University Hospital, Universidade de São Paulo, São Paulo, SP, Brazil.
Acute bronchiolitis is a leading cause of infant hospitalization and is most commonly caused by respiratory syncytial virus. Etiological tests are not required for its diagnosis, but the influence of viral screening on the therapeutic approach for acute bronchiolitis remains unclear.
A historical cohort was performed to assess the impact of viral screening on drug prescriptions. The study included infants up to one year of age who were hospitalized for bronchiolitis. Virus screening was performed using immunofluorescence assays in nasopharyngeal aspirates. The clinical data were obtained from the patients' medical records. Therapeutic changes were considered to be associated with viral screening when made within 24 hours of the release of the results.
The frequency of prescriptions for beta agonists, corticosteroids and antibiotics was high at the time of admission and was similar among the 230 patients. The diagnosis of pneumonia and otitis was associated with the introduction of antibiotics but did not influence antibiotics maintenance after the results of the virus screening were obtained. Changes in the prescriptions were more frequent for the respiratory syncytial virus patients compared to patients who had negative viral screening results (p =0.004), especially the discontinuation of antibiotics (p<0 .001=".001" associated="associated" class="highlight" identification="identification" nbsp="nbsp" of="of" respiratory="respiratory" span="span" style="border: 0px; font-size: 15.600000381469727px; font: inherit; margin: 0px; padding: 0px; vertical-align: baseline;" suspension="suspension" syncytial="syncytial" the="the" virus="virus" was="was" with="with">antibiotics0>
(p= 0.003), even after adjusting for confounding variables (p = 0.004); however, it did not influence the suspension of beta-agonists or corticosteroids.
The identification of respiratory syncytial virus in infants with bronchiolitis was independently associated with the discontinuation of antibiotics during hospitalization.
From the MRC Centre for Inflammation Research, Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, Department of Respiratory Medicine and Department of Pharmacy (Respiratory Medicine), Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK.
The aim of our study was to assess the impact of 8-weekly intravenous (IV) antibiotics on exacerbation frequency and health-related quality of life in bronchiectasis.
Patients were recruited prospectively from June 2008 to December 2010. Patients with recurrent exacerbations (five or more exacerbations per year) and subjectively reporting ill health between antibiotic courses were recruited. Eight-weekly IV antibiotics (for 14 days) were initiated. Patients were followed up for 1 year. Main outcome was reduction in exacerbation frequency and improvement in health-related quality of life (HRQoL) at 1 year after starting intravenous antibiotic therapy. Other outcomes recorded were forced expiratory volume in 1 s (FEV(1)), forced vital capacity (FVC), incremental shuttle walk test (ISWT), 24-h sputum volume, sputum microbiology, body mass index (BMI), markers of inflammation-white cell count (WCC), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).
In total, 19 patients were recruited. Mean age was 64.1 years and 52.6% were female. With 8-weeklyantibiotics, there was a significant reduction in the number of exacerbations [mean (SE): 9.3 (0.5) in the year before vs. 8.0 (0.4) in the year after; P = 0.02]. In 63.2%, Leicester Cough Questionnaire (LCQ) improved by ≥1.3 U (P = 0.006)] and in 42.1% St. George's Respiratory Questionnaire (SGRQ) improved by ≥4 U (P = 0.03). Exercise capacity increased by 58.7 m (P = 0.004). There was no improvement in the other end points.
Treatment with 8-weekly intravenous antibiotics in severe bronchiectasis reduced exacerbation frequency and improved exercise tolerance and health-related quality of life.
HOUSTON (KTRK) -- If you have fall allergies, prepare yourself. You're entering the season. And if your allergies tend to morph into sinus infections, those of you who go to the doctor for antibiotics may leave empty-handed.
Sinus infection sufferer Stephanie Santino said, "There were times where just literally sitting upright, that pain of holding your head upright was just really intense."
