Example of antimicrobial stewardship program in a community hospital in Italy.

BACKGROUND: Inappropriate use of antibiotics has caused the emergence of resistant strains of bacteria. The hospital of Alessandria, Italy, implemented an antimicrobial stewardship (AS) pilot program between 2013 and 2015 in the intensive care units (ICUs) and internal medicine departments of Casale Monferrato and Tortona. We aimed to describe the project, results at the end of the intervention, and its strengths and weaknesses. METHODS: The protocol, designed by the local infection control committee, included three consecutive steps: local guidelines for empirical antibiotic therapy and list of prescription antibiotics with justification, monitoring of antibiotic consumption and antimicrobial resistance trend, and peer-to-peer audit sessions in the wards. RESULTS: One thousand and eighty-five observations were made, corresponding to 850 patients admitted to the ICUs (16.7%) and internal medicine departments (83.3%). Appropriate antibiotic prescriptions increased by 6.4% between 2013 and 2015. The greatest improvement in appropriate prescriptions was observed for glycopeptides and fluoroquinolones (+17.4% and +16.2%, respectively). We reported 305 inappropriate prescriptions, with the most frequent errors being absence of an infectious process (33.3%), inadequate combination therapy (12.8%), and absence of microbiological investigations (8.5%). A reduced incidence of methicillin-resistant Staphylococcusaureus (MRSA) was also observed (p<0.0037). CONCLUSIONS: Antimicrobial stewardship programs contribute to improving antibiotic prescription and can be implemented in small community hospitals. Narrower interventions, focused on a single disease or single antibiotic should be encouraged.

Vinorelbine is an effective and safe drug for AIDS-related Kaposi's sarcoma: results of a phase II study.

PURPOSE: To assess the safety and efficacy of vinorelbine in patients with AIDS-related Kaposi's sarcoma (KS). PATIENTS AND METHODS: From December 1994 to May 1997, within the Italian Cooperative Group on AIDS and Tumors, we enrolled 36 patients with AIDS-related KS who experienced disease progression after one or more regimens of systemic chemotherapy. Patients were treated with vinorelbine 30 mg/m(2) every 2 weeks by intravenous bolus. RESULTS: Of 35 assessable patients, three (9%) had a clinical complete response and 12 (34%) had a partial remission, for an overall objective response rate of 43% (95% confidence interval, 26% to 61%). For the 15 patients with objective responses, the median duration of response from the beginning of therapy until the development of progression was 176 days, whereas the median progression-free survival and the median survival durations for 35 assessable patients were 151 days and 216 days, respectively. Vinorelbine also induced responses in patients who had become resistant to regimens that included other vinca alkaloids. Overall, vinorelbine was well tolerated. Toxicity, including neurologic toxicity, was mild and reversible. Neutropenia was the most frequent dose-limiting toxicity. CONCLUSION: Vinorelbine is safe and effective in the treatment of patients with advanced KS who have been previously treated with one or more chemotherapy regimens.

Asymptomatic respiratory tract microsporidiosis due to Encephalitozoon hellem in three patients with AIDS.

Microsporidia of the genera Enterocytozoon and Encephalitozoon have been identified as frequent causes of intestinal and disseminated infections, respectively, in patients with AIDS. Even though most subjects infected with these protozoa develop overt disease, simple colonization without illness may occur, as we observed in three severely immunosuppressed patients with AIDS. The parasites, recognized in and isolated from bronchoalveolar lavage sediment specimens, were characterized as Encephalitozoon hellem. Colonization of the bronchial tree was temporary, and treatment with albendazole was not needed to clear the infection.

[Furuncular myiasis caused by Cordylobia anthropophaga: description of a case from Tanzania]. / Miasi foruncolosa da Cordylobia anthropophaga: descrizione di un caso proveniente dalla Tanzania.

We report a case of a tourist, coming back from Tanzania, who presented with a foruncle on the left thigh diagnosed as a bacterial infection, which eventually turned out to be a myiasis foruncle. The patient said he had sat on the ground in short trousers. The lesion was covered with petroleum jelly and the larva was observed migrating from the lesion and subsequently extracted with forceps. The morphology of larval spiracles allowed to characterize the species as Cordylobia anthropophaga. Behaviour of the most common myiasis-producing flies, their life cycle and the way of infection are briefly described. Foruncular myiasis is a typical example of a tropical disease that can be misdiagnosed by clinicians in Western Countries where this pathology is uncommon.

HIV-1 and parasitic infections in rural Tanzania.

