Trends of isolation of intrinsically resistant to colistin Enterobacteriaceae and association with colistin use in a tertiary hospital.

The objective of this investigation was to evaluate the association between colistin consumption and the isolation of intrinsically resistant to colistin Enterobacteriaceae (IRCE) in a university hospital in Crete, Greece. The database of the microbiological laboratory was reviewed retrospectively during 2006-2010. All positive cultures for IRCE were retrieved. We assessed the total consumption of colistin in medical, surgical, and intensive care units (ICUs). A total of 1,304 single-patient IRCE isolates were recorded. Of these, 466 (35.7%) were hospital-acquired, while 838 (64.3%) were community-acquired. Proteus spp. accounted for 72% of them, Serratia spp. for 16.6%, Morganella morganii for 8.4%, and Providencia spp. for 3%. Urine (44.8%), pus (20.4%), and lower respiratory tract specimens (12.8%) accounted for the majority of specimens. IRCE isolated during the first half (2006 to 1st semester of 2008) and second half (2nd semester of 2008 to 2010) of the study period accounted for 5.8% and 7.4% of Gram-negative isolates, respectively (p < 0.001). Colistin consumption was not different in the two periods in the hospital, but in the ICU, it was higher in the second half of the study period (p = 0.013). Colistin consumption was associated with the isolation of hospital-acquired IRCE (p = 0.037); a trend was noted between colistin consumption and the isolation of IRCE in the ICU (p = 0.057). In this study, colistin consumption was associated with the isolation of hospital-acquired IRCE. The use of colistin increased in the ICU during the study period. Prudent use of colistin is essential for the prevention of nosocomial outbreaks due to resistant IRCE.

Accuracy of ß-D-glucan for the diagnosis of Pneumocystis jirovecii pneumonia: a meta-analysis.

Pneumocystis jirovecii pneumonia (PCP) can affect various types of immunocompromised patients. We sought to evaluate the diagnostic accuracy of (1→3)-ß-D-glucan (BDG) for the diagnosis of PCP. We carried out a meta-analysis of relevant studies, identified through PubMed and Scopus. Eligible studies were those that reported BDG diagnostic data in cases with documented PCP and controls with other conditions. Cases of invasive fungal infections and healthy controls were excluded. We performed a bivariate meta-analysis of sensitivity and specificity and constructed a hierarchical summary receiver operating characteristics (HSROC) curve. Fourteen studies were included in the meta-analysis. BDG data were analysed for 357 PCP cases and 1723 controls. The average (95% confidence interval) sensitivity and specificity of BDG were 94.8% (90.8-97.1%) and 86.3% (81.7-89.9%), respectively. The positive and negative likelihood ratios were 6.9 (5.1-9.3) and 0.06 (0.03-0.11), respectively. The area under the HSROC curve was 0.965 (0.945-0.978). Serum BDG shows excellent sensitivity and very good specificity in the diagnosis of PCP. Still, in clinical practice the test results should be interpreted in the context of the underlying clinical characteristics of the individual patient.

Inhaled colistin as adjunctive therapy to intravenous colistin for the treatment of microbiologically documented ventilator-associated pneumonia: a comparative cohort study.

Ventilator-associated pneumonia (VAP) as a result of multidrug-resistant Gram-negative bacteria has contributed to the revival of the use of intravenous (i.v.) colistin. However, the additional administration of inhaled colistin for VAP is controversial. We performed a retrospective cohort study of patients with microbiologically documented VAP who received i.v. colistin with or without inhaled colistin. Seventy-eight patients with VAP received i.v. plus inhaled colistin, whereas 43 patients received i.v. colistin alone. The mean +/- SD daily dosage of i.v. colistin was 7.0 +/- 2.4 and 6.4 +/- 2.3 million international units (IU), respectively (p 0.13); the average daily dosage of inhaled colistin was 2.1 +/- 0.9 million IU. The outcome of infection was cure for 62/78 (79.5%) patients who received i.v. plus inhaled colistin vs. 26/43 (60.5%) patients who received i.v. colistin alone (p 0.025); all-cause in-hospital mortality was 31/78 (39.7%) vs. 19/43 (44.2%), respectively (p 0.63); all-cause intensive care unit (ICU) mortality was 28/78 (35.9%) vs. 17/43 (39.5%), respectively (p 0.92). The use of inhaled colistin was independently associated with the cure of VAP in a multivariable analysis (OR 2.53, 95% CI 1.11-5.76). Independent predictors of mortality were a higher APACHE II score (OR 1.12, 95% CI 1.04-1.20), presence of malignancy (OR 4.11, 95% CI 1.18-14.23) and lower daily dosage of i.v. colistin (OR 0.81, 95% CI 0.68-0.96). The outcome of VAP was better in patients who received inhaled colistin with i.v. colistin than those who received i.v. colistin alone. There was no difference in all-cause in-hospital and ICU mortality between the two groups. Randomized controlled trials are needed to evaluate further the role of inhaled colistin in VAP.

Open access World Wide Web resources on upper and lower respiratory tract infections.

BACKGROUND: Respiratory tract infections represent a common problem in everyday practice. The development of the World Wide Web can assist clinicians and other medical care professionals in finding useful information on various clinical conditions, including upper and lower respiratory tract infections. METHODS: To identify websites containing information for health care professionals on upper and lower respiratory tract infections, we searched popular search engines such as Google and Yahoo. We also reviewed the sites of major institutions as well as relevant organisations and professional societies and associations. Only those sites that included material in the English language, were open access and developed by a governmental and/or academic institution, or a national or international professional society or associations were included. RESULTS: We selected 106 sites that provide information on upper respiratory tract infections and 67 sites that provide information on lower respiratory tract infections. CONCLUSIONS: We tried to identify freely available Internet resources with relevant information on upper and lower respiratory tract infections. We believe that the list of relevant World Wide Web resources we generated may be useful as an educational tool for clinicians and trainees.

Macrolides, quinolones and amoxicillin/clavulanate for chronic bronchitis: a meta-analysis.

The comparative effectiveness and safety of macrolides, quinolones and amoxicillin/clavulanate (A/C) for the treatment of patients with acute bacterial exacerbation of chronic bronchitis (ABECB) was evaluated in the present study. PubMed, Current Contents and the Cochrane Central Register of Controlled Trials were searched to identify relevant randomised controlled trials (RCTs). In total, 19 RCTs (20 comparisons) were included in the present analysis. There was no difference regarding treatment success in intention-to-treat and clinically evaluable patients between macrolides and quinolones, A/C and quinolones or A/C and macrolides. The treatment success in microbiologically evaluable patients was lower for macrolides compared with quinolones (odds ratio (OR) 0.47, 95% confidence interval (CI) 0.31-0.69). Fewer quinolone-recipients experienced a recurrence of ABECB after resolution of the initial episode compared with macrolide-recipients during the 26-week period following therapy. Adverse effects in general were similar between macrolides and quinolones. Administration of A/C was associated with more adverse effects (mainly diarrhoea) than quinolones (OR 1.36, 95% CI 1.01-1.85). Macrolides, quinolones and amoxicillin/clavulanate may be considered equivalent for the treatment of patients with an acute bacterial exacerbation of chronic bronchitis in terms of short-term effectiveness. Quinolones are associated with better microbiological success and fewer recurrences of acute bacterial exacerbation of chronic bronchitis than macrolides, while amoxicillin/clavulanate is associated with more adverse effects than both comparators.