TIME UNTIL THE START OF ANTIBIOTIC PROPHYLAXIS AND THE RISK OF OPEN FRACTURE INFECTION: A SYSTEMATIC REVIEW.

Open fractures are highly incident injuries closely related to the modern life, in which accidents caused by motor vehicles or other machines impart high energy to bone tissue. Individual morbidity is represented by the functional impairment resultant of infection, nonunion, or vicious healing. In terms of public health, there are huge costs involved with the treatment of these fractures, particularly with their complications. One of the critical issues in managing open fractures is the use of antibiotics (ATB), including decisions about which specific agents to administer, duration of use, and ideal timing of the first prophylactic dose. Although recent guidelines have recommended starting antibiotic prophylaxis as soon as possible, such a recommendation appears to stem from insufficient evidence. In light of this, we conducted a systematic review, including studies that addressed the impact of the time to first antibiotic and the risk of infectious outcomes. Fourteen studies were selected, of which only four found that the early initiation of treatment with antibiotics is able to prevent infection. All studies had important risks of bias. The results indicate that this question remains open, and further prospective and methodologically sound studies are necessary in order to guide practices and health policies related to this matter. Level of Evidence II; Therapeutic Studies Investigating the Results Level of Treatment.

As fraturas expostas são lesões altamente incidentes, intimamente relacionadas à vida moderna, na qual os acidentes causados por veículos automotores ou outros aparatos transmitem alta energia ao tecido ósseo. A morbidade individual é representada pelo comprometimento funcional resultante de infecção, não-união ou cicatrização viciosa. Há enormes custos envolvidos no tratamento dessas fraturas em termos de saúde pública, principalmente quanto as complicações. Uma das questões críticas no tratamento de fraturas expostas é o uso de antibióticos, incluindo as decisões sobre quais agentes específicos devem ser administrados, a duração e o momento ideal para a primeira dose profilática. Embora as diretrizes recentes tenham recomendado o início da profilaxia antibiótica o mais rápido possível, essa recomendação parece se basear em evidências insuficientes. Em vista disso, realizamos uma revisão sistemática, incluindo estudos que abordaram o impacto do tempo até o primeiro antibiótico e o risco de resultados infecciosos. Foram selecionados 14 estudos, dos quais apenas quatro concluíram que o início precoce do tratamento com antibióticos é capaz de prevenir infecções. Todos os estudos tinham riscos importantes de viés. Os resultados indicam que essa questão permanece em aberto, sendo necessários mais estudos prospectivos e metodologicamente sólidos para orientar as práticas e políticas de saúde relacionadas a esse assunto. Nível de Evidência II; Estudos Terapêuticos que Investigam o Nível de Resultados do Tratamento.

Low Serum Trough Concentrations and High Vancomycin Minimum Inhibitory Concentration in Methicillin-Sensitive Staphylococcus aureus From Hemodialysis Patients in Brazil.

BACKGROUND: The empiric antimicrobial therapy for bacteremia of long-term hemodialysis (HD) outpatients is currently based on the combination of vancomycin and gentamicin because of the high frequency of isolated Staphylococcus species. The vancomycin trough level range from 15 to 20 mcg/mL is expected for therapeutic success against methicillin-resistant Staphylococcus aureus with vancomycin minimum inhibitory concentration (MIC) ≥1.0 mcg/mL. Despite the availability of clinical practice guidelines for vancomycin therapeutic drug monitoring, these target serum concentrations are not reached in many patients. METHODS: In this study, the authors investigated the vancomycin trough levels in 20 HD patients with S. aureus bacteremia and the antimicrobial susceptibility pattern of 45 S. aureus strains isolated from 45 HD patients. The vancomycin serum concentration was determined by chemiluminescent assay. The MIC was determined by broth microdilution method. RESULTS: None of the HD patients included in this study had vancomycin trough concentrations within the therapeutic range. Also, the vancomycin MIC for most methicillin-sensitive S. aureus isolated from bacteremia was ≥1.0 mcg/mL. CONCLUSIONS: The therapeutic range of vancomycin was not achieved, and vancomycin MIC was surprisingly high in methicillin-sensitive S. aureus.

