Antimicrobial susceptibility patterns among bacteria isolated from intensive care units of the largest teaching hospital at the northwest of Iran

ABSTRACT This study was conducted to determine the antimicrobial susceptibility patterns among common pathogens in the intensive care units (ICUs) of a university hospital in northwestern Iran. A retrospective study was done on laboratory records of patients with nosocomial infection who were admitted to five ICUs of Imam Reza Hospital during a 21-month period from March 2010 to January, 2012. A total number of 556 isolates from 328 patients were evaluated. The most common sites of infections included respiratory (51.7%), urinary (24.8%), and blood (10.4%). The most frequently isolated microorganisms were Enterobacter aerogenes (50.6%) followed by Escherichia coli (16.7%) and Pseudomonas aeruginosa (7.5%). Staphylococcus aureus was the most frequent pathogen among gram-positives (39.7%). The rate of methicillin-resistant Staphylococcus aureus (MRSA) was 87.5%. Multidrug-resistant (MDR) gram-negative bacteria were documented in 25.8% of Acinetobacter, 20% of Klebsiella, and 16.6% of Pseudomonas. The most active antimicrobials were vancomycin (93.5%) followed by amikacin (71.5%) and gentamicin (46%). The overall antibiotic susceptibility was as follows: 36% ciprofloxacin, 19% imipenem, 20% trimethoprim-sulfamethoxazole, 20.5% ceftazidime, and 12% ceftriaxone. Due to the high rate of antimicrobial resistance in the ICU setting, more surveillance and control of the use of antimicrobials is needed to combat infections.

The pattern and risk factors associated with adverse drug reactions induced by Reteplase in patients with acute ST-elevation myocardial infarction: The first report from Iranian population.

OBJECTIVE: Acute myocardial infarction (AMI) is one of the main leading causes of mortality and morbidity. Reteplase is a fibrin-specific thrombolytic which is used in the treatment of AMI. There is a limited number of studies reporting the postmarketing adverse drug reactions (ADRs) induced by reteplase. This study was aimed to examine the reteplase pattern of ADR and its associated risk factors in patients with acute ST-elevation myocardial infarction. METHODS: A cross-sectional, prospective study in an 8-month period was done at the University affiliated referral cardiovascular center. The Naranjo probability scale and World Health Organization criteria for severity of ADRs were used for assessing the ADRs. The linear regression and logistic regression tests were used to evaluate the correlation between ADRs and risk factors. FINDINGS: The all 20 patients who received reteplase during the study period were entered. The majority of patients (n = 17) experienced at least one ADR. The results showed that the incidence of ADRs was mainly associated with gender and age, and the number of ADRs was associated with the history of diabetes and taking anti-diabetic agents. The gender was the main predictor in the occurrence of ADRs (odds ratio: 32, 95% confidence interval: 1.38-737.45; P = 0.030). CONCLUSION: The results showed that gender, age, diabetes mellitus, and using of anti-diabetes medications are the risk factors associated with the incidence of ADRs by reteplase.

A pilot randomized trial of pentoxifylline for the reduction of periprocedural myocardial injury in patients undergoing elective percutaneous coronary intervention.

PURPOSE: Periprocedural myocardial injury (PMI) following percutaneous coronary intervention (PCI) has received great attention due to its significant association with mortality and morbidity. Accordingly, cardioprotection during PCI is one of the important therapeutic concerns. Regarding the potential cardiovascular benefits of pentoxifylline this study was performed to evaluate whether the pretreatment pentoxifylline could reduce PMI in patients who are undergoing elective PCI. METHODS: A randomized clinical trial on 85 patients undergoing elective PCI was performed. The intervention group (n = 41) received 1200 mg pentoxifylline in divided doses plus the standard treatment before PCI, while the control group (n = 44) received the standard treatment. For assessing myocardial damage during PCI, the levels of CK-MB and troponin-I were measured at baseline, 8, and 24 h after the procedure. Then, patients were followed up for a 1-month period regarding the major adverse cardiac effect. RESULTS: Comparing with the control group, no significant change of CK-MB at 8 (p = 0.315) and 24 h (p = 0.896) after PCI was documented in pentoxifylline group. Similarly, no significant change was found in troponin-I at 8 (p = 0.141) and 24 h (p = 0.256) after PCI. CONCLUSIONS: This study could not support the pretreatment with pentoxifylline in the prevention of PMI in patients undergoing elective PCI. However, the trend was toward the potential benefit of pentoxifylline.