Santino describes the pain of her sinus infections. Typically, when it happened, she'd get an antibiotic from her doctor. But this year that is likely to change. Because doctors say, antibiotics often just don't work. Sinus specialist Dr. Subinoy Das explained, "For the vast, vast majority of people we give antibiotics, it's not really providing the benefit that we would have hoped." In fact, antibiotics for sinus infections may be making things worse. Up to 90 percent of sinus infections are caused by a virus and antibiotics don't help at all. For decades doctors prescribed them anyway and now we've grown some drug resistant bacteria. "We are creating a race of super-bacteria for which we will not be able to treat," Dr. Das said. So how do you treat sinus infections? Here are the new guidelines from infectious diseases experts: try an over-the-counter saltwater rinse. But do go to a doctor if your face swells, if you have fever, or your vision changes. "Seek medical attention early but go with an open mind that I'm not going expecting an antibiotic," Dr. Das said. Besides saltwater rinses you can buy at the pharmacy, some people with chronic problems get relief with sinus surgery, where passages are cleaned out and opened up. Talk to your pharmacist about other over-the-counter options that might give you relief. HealthCheck
Appendicitis could be treated with antibiotics rather than surgery
Friday Sept 28, 2012
Eight out of ten cases of appendicitis could be treated with antibiotics rather than surgery, a trial suggests.
A study found that although the standard approach to appendicitis is to remove the appendix, treatment with antibiotics can be just as effective.
Jeanette Hansson, of the University of Gothenburg, examined two clinical studies of adult patients with acute appendicitis.
She compared those who had received treatment with just antibiotics to those who had surgery with antibiotic therapy.
Ms Hansson says in her thesis, carried out at Sahlgrenska University Hospital and Kungälv Hospital, that treatment with antibiotics was just as effective as surgery for the majority of patients.
She said: "Some patients are so ill that the operation is absolutely necessary, but 80 percent of those who can be treated with antibiotics recover and return to full health," says Jeanette Hansson.
The thesis also showed that patients who are treated with antibiotics are at risk of fewer complications than those who undergo surgery.
The risk of reoccurence within 12 months of antibiotic treatment is between ten and 15 per cent, but Ms Hansson said the medicine is still a viable alternative to surgery.
She said: "It's important to note that our studies show that patients who need surgery because of recurrences, or because the antibiotics haven't worked, are not at risk of any additional complications relative to those operated on in the first place."
Division of Pediatric Gastroenterology, Hepatology and Nutrition, Marmara University School of Medicine, Fevzi Çakmak Mah. Mimar Sinan Cad. No 41, Pendik, İstanbul, Turkey, email@example.com.
Helicobacter pylori infection is recognised as a cause of gastritis and peptic ulcer disease (PUD) and usually acquired during the first years of life. While there is a decline in the prevalence of H. pylori infection in northern and western European countries, the infection is still common in southern and eastern parts of Europe and Asia. Symptoms of H. pylori-related PUD are nonspecific in children and may include epigastric pain, nausea and/or vomiting, anorexia, iron deficiency anaemia and hematemesis. Besides, only a small proportion of children develop symptoms and clinically relevant gastrointestinal disease. H. pylori infection can be diagnosed either by invasive tests requiring endoscopy and biopsy or non-invasive tests including the (13)C-urea breath test, detection of H. pylori antigen in stool and detection of antibodies in serum, urine and saliva. The aim of treatment is at least 90 % eradication rate of the bacteria, and a combination of two antibiotics plus a proton pump inhibitor has been recommended as first-line treatment. However, frequent use of antibiotics during childhood is associated with a decline in eradication rates and the search for new treatment strategies as well. This is an overview of the latest knowledge and evidence-based guidelines regarding clinical presentation, diagnosis and treatment of H. pylori infection in childhood.
Health Protection Agency Primary Care Unit, Microbiology Department, Gloucestershire Royal Hospital, Gloucester GL1 3NN, UK.
