibility patterns of the isolates to 14 antibiotics were examined using Kirby-Bauer method. MICs of 15 antibiotics to 156 MRSA isolates were determined by E test method. Cross-resistances of MRSA isolates (137+19) to the other tested antibiotics were also determined. S.aureus with high frequencies were isolated from the blood, sputum and deep wound samples. All of 200 MSSA isolates were sensitive to oxacillin, vancomycin, tecoplanin, rifampin, linezolid, quinupristin/dalfopristin, mupirocin and fusidic acid. A gradient of reduced susceptibility of MSSA to cephalexin, co-trimoxazole, ciprofloxacin, clindamycin, tetracycline, erythromycin and gentamicin were evident. MRSA isolates were sensitive to vancomycin, tecoplanin, linezolid, quinupristin/dalfopristin, mupirocin and fusidic acid, while reduced susceptibility of them to rifampin, co-trimoxazole, clindamycin, cephalexin, tetracycline, ciprofloxacin, erythromycin and gentamicin were observed. MRSA isolates exhibited a high range of cross-resistance to the eight tested antibiotics. Overall, co-trimoxazole, ciprofloxacin, clindamycin, tetracycline, erythromycin and gentamicin showed low activity against MSSA and MRSA isolates which may indicate they are not suitable to be used in clinical practices. To preserve the effectiveness of antibiotics, rational prescription and concomitant application of preventive measures against the spread of MRSA are recommended.

Quinolone Resistance in Community-Acquired Acute Pyelonephritis / 대한신장학회잡지

BACKGROUND: Quinolone antibiotics are now frequently used for the empirical therapy of acute pyelonephritis (APN). However, failure of this empirical therapy is often encountered in clinical practice, and the emergence of quinolone resistance should be concerned. This study was undertaken to investigate the prevalence of quinolone resistance in community-acquired APN and to analyze the clinical characteristics of quinolone-resistant APN. METHODS: Clinical data were retrospectively analyzed from 367 patients who were admitted to Hanyang University Hospital for APN from January 2002 through December 2004. According to the result of urine culture, the patients were divided into quinolone-susceptible and quinolone-resistant groups, and clinical characteristics were compared. RESULTS: Urine culture was positive in 241 out of 367 patients, and E. coli was the most common (90%) isolate. The prevalence of quinolone resistance based on the in vitro ciprofloxacin susceptibility test was found to be 19.5%, and among the E. coli isolates the prevalence of quinolone resistance was 19.8 %. 91 patients had underlying diseases and they were more frequently complicated by urosepsis. The ages and the prevalence of azotemia were not significantly different between two groups. Quinolone-resistant group had a lesser frequency of urosepsis compared with quinolone-susceptible group. Diabetic patients were more frequently quinolone-susceptible than quinolone-resistant. CONCLUSION: Although the prevalence of quinolone resistance is rather high in community-acquired APN based on the in vitro susceptibility test, the choice of quinolone antibiotics seems to be valid for the empirical therapy.

Empiric Therapy with Cefazolin and Ceftazidime (or Aminoglycoside) is Effective as the Initial Choice for the Treatment of Peritoneal Dialysis Related Peritonitis / 대한신장학회잡지

BACKGROUND: This study aims to verify the effectiveness of initial empirical antibiotic choice recommended by the International Society for Peritoneal Dialysis (ISPD) guideline for PD related peritonitis among the Korean PD population. METHODS: 227 episodes of PD-related peritonitis from January 2000 to June 2003 in two tertiary care hospitals were reviewed retrospectively for the antibiotic resistance pattern and their clinical outcome after treatment based on the ISPD guideline. RESULTS: There was 349 prevalent patients during this period. The incidence of peritonitis was 1 episode/41.3 patient-month. For 173 episodes, the etiologic organism was identified. Among the isolates, 99 (43.6%) were gram positive organisms and 57 (25.1%) were gram negative organisms. Among gram positive bacterial peritonitis, multiple logistic regression analysis showed that antibiotic resistance was not a risk factor for treatment failure (OR=0.84, p=0.79). Among the 45 cases with Staphylococcus- associated peritonitis, and empirical cefazolin and ceftazidime (or aminoglycoside) administration, 27 were methicillin-sensitive (MS) and 18 were methicillin-resistant (MR). There was no significant difference in the rate of relapse, catheter removal and death and successful treatment. Patients in the MR group were more likely to change antibiotics during the therapy than MS group (55.6% vs 7.4%, p=0.01) CONCLUSION: Despite a high rate of antibiotic resistance, initial empirical therapy with cefazolin and ceftazidime (or aminoglycoside) based on ISPD guideline is effective as the initial antibiotics choice for gram positive bacterial peritonitis.