Education alone is not enough in ventilator associated pneumonia care bundle compliance.

OBJECTIVE: Ventilator-associated pneumonia (VAP) described as a secondary and preventable consequence in mechanically ventilated patients, emerges 48 h or more after patients intubation. Considering the high morbidity and mortality rate of VAP and the fact that VAP is preventable, it seemed necessary to evaluate care bundle compliance rate and effect of education on its improvement. METHODS: This observational study was conducted on 10 Intensive Care Units (ICUs) of four university affiliated hospitals in three steps. In the first step, VAP care bundle compliance including head of bed (HOB) elevation, endotracheal cuff pressure (ETCP), mouthwash time, utilizing close suction systems, subglottic secretion drainage, type of suction package, and hand wash before suctioning was evaluated. In the second and third steps, ICU staffs were trained and its effect on VAP care bundle compliance was investigated. Finally, an inquiry from nurses was conducted to evaluate the obtained results. FINDINGS: A total of 552 checklists consisting of 294 observations in the pre-education group and 258 observations in the posteducation group were filled. Mean VAP care bundle compliance in pre-education and posteducation stages was 36.5% and 41.2%, respectively (P > 0.05). Except for patients' mouth washing, there were no improvement in HOB elevation (>30°), hand washing and ETCP after education. Based on the results of questionnaire received from nurses at the end of study, more than 90% of nurses believed that lack of rigid monitoring of VAP care bundle is a main reason of low adherence for VAP care bundle compliance. CONCLUSION: The adherence to VAP care bundle was inappropriate. Education seems to be ineffective on improving VAP care bundle compliance. Frequent recall of the necessity of the VAP care bundle and the continuous supervision of ICU staffs is highly recommended.

Hydrocortisone reduces Toll-like receptor 4 expression on peripheral CD14+ monocytes in patients undergoing percutaneous coronary intervention.

BACKGROUND: Evidence from several lines of investigations suggests that Toll-like receptor 4 (TLR4) is involved in atherosclerosis as a bridge between innate and acquired immunity. Percutaneous coronary intervention (PCI) can trigger inflammation through activation of human TLR4 (hTLR4) on monocytes. Hydrocortisone as an anti-inflammatory and immuno-suppressant agent has multiple mechanisms of action. In this study, we aimed at assessing the effects of hydrocortisone on monocyte expression and activity of hTLR4 in patients underwent PCI. METHODS: Blood samples were taken from a total of 71 patients with chronic stable angina who were scheduled for a PCI, before the intervention. Thirty patients received 100 mg hydrocortisone prior to the procedure. Control group was composed of 41 patients underwent PCI without receiving hydrocortisone. Blood collection was repeated 2 and 4 h after PCI. The expression of hTLR4 on the surface of CD14+ monocytes and the serum levels of TNF-α and IL-1ß were measured using flowcytometry and Sandwich ELISA. RESULTS: Compared with controls, hydrocortisone significantly reduced monocyte expression of hTLR4 in test group (P<0.01). In addition, it had a significant effect on reduction of serum concentrations of TNF-α and IL-1ß in test group in a time-dependent manner (P<0.01). CONCLUSION: In this study, hydrocortisone was able to reduce the hTLR4/CD14 positive monocytes and its related pro-inflammatory cytokines, thus it can decrease inflammatory responses following PCI.

Study of patient pain management after heart surgery.

