Evaluation of the Xpert vanA/vanB assay using enriched inoculated broths for direct detection of vanB vancomycin-resistant Enterococci.

Rapid and accurate detection of VRE (vancomycin-resistant enterococci) is required for adequate antimicrobial treatment and infection prevention measures. Previous studies using PCR for the detection of VRE, including Cepheid's Xpert vanA/vanB assay, reported accurate detection of vanA VRE; however, many false-positive results were found for vanB VRE. This is mainly due to nonenterococcal vanB genes, which can be found in the gut flora. Our goal was to optimize the rapid and accurate detection of vanB VRE and to improve the positive predictive value (PPV) by limiting false-positive results. We evaluated the use of the Xpert vanA/vanB assay on rectal swabs and on enriched inoculated broths for the detection of vanB VRE. By adjusting the cycle threshold (CT) cutoff value to ≤ 25 for positivity by PCR on enriched broths, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 96.9%, 100%, 100%, and 99.5% for vanB VRE, respectively. As shown in this study, CT values of ≤ 25 acquired from enriched broths can be considered true positive. For broths with CT values between 25 and 30, we recommend confirming the results by culture. CT values of >30 appeared to be true negative. In conclusion, this study shows that the Cepheid's Xpert vanA/vanB assay performed on enriched inoculated broths with an adjusted cutoff CT value is a useful and rapid tool for the detection of vanB VRE.

A randomized trial of alcohol 70% versus alcoholic iodine 2% in skin disinfection before insertion of peripheral infusion catheters.

Skin disinfection before insertion of peripheral infusion catheters is standard practice, but a comparison in effectiveness of the two most widely used disinfectants is lacking. We compared alcohol 70% and alcoholic iodine 2% in a prospective randomized trial. Data from 109 patients on a pulmonary ward were analysed. Phlebitis occurred six times in the alcohol group and 12 times in the iodine group. This relative risk reduction of 53% failed to reach significance (P = 0.18). The power of the study, however, was only 0.55, meaning a 45% chance of missing a true difference. As countless catheters are inserted each year, a small difference in phlebitis rate could save discomfort to many patients. Thus, a larger trial seems warranted. The addition of theophylline to the prednisone infusion resulted in a significantly higher phlebitis rate: 27.3 versus 9.2% (P = 0.03).

A single-blind comparison of three-day azithromycin and ten-day co-amoxiclav treatment of acute lower respiratory tract infections.

The efficacy and safety of a three-day regimen of azithromycin (500 mg od) and a ten-day regimen of co-amoxiclav (625 mg tid) were compared in a single-blind study in 99 patients with acute lower respiratory tract infections. Of these, 70 (71%) suffered an infective exacerbation of their chronic obstructive pulmonary disease. Nine patients had pneumonia and 19 purulent bronchitis. Treatment success, defined as cure or improvement, occurred in 43 of 48 (90%) patients in the azithromycin group, compared with 45 of 51 (88%) patients in the co-amoxiclav group. The most common isolated pathogens were Haemophilus influenzae (25 cases; MIC range of azithromycin (A) < or = 0.06-4 mg/L; for co-amoxiclav (CA) 0.25-4 mg/L; Streptococcus pneumoniae (10 cases; A: < or = 0.06- > 128; CA: < or = 0.06); and Moraxella catarrhalis (four cases; A: < or = 0.06; CA: < or = 0.06-0.25). Microbiological response rates were comparable in the two groups. In 5% of patients, serological evidence for virus or atypical pathogens was found. Thirteen (26%) patients treated with co-amoxiclav had gastrointestinal complaints (seven with diarrhoea), compared with five (10%) treated with azithromycin (P = 0.09). Additional complaints occurred in three patients treated with co-amoxiclav and in one patient treated with azithromycin. It was concluded that a three-day regimen of azithromycin was as effective, clinically and microbiologically, as a ten-day regimen of co-amoxiclav in the treatment of acute lower respiratory tract infections.

Double-blind randomized study comparing the efficacies and safeties of a short (3-day) course of azithromycin and a 5-day course of amoxicillin in patients with acute exacerbations of chronic bronchitis.