Clonal dissemination of vancomycin-resistant Enterococcus faecium ST412 in a Brazilian region

ABSTRACT Vancomycin-resistant Enterococcus faecium (VREfm) has emerged as an important global nosocomial pathogen, and this trend is associated with the spread of high-risk clones. Here, we determined the genetic and phenotypic features of 93 VREfm isolates that were obtained from patients in 13 hospitals in Vitória, Espírito Santo, Brazil, during 2012-2013. All the isolates were vancomycin-resistant and harbored the vanA gene. Only 6 (6.5%) of the VREfm isolates showed the ability to form biofilm. The 93 isolates analyzed belong to a single pulsed-field gel electrophoresis lineage and presented six subtypes. MLST genotyping showed that all VREfm belonged to ST412 (the high-risk clone, hospital-adapted). The present study describes the dissemination of ST412 clone in the local hospitals. The clonal spread of these ST412 isolates in the area we analyzed as well as other hospitals in southeastern Brazil supports the importance of identifying and controlling the presence of these microorganisms in health care-related services.

Clonal dissemination of vancomycin-resistant Enterococcus faecium ST412 in a Brazilian region.

Vancomycin-resistant Enterococcus faecium (VREfm) has emerged as an important global nosocomial pathogen, and this trend is associated with the spread of high-risk clones. Here, we determined the genetic and phenotypic features of 93 VREfm isolates that were obtained from patients in 13 hospitals in Vitória, Espírito Santo, Brazil, during 2012-2013. All the isolates were vancomycin-resistant and harbored the vanA gene. Only 6 (6.5%) of the VREfm isolates showed the ability to form biofilm. The 93 isolates analyzed belong to a single pulsed-field gel electrophoresis lineage and presented six subtypes. MLST genotyping showed that all VREfm belonged to ST412 (the high-risk clone, hospital-adapted). The present study describes the dissemination of ST412 clone in the local hospitals. The clonal spread of these ST412 isolates in the area we analyzed as well as other hospitals in southeastern Brazil supports the importance of identifying and controlling the presence of these microorganisms in health care-related services.

Modification of the Congo red agar method to detect biofilm production by Staphylococcus epidermidis.

Staphylococcus epidermidis in immunocompromised patients can cause bacteremia related to the use of catheter due to biofilm production. There are different phenotypic methods to detect biofilm formation. One method is based on culture in brain heart infusion agar (BHIA) containing sucrose and red Congo dye (original Congo red agar). Our group created a new CRA formula and we have confirmed its capacity to detect biofilm production in 210 S. epidermidis strains, including 76 (36.2%) icaAB gene-positive strains. Other parameters were also evaluated. The new CRA formula that gave the best results was BHIA with sucrose (5%), Congo red (0.08%), NaCl (1.5%), glucose (2%), and vancomycin (0.5 mg/mL) (vancomycin-modified CRA-CRAmod). The CRAmod plus vancomycin may be a promising tool and can help to determine the real participation of S. epidermidis in the infectious process.

Evaluation of the synergistic potential of vancomycin combined with other antimicrobial agents against methicillin-resistant Staphylococcus aureus and coagulase-negative Staphylococcus spp strains.

Methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative Staphylococcus spp (CNS) are the most common pathogens that cause serious long term infections in patients. Despite the existence of new antimicrobial agents, such as linezolid, vancomycin (VAN) remains the standard therapy for the treatment of infections caused by these multidrug-resistant strains. However, the use of VAN has been associated with a high frequency of therapeutic failures in some clinical scenarios, mainly with decreasing concentration of VAN. This work aims to evaluate the synergic potential of VAN plus sulfamethoxazole/trimethoprim (SXT), VAN plus rifampin (RIF) and VAN plus imipenem (IPM) in sub-minimum inhibitory concentrations against 22 clinical strains of MRSA and CNS. The checkerboard method showed synergism of VAN/RIF and VAN/SXT against two and three of the 22 strains, respectively. The combination of VAN with IPM showed synergistic effects against 21 out of 22 strains by the E-test method. Four strains were analyzed by the time-kill curve method and synergistic activity was observed with VAN/SXT, VAN/RIF and especially VAN/IPM in sub-inhibitory concentrations. It would be interesting to determine if synergy occurs in vivo. Evidence of in vivo synergy could lead to a reduction of the standard VAN dosage or treatment time.