A sample of 300 sexually-active adults was selected at random from patients, from the rural area of Malenga Makali, Tanzania, who were attending a dispensary because they had diarrhoea of at least 2 weeks' duration. The potential associations between the patient's health (in terms of the World Health Organization's clinical definition of AIDS), HIV-1 seroprevalence and malaria and other parasitic infections were then investigated. Although, HIV-1 seroprevalence was 20.6% overall, the level of seroprevalence was directly correlated with the distance between the patients' home villages and the nearest main road. Strict application of the clinical definition of AIDS gave 98.7% specificity, 46% sensitivity and a predictive value of 90.6% when validated by HIV-1 seropositivity. Although malaria infection was more common in HIV-1 seropositives than in the seronegatives, the intensity of the Plasmodium falciparum infections, intestinal amoebiasis and giardiasis did not appear to be correlated with HIV-1 infection. In contrast, intestinal infections with Cryptosporidium parvum and Isospora belli were virtually restricted to HIV-1 seropositive individuals who had had diarrhoea for a relatively long time.

Activity of bilobalide, a sesquiterpene from Ginkgo biloba, on Pneumocystis carinii.

The sesquiterpene bilobalide, extracted from Ginkgo biloba leaves, was tested in vitro and in vivo for the ability to inhibit Pneumocystis carinii growth. Bilobalide was inhibitory to trophozoites cultured on human embryonic lung fibroblasts (HEL 299) at approximately the same concentration as trimethoprim plus sulfamethoxazole (lowest effective concentration, 50 micrograms of bilobalide per ml versus 9/45 microgram of trimethoprim-sulfamethoxazole per ml), inducing microscopically detectable morphological changes in the cytoplasm of the parasite. In pharmacologically immunosuppressed Sprague-Dawley rats transtracheally infected with a suspension of about 5 x 10(6) P. carinii trophozoites per ml, the daily intraperitoneal administration of bilobalide (10 mg/kg of body weight for 8 days) lowered the number of organisms by approximately 2 logs (that is, about 99%). There was no apparent toxicity either in uninfected HEL 299 feeder cells or in infected and uninfected animals. These studies suggest that the sesquiterpene bilobalide might be useful for therapy of and prophylaxis against P. carinii infections in humans.

Pneumocystis carinii pneumonia and tuberculosis in Tanzanian patients infected with HIV.

PIP: Between August and December 1991 in Tanzania, a study to determine the prevalence of Pneumocystis carinii and of tuberculosis occurred among 83 18-38 year old HIV seropositive people living in the rural area of Malenga Makali in Iringa district. The adults had difficulty breathing, cough, fever of at least 2 weeks duration, or overt pneumonia. 3.6% of the sputum samples were confirmed positive for P. carinii. 38.5% of preparations and 13.2% of cultures tested positive for Mycobacterium tuberculosis. All these isolates were completely sensitive to standard antibiotics. 2 of the 3 patients testing positive for P. carinii also had pulmonary tuberculosis. These findings showed that sputum contains many mycobacteria. They also confirmed that TB is associated with HIV infection in several African countries and that P. carinii infection occurs less frequently than it does in Europe and the US, but occurs nevertheless. A possible explanation for the low prevalence of P. carinii infection in Africa is that more virulent infections kill AIDS patients before P. carinii pneumonia has a chance to develop. The researchers admit that their inability to use more suitable specimens obtained by bronchoalveolar lavage or transbronchial biopsy could have resulted in considerable underdiagnosis. They recommended further clinical research to determine the real importance of P. carinii in developing countries.^ieng

Intestinal capillariasis (Capillaria philippinensis) acquired in Indonesia: a case report.

We report a case of intestinal capillariasis in a 32-year-old Italian man. After he made a trip to Indonesia that lasted approximately one month, he developed heartburn, abdominal pain, irregular bowel movements, headache, fatigue, weight loss, low-grade fever, and severe itching. The diagnosis was provided by the recovery of Capillaria philippinensis eggs in the stool. Treatment with oral albendazole, 200 mg twice a day for 21 days, resulted in clinical and parasitologic cure. This is the first report of C. philippinensis infection acquired in Indonesia.

New rapid staining methods of Cryptosporidium oocysts in stools.

Two new extemporaneous negative-staining methods are proposed to detect Cryptosporidium oocysts in stools, using light-green and merbromine in 1% and 2% aqueous solution, respectively. A Ziehl-Neelsen stain as modified by Henriksen and Polhenz was used as a reference technique. A comparison between these two new stains and the reference, a modified Ziehl-Neelsen mod. method gave almost identical sensitivity and specificity. We propose their use in routine diagnosis for enteric cryptosporidiosis.

Cryptosporidium parvum life cycle in suckling mice: a Nomarski interference-contrast study of a human-derived strain.