The efficacies and safeties of a three-dose regimen of azithromycin (500 mg once daily for 3 days) and a 15-dose regimen of amoxicillin (500 mg three times daily for 5 days) were compared in a double-blind manner in patients with an acute exacerbation of chronic bronchitis. A total of 92% of patients suffered a type 1 exacerbation. Treatment success, defined as cure or major improvement, was achieved in all patients in the azithromycin group by day 5, compared with 23 (92%) of 25 patients in the amoxicillin group. On day 12, these data were 24 of 25 (96%) in the azithromycin group and 20 of 25 (80%) in the amoxicillin group (results were not significantly different). Several pathogens were isolated (MIC ranges [micrograms per milliliter] in parentheses): Haemophilus influenzae or Haemophilus parainfluenzae was isolated 23 times (azithromycin, less than or equal to 0.06 to 32; amoxicillin, 0.12 to 2); Streptococcus pneumoniae was isolated from 11 patients (azithromcyin, less than or equal to 0.06 greater than 256; amoxicillin, less than or equal to 0.06 to 0.25); Moraxella (Branhamella) catarrhalis was isolated from eight patients (azithromycin, less than or equal to 0.06; amoxicillin, less than or equal to 0.06 to 16); and other members of the family Enterobacteriaceae were isolated from eight patients. One patient treated with azithromycin had Legionella pneumophila pneumonia, and another in that group had a significant rise in titer of antibody against influenza A virus. One patient treated with amoxicillin also had a significant rise in titer of antibody against influenza A virus. Microbiological response rates were comparable. One patient who received azithromycin developed abnormal liver function. Two patients treated with amoxicillin developed abnormal liver functions, one developed exanthema, and one treatment was stopped because of nausea. It is concluded that a three-dose (3-day) regimen of azithromycin is as effective clinically and microbiologically as a 15-dose (5-day) regimen of amoxicillin in the treatment of acute exacerbations of chronic bronchitis.

Natural course of bleomycin-induced pneumonitis. A follow-up study.

In this study, long-term pulmonary complications of bleomycin were evaluated in 8 patients with bleomycin-induced pneumonitis (BIP). The lung function parameters: VC, alveolar volume, transfer factor for carbon monoxide of the lungs, diffusing capacity of the alveolocapillary membrane, and pulmonary capillary blood volume were studied in all patients for as long as 2 yr after the development of BIP. Perfusion scans with 133Xe and 99mTc were performed in these patients 2 yr after BIP developed. We concluded that if a patient survives the acute event of BIP, the pulmonary symptoms and the changes in these lung function parameters are completely reversible.

A reduction in pulmonary capillary blood volume in patients with disseminated testicular carcinoma.

Pulmonary function tests, including the transfer factor for carbon monoxide of the lungs (T1CO) and pulmonary capillary blood volume (Vc), were measured in 43 patients with disseminated testicular carcinoma and in eight patients with disseminated malignant melanoma before the start of a bleomycin-containing cytostatic combination. Their relation to the development of bleomycin-induced pulmonary toxicity was evaluated. We found two subgroups of patients, one group with and one group without an abnormal pretreatment T1CO and Vc. In the latter group the risk of bleomycin-induced pulmonary toxicity is not increased. Reduction in bleomycin dose during treatment is not necessary. The hypothesis is formulated that tumor embolism could be the explanation for this phenomenon.

Changes in pulmonary function during and after bleomycin treatment in patients with testicular carcinoma.

Pulmonary function tests, including spirometry, transfer factor of the lungs for carbon monoxide (TlCO), and the two components of TlCO, the diffusing capacity of the alveolocapillary membrane (Dm) and pulmonary capillary blood volume (Vc), were carried out in a group of patients with testicular carcinoma during and after treatment with the Einhorn regimen. The lung function parameters of patients who developed bleomycin-induced pneumonitis were compared with those recorded in a group of patients who did not develop this syndrome. We suggest that bleomycin-induced damage to the pulmonary capillary vasculature can be monitored by measuring Vc and that ensuing fibrosis can be measured by recording Dm. The decrease in Dm is probably compensated for by an increase in Vc, leading to a smaller change in TlCO.

Predictive factors for bleomycin-induced pneumonitis.

Five pulmonary function tests (transfer factor for carbon monoxide, diffusing capacity of the alveolar-capillary membrane, pulmonary capillary blood volume, alveolar volume, vital capacity) were performed, and creatinine clearance was measured in 39 patients with disseminated testicular nonseminomatous tumor treated with a combination chemotherapy containing bleomycin. Eight of these patients (20.5%) developed bleomycin-induced pneumonitis (BIP). To investigate which parameter has value in predicting BIP, a discriminant analysis was performed. The combination of a low normal creatinine clearance, a decrease in vital capacity and alveolar volume without a decrease in pulmonary capillary blood volume, pointed to an increased risk. We concluded that it is worthwhile to monitor these parameters and, if necessary, to adapt the chemotherapy of a patient at risk.

Influence of platinum-induced renal toxicity on bleomycin-induced pulmonary toxicity in patients with disseminated testicular carcinoma.

Pulmonary function tests, including T1CO, and renal function tests were performed and GFR and ERPF measured in 18 patients with disseminated testicular non-seminoma before and after remission induction according to the Einhorn regimen. We found a significant positive correlation between delta GFR and delta T1CO (p less than 0.05). No significance could be demonstrated between delta ERPF and delta T1CO. It is concluded that caution should be exercised in administrating bleomycin to patients with severely impaired renal function.