Evaluation of the synergistic potential of vancomycin combined with other antimicrobial agents against methicillin-resistant Staphylococcus aureus and coagulase-negative Staphylococcus spp strains

Methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative Staphylococcus spp (CNS) are the most common pathogens that cause serious long term infections in patients. Despite the existence of new antimicrobial agents, such as linezolid, vancomycin (VAN) remains the standard therapy for the treatment of infections caused by these multidrug-resistant strains. However, the use of VAN has been associated with a high frequency of therapeutic failures in some clinical scenarios, mainly with decreasing concentration of VAN. This work aims to evaluate the synergic potential of VAN plus sulfamethoxazole/trimethoprim (SXT), VAN plus rifampin (RIF) and VAN plus imipenem (IPM) in sub-minimum inhibitory concentrations against 22 clinical strains of MRSA and CNS. The checkerboard method showed synergism of VAN/RIF and VAN/SXT against two and three of the 22 strains, respectively. The combination of VAN with IPM showed synergistic effects against 21 out of 22 strains by the E-test method. Four strains were analyzed by the time-kill curve method and synergistic activity was observed with VAN/SXT, VAN/RIF and especially VAN/IPM in sub-inhibitory concentrations. It would be interesting to determine if synergy occurs in vivo. Evidence of in vivo synergy could lead to a reduction of the standard VAN dosage or treatment time.

[Evaluation of methods commonly used in laboratories to determine the susceptibility to oxacillin among Staphylococcus sp samples isolated from a hospital in Vitória, State of Espírito Santo]. / Avaliação de métodos comumente usados em laboratórios para a determinação da suscetibilidade à oxacilina entre amostras de Staphylococcus sp, isoladas de um hospital de Vitória, Estado do Espírito Santo.

INTRODUCTION: The genus Staphylococcus is of great importance because of its high prevalence in hospital infections and because it presents high rates of resistance to oxacillin and other antimicrobials. Thus, evaluation of the accuracy of the phenotypic methods that are used to determine the profile of antimicrobial resistance is essential to ensure that the most appropriate therapy is chosen. METHODS: One hundred and fourteen strains of Staphylococcus sp (53 S. aureus and 61 CNS) were used to evaluate the accuracy of the methods of disk diffusion, agar microdilution, oxacillin screening agar and automated systems, in comparison with PCR for investigating resistance to oxacillin. RESULTS: The mecA gene was detected in 48 strains (42.1%), and 27 strains (23.7%) showed discrepant results in at least one of the methods (74.1% of CNS, 25.9% of S. aureus). For S. aureus, with the exception of the Microscan Walkaway, all the methods showed 100% specificity and sensitivity. In relation to CNS, the automated system and cefoxitin disk had lower accuracy. CONCLUSIONS: Use of two methods should be the best option for improved accuracy, especially when the diagnostic laboratory only uses an automated system or oxacillin disk diffusion test. Combination of these methods with others presented almost 100% sensitivity and specificity in our study.

Avaliação de métodos comumente usados em laboratórios para a determinação da suscetibilidade à oxacilina entre amostras de Staphylococcus sp, isoladas de um hospital de Vitória, Estado do Espírito Santo / Evaluation of methods commonly used in laboratories to determine the susceptibility to oxacillin among Staphylococcus sp samples isolated from a hospital in Vitória, State of Espírito Santo

INTRODUÇÃO: O gênero Staphylococcus é de grande importância devido a sua alta prevalência em infecções hospitalares e por apresentar taxas elevadas de resistência a oxacilina e a outros antimicrobianos. Assim, a avaliação da acurácia dos métodos fenotípicos usados para determinação do perfil de suscetibilidade a antimicrobianos é essencial para garantir a escolha da terapia mais adequada. MÉTODOS: Foram usadas 114 amostras de Staphylococcus sp (53 S. aureus e 61 SCN) na avaliação da acurácia dos métodos de difusão de disco, microdiluição em agar, ágar triagem oxacilina e sistema automatizado em comparação com a PCR para verificação da resistência a oxacilina. RESULTADOS: O gene mecA foi detectado em 48 (42,1 por cento) amostras e 27 (23,7 por cento) amostras apresentaram discrepância de resultados em pelo menos um dos métodos (74,1 por cento SCN, 25,9 por cento S. aureus). Para S. aureus, com exceção do Microscan Walkaway, todos os métodos apresentaram 100 por cento de especificidade e sensibilidade. Já para os SCN, o sistema automatizado e o disco de cefoxitina apresentaram menor acurácia. CONCLUSÕES: O uso de dois métodos deve ser a melhor opção para a melhora da acurácia, principalmente quando o laboratório de diagnóstico utiliza somente sistema automatizado ou teste de difusão do disco de oxacilina. A associação destes métodos com outros apresentaram praticamente 100 por cento de sensibilidade e especificidade em nosso estudo.