Cryptosporidiosis has emerged as one of the life-threatening opportunistic enteric infections in HIV-infected persons. To date, Cryptosporidium parvum is known to infect man via person-to-person or zoonotic transmission. We studied the sequential stages of the life cycle of C. parvum by Normarski interference-contrast microscopy in fresh gut specimens of newborn mice, infected with a strain derived from an AIDS patient with cryptosporidial diarrheal enteritis. Many 4- to 5-day-old suckling BALB/C mice were orally inoculated with 1 x 10(6) oocysts, obtained by acid flocculation of the patient's stools. The animals were sacrificed from 4 to 96 h post-infection and the ileum was examined microscopically. All stages of the asexual life cycle of C. parvum, from excysted sporozoites in the intestinal lumen through the development of type II mature meronts, 12- to 72-h post-infection, were documented by extemporaneous microscopic evaluation of fresh gut samples. The sexual cycle, characterized by the appearance of micro- and macrogametocytes, followed by a zygote developing into a sporulated oocyst, was documented as early 48-h post-infection. Our Nomarski interference-contrast observations on the life cycle of C. parvum yielded data comparable with those originally published by Current and Reese, and confirm the results of previous electron microscopic studies performed by several other authors.

Phagocytosis of human erythrocytes by Naegleria is not related to species pathogenicity. A phase-contrast cinemicrographic study.

This phase contrast cinemicrographic study evaluated the phagocytic activity of Naegleria spp. (Naegleria fowleri, Naegleria australiensis and Naegleria lovaniensis) towards human red cells. Thus erythrophagocytosis, a marker of pathogeneicity for Entamoeba histolytica, did not correlate with virulence in either the pathogenic or non-pathogenic Naegleria spp. tested. Our study also revealed no quantitative differences in phagocytosis by Naegleria spp. of human erythrocytes.

Rapid microscopy technique for detection of Pneumocystis carinii in fresh clinical specimens.

A direct method for detection of Pneumocystis carinii was evaluated in 14 patients with impaired immune function (3 seropositive for HIV, 8 with AIDS and 3 with heart transplants) and signs and symptoms suggestive of Pneumocystis carinii pneumonia. Direct examination by phase-contrast and interference-contrast microscopy of fresh clinical specimens obtained by sputum induction, bronchoalveolar lavage or transbronchial lung biopsy was found to be a simple and rapid method for detection of Pneumocystis carinii, the sensitivity of the method being comparable to that of the classical toluidine blue O and Diff-Quik staining methods. These findings suggest that this direct microscopy technique could be considered for routine clinical application in patients with suspected Pneumocystis carinii pneumonia.

[Visceral and ocular Larva migrans: epidemiologic study, clinical and immunologic findings on 20 cases, adult and child]. / Larva migrans viscérale et oculaire: étude épidémiologique, clinique et immunologique portant sur 20 cas, adultes et enfants.

The authors report a case-study of 20 subjects affected by visceral Larva migrans (VLM) and ocular Larva migrans (OLM). Of the 20 patients, 11 were male, and 9 female (mean age: 45 years); 7 were children, from 1 to 8 years old. Seventeen patients presented clinical and bio-humoral features which could be correlated with VLM syndrome; alongside cases with clearly suggestive symptomatology, in some patients the infection by Toxocara sp. was found to show few or minor symptoms, or even to be asymptomatic and occasionally it was suspected because of a marked peripheral eosinophilia. In 3 cases the infection was exclusively ocular. So far as immunology is concerned, serological tests confirmed in all 20 cases the clinico-epidemiological and/or bio-humoral suspicion; in particular the ELISA IgG test showed high titres in 16 cases, while the RAST showed significant levels of specific IgE in 17 cases. From the therapeutic point of view, the subjects treated were exclusively those presenting a manifest clinical picture: in 5 patients the first choice drug was thiabendazole, with clinical cure in only 2 cases; diethylcarbamazine resolved the clinico-parasitological picture in 1 case; 1 patient is still under treatment with albendazole.

An in vitro comparative study on the effect of amphotericin B, econazole, and 5-fluorocytosine on Naegleria fowleri, Naegleria australiensis, and Naegleria australiensis s.sp. italica.

We tested in vitro amphotericin B (AMP-B), econazole (ECO), and 5-fluorocytosine (5-FC) on pathogenic Naegleria fowleri (KUL strain), Naegleria australiensis s.sp. italica (AB-T-F3, original strain) to assess their sensitivity to chemotherapeutic compounds. Previous reports have shown the polyene antibiotic AMP-B to be the most active agent. It was, however, much more active on N. fowleri than on N. australiensis and N. australiensis s.sp italica. 5-FC and ECO gave rise to non appreciable effect at non-toxic corresponding dosages in vivo. The results of these in vitro tests are discussed.