PURPOSE: To investigate postoperative pain control and analgesic use after heart surgery. METHODS: 20 patients undergone heart surgery, randomly entered the study. Each patient was asked to score his pain intensity on visual analog scale (VAS) at four different occasions. RESULTS: 120 patients aged 59 year-old; including 81 male were enrolled in the study. 69.2% had coronary artery disease and 16.7% had heart-valve problem. Main types of surgeries were coronary artery bypass surgery (70.5%) and valve repairement (23%). Duration of ICU stay was 4.78±2.7 days and duration of intubations was 17.38 ± 36.46 hours. Pre-surgery pain relief was administrated to 42% of the subjects and morphine and promethazine was the main pre-surgery analgesia medication. Post surgery analgesic included morphine (injection), petidine (injection) and NSAIDS (oral or rectal). According to VAS, mean pain level, 1 and 4 hours after extubation, and before and one hour after transferring to wards was 5.05±2.5, 4.09±2.0, 3.52±1.8, 2.36±1.89, respectively. Although the level of pain reported was mostly moderate, 80% were reported satisfaction with their post-surgery pain management. CONCLUSION: A closer pain management control is needed for patients after heart surgery. Introduction of newer pain management techniques, medications and dosages could reduce the pain and suffering.

Antenatal Micronutrient Supplementation Relationship with Children's Weight and Height from Birth up to the Age of 18 Months.

BACKGROUND: Maternal nutritional is the most important environmental factor influencing pregnancy outcome. While studies showed association between maternal iron-micronutrient deficiencies with pregnancy outcome, data examining impact of micronutrient supplementation on growth rate beyond birth are sparse. Present study examined the relationship between iron and multivitamins supplementation on growth rate of babies up to age of 18 month. METHODS: This study was a statistical analysis on data recorded through a routine procedure in health houses from 1994 to 2007. Subjects were selected by a two-stage randomization method and required data extracted from the records. Analyses were performed using STATA 10 software. RESULTS: Data was collected for 3835 pairs of mother-baby. Mothers received 61.7±5.4 and 115.6±53.8 multivitamins and iron tablets, respectively. Analyses showed significant relationship between children's weight and height at birth with iron supplementation and children's height at 6, 12 and 18 month with multivitamins supplementation. CONCLUSIONS: Mechanisms of these effects are unclear but it is safe to suggest supplementation during pregnancy is necessary.

Hyoscine-N-butylbromide versus atropine as labour accelerant and analgesic: a randomized clinical trial.

The aim of this study was to compare the efficacy of atropine and hyoscine-N-butyl bromide in reducing the pain and time length of the first stage of labour. In a single blind randomized clinical trial, 120 term pregnancies were enrolled from July 2009 to March 2011. A parallel design was used to randomly assign subjects into two equal groups including 60 participants in each group. Hyoscine-N-butylbromide was administered 40 mg intravenously in the first group and intravenous atropine was given in second group at a dose of 0.5 mg. The participants of the two trial arms were similar according to the distribution of background variables. The pain trend through the study follow up was found to be different between groups (p < 0.05). Mean length of the first stage of labor was 218.5 min (SD: 81.4) in hyoscine versus 339 min (SD: 83.3) in atropine group (p < 0.001). Mean 1st and 5th min APGAR score was similar in both groups. Drug side effects were less frequent in hyoscine group observed in 13 cases compared to atropine group observed in 56 cases (p < 0.001). Hyoscine appeared to be preferable to atropine specially in reducing the length of first stage of pregnancy.

Monocyte expression of Toll-like receptor-4 in patients with stable angina undergoing percutanoeus coronary intervention.