The importance of atypical pathogens to the guidelines of community acquired pneumonia in the world / 中国实用内科杂志

Atypical pathogens are very common in community-acquired pneumonia(CAP) with the morbidity of about 22%(20%～28%).Therefore,CAP guidelines around the world usually emphasize the importance of atypical pathogens.The diagnosis tests are also listed in the guidelines,but only applied among inpatients.Japanese Respiratory Society recommended the diagnosis criteria of atypical pneumonia based on the clinical characteristics for the first time in the world.All guidelines recommended that empirical antibiotic therapy should cover those atypical pathogens when Mycoplasma pneumoniae,Chlamydia pneumonia or legionella pneumophilia infection are possibly exist.Antibiotic therapy against Mycoplasma pneumoniaen and Chlamydia pneumonia should be considered among outpatients and inpatients as well as anti-legionella pneumophilia therapy in severe patients in ICU.The recommended regimen is beta-lactam antibiotics combined with macrolides or fluoroquinolones alone.

Etiology of Community-Acquired Pneumonia Surveyed by 7 University Hospitals / 감염

BACKGROUND: Community-acquired pneumonia (CAP) is one of the leading causes of mortality and morbidity, but its management is still challenging. The limitations of diagnostic methods to identify etiologic agents rapidly make it necessary to use empiric antibiotics in almost all patients, and furthermore the discovery of new respiratory pathogens and the emergence of antibiotic-resistant organisms pose difficulties to the selection of an empiric antibiotic regimen. To clarify the factors necessary for the optimal choice of empirical antibiotics, such as the frequency of etiologic agents, the attributable rates to death and antimicrobial resistance rates in the community, six university hospitals in Seoul and one university hospital in Cheonan were participating in this study. METHODS: Medical records of adults (> 15 years of age) hospitalized for CAP or pulmonary tuberculosis between March 1995 and February 1996, were reviewed. Patients who satisfied all of the following criteria were included in the study: (1) fever or hypothermia; (2) respiratory symptoms; and (3) pulmonary infiltrates on chest roentgenogram. To exclude cases of pulmonary tuberculosis whose roentgenographic features were so typical that it could be easily differentiated from conventional pneumonia, two additional criteria were required for inclusion: antibiotic treatment during the first week of hospital admission and initiation of anti-tuberculosis medications thereafter. Organisms isolated from sterile body sites, acid-fast bacilli or Mycobacterium tuberculosis isolated from sputum, pathogens diagnosed by a 4-fold rising titer to "atypical" pathogens, or pathogens revealed by histopathology were defined as definitive cause of pneumonia; isolates from sputum with compatible Gram stain, pathogens diagnosed by a single diagnostic titer plus use of a specific antimicrobial agent, or tuberculosis diagnosed by clinical response to anti-tuberculosis medications were considered probable cause of pneumonia. The records of the clinical microbiology were reviewed for isolates of S. pneumoniae, H. influenzae, M. catarrhalis, Mycobacterium or acid-fast bacilli, and mycoplasma. Then the frequency of these agents, antimicrobial resistance rates of respiratory pathogens from all body sites, and their clinical significance were evaluated. RESULTS: After excluding 365 patients (230 with pulmonary tuberculosis and 135 with CAP) who were screened for inclusion but did not meet the inclusion criteria, 246 persons were enrolled in this study. Their mean age was 58.2 years old with slight male predominance (58.2%), and 171 (71%) patients had underlying illnesses. Blood cultures were performed on 191 (77.6%) patients and serologic tests on 44 (18.3%) patients. The etiologic agents were identified in 31.3%, and the list of individual agents, in decreasing order, was pulmonary tuberculosis (17 definite and 3 probable: data of six hospitals), S. pneumoniae (8 definite and 10 probable), non-pneumococcal streptococci (3 definite), aerobic gram-negative bacilli (7 definite and 4 probable), Haemophilus spp. (11 probable), mycoplasma (1 definite and 4 probable), polymicrobial infections (2 definite and 2 probable : E. coli and S. agalactiae, M. tuberculosis and S. aureus, S. pneumoniae and H. influenzae, and A. baumannii and K. pneumoniae), S. aureus (2 definite and 2 probable), and mucormycosis (1 definite). Among gram-negative bacilli, K. pneumoniae was the most common agent (8 isolates). The rates of admission to the intensive care unit and of using assisted ventilation were 18% and 9.3% respectively. The mortality was 13.8% and logistic regression analysis showed that hypothermia and tachypnea were associated with death. Hospital stay averaged 19 days. Susceptible rates of S. pneumoniae isolated from all body sites to penicillin ranged from 8% to 28% but all seven isolates from blood of patients with pneumonia were susceptible to penicillin. Also all 8 isolates of K. pneumoniae from patients with pneumonia were susceptible to cefotaxime and gentamicin. CONCLUSION: In Korea, in addition to S. pneumoniae, M. tuberculosis is an important agent causing community-acquired pneumonia. The low incidence of etiologic diagnosis is probably related to infrequent requesting of test to "atypical" pathogens and does not represent the true incidence of infections by "atypical" pathogens, which will be answered by a prospective study. The antimicrobial resistance rates of major respiratory pathogens from sterile body sites are low, however, because of a small number of the isolates this result needs confirmation by a nationwide surveillance of antimicrobial resistance.