On 18 November 2012, the UK will once again support the annual European Antibiotic Awareness Day (EAAD). In particular, hospitals will be asked to promote the Start Smart-Then Focus guidance for hospitals launched in 2011, while the Royal College of General Practitioners will publish the TARGET Antibiotics toolkit on their web site. TARGET (Treat Antibiotics Responsibly, Guidance, Education, Tools) emphasizes the need for both primary care staff and the public to use antibiotics responsibly, and provides guidance, education and tools. The web site has been developed by a multi professional group and hosts national antibiotic guidance, an antibiotic app, leaflets designed to be shared by patients during consultations, a presentation for clinicians, an interactive self-assessment tool, audit tools, posters and videos for the waiting room and links to other materials. The EAAD is still very relevant and worth promoting enthusiastically through all clinical professionals in an effort to encourage responsible use of antibiotics and thereby control antibiotic resistance.
Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois;
BACKGROUND AND OBJECTIVES:
Filling a prescription is the important first step in medication adherence, but has not been studied in pediatric primary care. The objective of this study was to use claims data to determine the rate of unfilled prescriptions in pediatric primary care and examine factors associated with prescription filling.
This retrospective observational study of pediatric primary care patients compares prescription data from an electronic medical record with insurance claims data. Illinois Medicaid provided claims data for 4833 patients who received 16 953 prescriptions during visits at 2 primary care sites over 26 months.
Prescriptions were compared with claims to determine filling within 1 day and 60 days. Clinical and demographic variables significant in univariate analysis were included in logistic regression models.
Patients were 51% male; most (84%) spoke English and were African American (38.7%) or Hispanic (39.1%). Seventy-eight percent of all prescriptions were filled. Among filled prescriptions, 69% were filled within 1 day. African American, Hispanic, and male patients were significantly more likely to have filled prescriptions. Younger age was associated with filling within 1 day but not with filling within 60 days. Prescriptions for antibiotics, from one of the clinic sites, from sick/follow-up visits, and electronic prescriptions were significantly more likely to be filled.
More than 20% of prescriptions in a pediatric primary care setting were never filled. The significant associations with clinical site, visit type, and electronic prescribing suggest system-level factors that affect prescription filling. Development of interventions to increase adherence should account for the factors that affect primary adherence.
Department of Internal Medicine, National Cheng Kung University Hospital, Tainan 704, Taiwan.
To investigate the clinical impact of age on bacteremia among adults visiting the emergency department (ED).
Bacteremic adults visiting the ED from January 2008 to December 2008 were identified retrospectively. Demographic characteristics, severity, bacteremic pathogens with in vitro susceptibility, antimicrobial agents, and outcomes determined from chart records were analyzed as a case-control study.
Of 518 eligible bacteremic adults, 288 fifty six percent elderly patients greater then 65 years old were case patients and 230 younger patients, less then 65 years were regarded as control patients. The 28-day mortality rate was higher in the case patients than that in the control patients (11.8% vs 6.1%, P = .02). The proportion of inappropriate empirical antibiotic therapy between the survivors and nonsurvivors was similar in control patients (69.4% vs 64.3%, P = .77); but for the case patients, the proportion of inappropriate empirical antibiotic therapy in the survivors was lower than that in the non-survivors (27.6% vs 44.1%, P = .04). Of note, inappropriate empirical antibiotic therapy was also one of independent risk factors of 28-day mortality by the multivariate analyses in the case patients (odds ratio [OR] 3.65; P = .049). Other independent predictors of 28-day mortality in case patients included a high Pittsburgh bacteremia score (≥4 points; OR 22.16; P < .001), bacteremia due to foci other than urinary tract infection (OR 9.07; P = .002), malignancy (OR 10.87; P < .001), coronary artery disease (OR 5.68; P = .01), and high serum creatinine (>1.5 mg/dL; OR 3.44; P = .04).
For bacteremic adults, this study demonstrated the impact of inappropriate empirical antibiotic therapy on patients' outcome in the elderly was greater than that in the younger adults.