BACKGROUND: Toll like receptors (TLRs) are well recognized players in inflammatory conditions. Among them TLR-4 is involved in chronic inflammatory processes such as formation of atherosclerotic plaques. OBJECTIVE: The present study was aimed to examine the effects of percutanoeus coronary intervention (PCI) as a revascularization method on monocyte expression of hTLR-4 and on the serum levels of two proinflammatory cytokines (TNF-α and IL-1ß). METHODS: Blood samples were obtained from 41 patients with stable angina who were candidates for PCI. The samples were collected immediately before and 2h and 4h after PCI. The expression of hTLR-4 on CD14+ monocytes and the serum levels of TNF-α and IL-1ß were measured using flowcytometry and ELISA techniques, respectively. RESULTS: By comparing the frequency of circulating hTLR-4+/CD14+ monocytes at different time points, it was observed that PCI procedure up regulates the monocyte expression of hTLR-4 (p<0.05). The increase in expression was associated with the elevation of the serum levels of proinflammatory cytokines (p<005). There was a significant correlation between monocyte expression of hTLR-4 and serum levels of TNF-α and IL-1ß only before PCI. In spite of parallel increase in the serum levels of proinflammatory cytokines and the monocyte expression of hTLR-4, the correlation did not attain a significant level after PCI intervals. CONCLUSION: PCI is positively associated with an increase in the monocyte expression of hTLR-4. It is also associated with the elevation in the serum levels of proinflmmatory cytokines. These findings suggest that hTLR-4 monocyte expression may be used as a potential prognostic tool in patients with stable angina undergoing PCI.

Errors of oral medication administration in a patient with enteral feeding tube.

Enteral feeding tube is employed for feeding of critically ill patients who are unable to eat. In the cases of oral medication administration to enterally fed patients, some potential errors could happen. We report a 53-year-old man who was admitted to intensive care unit (ICU) of a teaching hospital due to the post-CPR hypoxemic encephalopathy. The patient was intubated and underwent mechanical ventilation. A nasogastric (NG) tube was used as the enteral route for nutrition and administration of oral medications. Oral medications were crushed then dissolved in tap water and were given to the patient through NG tube. In present article we report several medication errors occurred during enterally drug administration, including errors in dosage form selection, methods of oral medication administration and drug interactions and incompatibility with nutrition formula. These errors could reduce the effects of drugs and lead to unsuccessful treatment of patient and also could increase the risk of potential adverse drug reactions. Potential leading causes of these errors include lack of drug knowledge among physicians, inadequate training of nurses and lack of pharmacists participation in medical settings.

Self-reported Use and Attitudes Regarding Herbal Medicine Safety During Pregnancy in Iran.

BACKGROUND: Despite the vast use of herbal medicines in the world, little is known about their use in pregnancy and the attitudes of pregnant women regarding their safety during pregnancy. OBJECTIVES: The aim of this study was to evaluate the use and attitudes of pregnant women toward herbal medicine use in pregnancy in Iran. MATERIALS AND METHODS: A questionnaire was completed by 400 women selected by convenience sampling from postnatal and prenatal wards of two hospitals. Data were analyzed using the SPSS software version 13.5. Chi2 test was used to analyze the data. RESULTS: The median age was 26.4 (± 5.2) years and the mean number of pregnancies was 1.9 (± 0.98). The use of herbal remedies during pregnancy was positive in 22.3% of patients. They took herbal medicines recommended by their physician (46.1%), through self-medication (44.9%), or with the advice of family members or friends (9%). Additionally, 39.8% believed that it was safe to use herbal remedies during pregnancy, 32.3% believed that it was harmful for both mother and fetus, and 22% did not know whether it was safe or not. CONCLUSIONS: Herbal medicine use was not high among our subjects but was significantly affected by age. The level of education, place of living, and number of pregnancies significantly affected the attitudes of the subjects. Women with higher education mostly relied on their own information, whereas those with lower education relied on physician advice. Further educational programs are required to increase the information for this group of susceptible individuals.

Changes in plasma concentration of taurine in stroke.