INTRODUCTION: The genus Staphylococcus is of great importance because of its high prevalence in hospital infections and because it presents high rates of resistance to oxacillin and other antimicrobials. Thus, evaluation of the accuracy of the phenotypic methods that are used to determine the profile of antimicrobial resistance is essential to ensure that the most appropriate therapy is chosen. METHODS: One hundred and fourteen strains of Staphylococcus sp (53 S. aureus and 61 CNS) were used to evaluate the accuracy of the methods of disk diffusion, agar microdilution, oxacillin screening agar and automated systems, in comparison with PCR for investigating resistance to oxacillin. RESULTS: The mecA gene was detected in 48 strains (42.1 percent), and 27 strains (23.7 percent) showed discrepant results in at least one of the methods (74.1 percent of CNS, 25.9 percent of S. aureus). For S. aureus, with the exception of the Microscan Walkaway, all the methods showed 100 percent specificity and sensitivity. In relation to CNS, the automated system and cefoxitin disk had lower accuracy. CONCLUSIONS: Use of two methods should be the best option for improved accuracy, especially when the diagnostic laboratory only uses an automated system or oxacillin disk diffusion test. Combination of these methods with others presented almost 100 percent sensitivity and specificity in our study.

Heterogeneous resistance to vancomycin and teicoplanin among Staphylococcus spp. isolated from bacteremia.

This study evaluated the BHIA screening method with 4 or 6 mug/mL of vancomycin to detect glycopeptides heteroresistant staphylococci strains isolated from bacteremia. A total of 213 staphylococci strains were isolated from 106 patients between October/2001 and November/2002 in a tertiary hospital in Rio de Janeiro city. Fifty-seven (53.8%) patients presented Staphylococcus aureus, while coagulase-negative staphylococci (CNS) were isolated from 49 (46.2%). Resistance rates for oxacillin of 26.3% and 81.6% were found for the staphylococci isolates, respectively. Thirteen CNS isolated from nine (8.5%) patients grew on agar screening with 4 mug/mL of vancomycin and showed heterogeneous profiles of resistance for vancomycin and teicoplanin by the population analysis profile method. Only 30.8% of them grew at the concentration 6 mug/mL. Bacterial infection and use of antimicrobial therapy were common among these patients. Alert about the emergence of oxacillin-resistant staphylococci presenting heteroresistance to glycopeptides is important in order to achieve judicious use of antimicrobials. Vancomycin agar screening test could help to confirm the presence of these isolates in hospitals.

Simplified and reliable scheme for species-level identification of Staphylococcus clinical isolates.

Reliable and rapid identification of staphylococcal strains continues to be a problem faced by many microbiology laboratories. This study evaluates a simplified method that uses a flowchart to assist in the identification of 12 clinical species of Staphylococcus, including eight subspecies. A total of 198 isolates and 11 control strains were identified by the reference method, which employed 22 tests. The results were compared with those obtained by two other methods: an automated system (MicroScan WalkAway) and a simplified method composed of nine tests. The simplified scheme showed an accuracy of 98.5%, while the automated method showed an accuracy of 79.3% (P < 0.001), in identifying staphylococcal species. Atypical phenotypic profiles were detected by both the reference (55.6%) and the simplified (19.7%) methods. The simplified method proposed here was shown to be reliable, with the advantage of being more practical and economic than the reference method.