Interfakultäres Institut für Mikrobiologie und Infektionsmedizin, Lehrbereich Mikrobielle Genetik, Eberhard Karls Universität Tübingen, Tübingen, Germany.
Bacterial persister cells are non- or slow-growing reversible phenotypic variants of the wild type, tolerant to bactericidalantibiotics. We analyzed here Staphylococcus aureus persister levels by monitoring colony-forming unit counts of planktonically grown cells treated with six different antimicrobials over time. The model laboratory strains HG001-HG003, SA113 and the small colony variant (SCV) strains hemB and menD were challenged by the compounds at different logs of minimal inhibitory concentration (MIC) in exponential or stationary growth phase.
Antibiotic tolerance was usually elevated in SCV strains compared to normally growing cells and in stationary versus exponential phase cultures. Biphasic killing kinetics, typical for persister cell enrichment, were observed in both growth phases under different selective conditions. Treatment of exponential phase cultures of HG001-HG003 with 10-fold MIC of tobramycin resulted in the isolation of persisters which upon cultivation on plates formed either normal or phenotypically stable small colonies. Trajectories of different killing curves indicated physiological heterogeneity within persister subpopulations.
Daptomycin added at 100-fold MIC to stationary phase SA113 cells rapidly isolated very robust persisters. Fractions of antibiotic-tolerant cells were observed with all S. aureus strains and mutants tested. Our results refute the hypothesis that S. aureus stationary phase cells are equivalent to persisters, as not all of these cells showed antibiotic tolerance. Isolation of S. aureus persisters of different robustness seems to depend on the kind and concentration of the antibiotic, as well as on the strain used.
Deadly 'superbugs' on the rise: What you need to know
Concern has been raised once again over the threat of deadly ‘superbugs,’ after a seventh individual at the National Institutes of Health Clinical Center in Bethesda, Md., died Friday after contracting an antibiotic-resistant strain of bacteria.
According to the Washington Post, the boy from Minnesota contracted the bug while being treated at the hospital for complications from a bone marrow transplant. So far, he is the 19th patient at the NIH center to have contracted the bacteria – Klebsiella pneumoniae carbapenemase (KPC). The bug’s outbreak was traced back to a single patient who was carrying the bacteria when he was admitted to the hospital in the summer of 2011.
While the NIH declined to be interviewed on the matter, the agency released a statement about the incident.
“We are deeply saddened by the deaths at the NIH Clinical Center related to [KPC],” the NIH said in a statement. “The health and welfare of patients is NIH's top priority, and NIH has – and will continue to – take every measure possible to protect patients at the Clinical Center and quell transmission.”
The NIH went on to add that “the Clinical Center is taking strong action to keep KPC from spreading further, redoubling its efforts to ensure that all the infection control and isolation strategies recommended by the Centers for Disease Control and Prevention (CDC) are followed stringently.” They agency is also continuing to test for KPC and amp up their de-contamination procedures.
This latest death raises serious questions about the rise of bugs no longer treatable with antibiotics. The emergence of antibiotic-resistant strains of bacteria has become a recent dilemma in the past few years. A notable example has been the rise of the “staph” germ known as MRSA - methicillin-resistant Staphylococcus aureus – which caused unease after the CDC reported 18,650 American deaths from MRSA in 2005.
According to infectious disease experts, both MRSA and KPC are results of the same problem – the overuse of antibiotics. Utilized in livestock feed, by medical professionals and by consumers just to treat the common cold, the abundance of antibiotics in our society has prompted evolution to select for the antibiotic-resistant trait.
“Bacteria are becoming more and more resistant as more and more antibiotics are being used – and they’re becoming smarter,” Dr. Joseph Rahimian, an infectious disease specialist at Village Park Medical in New York City, told FoxNews.com. “….There are limited choices for treatment. Only a few antibiotics work in that scenario, and they’re typically antibiotics we don’t frequently use – some affect the kidney, some aren’t readily available, and some don’t lead to [good] blood levels.”
What is KPC?