Taurine is critical for proper brain functioning. Increase in plasma taurine concentration has already been shown in many diseases [1,2,5,10,12,14,17,22,25,47]. The plasma concentrations of taurine in 60 patients, suffering from stroke, were compared with that of 54 healthy volunteers. The plasma samples of the patients were obtained three times in the first five days of hospitalization. A Student's t-test showed a significant difference (P<0.0001) between the plasma concentrations of taurine of the patients group (136.5±8.2mmol/L) and the control group (41.9±2.5mmol/L). In addition, a one-way repeated measures ANOVA test showed that the mean plasma concentration of taurine in the patients during the first five days of hospitalization declined significantly from 136.9±8.2mmol/L in the first day of hospitalization to 120.1±5.9mmol/L on the third day and 110.2±7.0mmol/L by the fifth day (P>0.05). The plasma concentration of taurine was increased in the patients with stroke probably because of brain tissue damage. Although, according to the result of the study, mean plasma taurine concentration in stroke patients declined during five days of hospitalization. Further studies are needed to introduce taurine as a biomarker of recovery in stroke.

Pharmacokinetic and pharmacodynamic study of morphine and morphine 6-glucuronide after oral and intravenous administration of morphine in children with cancer.

The aim of this study was to characterize the pharmacokinetics and pharmacodynamics of morphine and morphine 6-glucuronide (M6G) in children with cancer. Serum concentrations of morphine and M6G in children who received single oral or short term continuous intravenous morphine were determined by HPLC and ELISA assays, respectively. The serum C(max) of morphine and M6G after i.v. morphine administration was 560.5 and 309.0 nM and the T(max) was 61 and 65 min, respectively. The elimination half-life was 140.0 and 328.7 min, respectively. After oral administration of morphine, the serum C(max) of morphine and M6G was 408.34 and 256.3 nM and the T(max) was 40.0 and 60 min, respectively. The half-life was 131.0 and 325.8 min, respectively. The side effects were: drowsiness (100%), nausea and/or vomiting (57%), pruritus (28%) and urinary retention (14%). There were no reports of respiratory complications. This study showed that pharmacokinetics factors of morphine and M6G in children were significantly different from adults. Therefore the required dose for children should be different from that of adults and should be based on studies performed on children rather than on studies on adults. Some adverse effects, particularly nausea and pruritus, may be commoner than is usually thought, while others, particularly respiratory problems did not occur.

Study of awareness among pregnant women of the effects of drugs on the fetus and mother in Iran.

OBJECTIVE: The aim of the study was to examine the awareness of Iranian pregnant women about the effects of drugs in pregnancy. METHODS: Awareness of 400 women in postnatal and prenatal wards was assessed using self-completion questionnaire, which included demographic information, medication use, and the level of information regarding the safety of drugs during pregnancy and the most susceptible periods in pregnancy. RESULTS: Out of 400 participants from prenatal and postnatal wards of two hospitals, 19.0% used medications other than vitamins and minerals supplements during pregnancy, and 7% believed in the safety of medications for mother and/or fetus during pregnancy. The first and second trimesters were believed to be the most and the least susceptible periods of pregnancy, respectively. Most information on drugs safety in pregnancy was obtained from physicians and health centers. CONCLUSIONS: Present study indicates weaknesses in the awareness of this population and weak role of pharmacists in informing this vulnerable population. This study shows the requirement of training of this group of people in order to enhance the health of our community.

Morphine in children with cancer: impact of age, chemotherapy and other factors on protein binding.

The aim of this study was to contrast protein binding of morphine and morphine-6 glucuronide in cord blood and children with adults and examine impact of chemotherapy and other factors. Morphine binding was measured in spiked samples from 18 adults and 18 neonates (cord blood), and compared with six children with cancer receiving morphine. The influence of the following was examined: Human serum albumin (HSA), alpha-1 acid glycoprotein (AAG), non-esterified fatty acids (NEFA); palmitic acid and oleic acid, pH, vincristine, methotrexate, 6-mercaptopurine and M6G. binding correlated with concentrations of albumin and alpha1 acid glycoprotein. In vitro, binding was not altered by vincristine, 6-mercaptopurine, methotrexate or M6G. Compared with HSA alone, AAG increased binding, palmitic acid reduced it and oleic acid had no effect. Binding was unaffected by pH in samples from patients. Morphine binding was influenced by concentrations of albumin, AAG and morphine itself, but not by age.