Heterogeneous resistance to vancomycin and teicoplanin among Staphylococcus spp. isolated from bacteremia

This study evaluated the BHIA screening method with 4 or 6 mug/mL of vancomycin to detect glycopeptides heteroresistant staphylococci strains isolated from bacteremia. A total of 213 staphylococci strains were isolated from 106 patients between October/2001 and November/2002 in a tertiary hospital in Rio de Janeiro city. Fifty-seven (53.8 percent) patients presented Staphylococcus aureus, while coagulase-negative staphylococci (CNS) were isolated from 49 (46.2 percent). Resistance rates for oxacillin of 26.3 percent and 81.6 percent were found for the staphylococci isolates, respectively. Thirteen CNS isolated from nine (8.5 percent) patients grew on agar screening with 4 mug/mL of vancomycin and showed heterogeneous profiles of resistance for vancomycin and teicoplanin by the population analysis profile method. Only 30.8 percent of them grew at the concentration 6 mug/mL. Bacterial infection and use of antimicrobial therapy were common among these patients. Alert about the emergence of oxacillin-resistant staphylococci presenting heteroresistance to glycopeptides is important in order to achieve judicious use of antimicrobials. Vancomycin agar screening test could help to confirm the presence of these isolates in hospitals.

Heterogeneous resistance to vancomycin in Staphylococcus epidermidis, Staphylococcus haemolyticus and Staphylococcus warneri clinical strains: characterisation of glycopeptide susceptibility profiles and cell wall thickening.

The population analysis profile (PAP) method as well as analysis of autolytic activity and cellular ultrastructure by transmission electron microscopy (TEM) were used to characterise Staphylococcus epidermidis, Staphylococcus haemolyticus and Staphylococcus warneri clinical strains with reduced susceptibility to glycopeptides. All strains showed heterogeneous profiles to vancomycin and teicoplanin by the PAP method. Subpopulations that grew in the presence of high concentrations of each drug were selected from the PAP as derivative strains. Their glycopeptide minimal inhibitory concentrations (MICs) were determined and subsequently all parental and derivative strains were grown in one-half of the MIC of vancomycin or teicoplanin. An increase in cell wall thickness of all derivative strains was seen by TEM, with statistically significant values (P<0.01) compared with their respective parental strains. In general, variable rates of autolysis among the strains were observed. Cell wall thickness is an important factor involved in glycopeptide resistance and, in association with PAP results, confirmed the Brazilian coagulase-negative staphylococci clinical isolates as being heteroresistant to glycopeptides. Detection of these heteroresistant organisms is important in order to achieve more judicious use of vancomycin and teicoplanin in hospitals.

Simultaneous detection of the mecA and ileS-2 genes in coagulase-negative staphylococci isolated from Brazilian hospitals by multiplex PCR.

Coagulase-negative Staphylococcus spp. (CNS) has been associated with primary bloodstream infections and implanted medical devices. Its importance is increasing due to the acquisition of resistance to oxacillin (Oxa) and, recently, resistance to mupirocin (Mup). Mupirocin, a topical antimicrobial, has been used in the prevention of staphylococci catheter colonization. Susceptibility to Oxa and Mup was analyzed by different testing methods in clinical CNS isolates. Among 112 CNS strains, 69 (61.6%) were Oxa(R) by the disk diffusion (DD) method and 72 (64.2%) grew on the oxacillin agar screen plate. S. epidermidis and S. haemolyticus presented high rates of oxacillin resistance, 75.4% and 96.1%, respectively. Twenty four (21.4%) strains were Mup(R) by the DD test and 21 of them (87.5%) were identified as S. epidermidis. The detection of the mecA and ileS-2 genes, determined by multiplex-PCR, showed that 72 (64.2%) CNS strains possessed the mecA gene, while 16 (14.3%) possessed the ileS-2 gene. Fifteen of these strains presented the two resistance genes simultaneously. The isolates containing the ileS-2 gene presented a minimum inhibitory concentration (MIC) >1024 microg/mL in the E-test, while low-level mupirocin resistance (MICs of 12-16 microg/mL) was observed in those strains without ileS-2. The resistances to high and low levels of mupirocin could not be distinguished when the DD test was used. The analysis of the Mup(R) S. epidermidis strains by Pulsed Field Gel Electrophoresis showed that 17 (80.9%) strains belonged to one of two patterns (A and B), which have been shown to be prevalent in hospitals in Rio de Janeiro. This report showed that the PCR method for detection of oxacillin and mupirocin resistance in CNS is necessary to determine accurate rates of these resistance, and will can help in the staphylococcal infections prevention and control policies in Brazil.