K. pneumonia is an organism that lives in the large bowel, which can cause the disease Klebsiella pneumonia – a condition marked by high fever, chills and the expulsion of a thick, viscous fluid called sputum from the lungs. To combat K. pneumonia, a class of antibiotics called Carbapenems is used; however, when the organism becomes resistant to Carbpaenems, it becomes known as Klebsiella pneumoniae carbapenemase.
Rahimian noted KPC is one of the more dangerous strains of antibiotic-resistant bacteria. Unlike MRSA – which has some other treatment options apart from antibiotics – KPC has very few options, making it much more difficult to combat.
The people most susceptible to contracting KPC are those who are critically ill or who have a weakened immune system, which is why outbreaks easily occur in hospitals. Although most of the cases have occurred at the NIH Clinical Center, all hospitals in the Northeast and beyond should be on the lookout for outbreaks of this kind.
“Since the 1990s, some drug resistant isolates of KPC have emerged,” Dr. Amy Ray, an infectious disease expert with UH Case Medical Center in Cleveland, Ohio, told FoxNews.com. “And certainly the Northeast has been a focus of concern, but no hospital in the United States is immune to KPC. In fact, the organism and KPC producing organism have been described worldwide – in Europe, Asia and South America.”
KPC spreads through direct contact of the skin, which can eventually lead to infection. According to Rahimian, a person can also be a carrier of the bacteria and not show any symptoms.
What you can do
“Unfortunately there’s not a lot you can do as a patient,” Rahimian said. “If other people are using unnecessary antibiotics, they are promoting the development of resistance, [which] might affect you even though you didn’t do anything.”
Because of its difficulty to identify and treat, both Rahimian and Ray say that prevention is key to combating KPC and other antibiotic-resistant bugs.
“The single biggest effort the hospitals can undertake is to ensure that their infection control and prevention departments are up to date,” Ray said. “Also that they are tracking and trending organisms such as these to understand their local epidemiology. And at the single health care worker level, the most important thing is hand hygiene and the use of standard precautions to prevent the transmission from person to person.”
For the average individual, taking proper precautions – such as thoroughly washing their hands and making sure their doctors are doing the same – is crucial.
Going beyond these anti-infection measures, many health care professionals and others are calling for more judicious use of antibiotics, in hopes to stop the emergence of antibiotic resistance. Numerous ‘antibiotic stewardship’ campaigns are in effect to stop people from taking or prescribing antibiotics when they are not truly necessary.
As far as research goes to develop smarter drugs to combat KPC, experts agree that funding and focus are lacking – meaning proper treatments may not be available for some time.
“We are facing a critical shortage of anti-microbial agents,” Ray said. “The field is desperate for drug discovery.”
Ecole Polytechnique Fédérale de Lausanne, Global Health Institute, Lausanne, Switzerland.
Tuberculosis, a global threat to public health, is becoming untreatable due to widespread drug resistance to frontline drugs such as the InhA-inhibitor isoniazid. Historically, by inhibiting highly vulnerable targets, natural products have been an important source of antibiotics including potent anti-tuberculosis agents. Here, we describe pyridomycin, a compound produced by Dactylosporangium fulvum with specific cidal activity against mycobacteria. By selecting pyridomycin-resistant mutants of Mycobacterium tuberculosis, whole-genome sequencing and genetic validation, we identified the NADH-dependent enoyl- (Acyl-Carrier-Protein) reductase InhA as the principal target and demonstrate that pyridomycin inhibits mycolic acid synthesis in M. tuberculosis. Furthermore, biochemical and structural studies show that pyridomycin inhibits InhA directly as a competitive inhibitor of the NADH-binding site, thereby identifying a new, druggable pocket in InhA. Importantly, the most frequently encountered isoniazid-resistant clinical isolates remain fully susceptible to pyridomycin, thus opening new avenues for drug development.
Eye Institute, The University of Hong Kong, Room 301, Level 3, Block B, 100 Cyberport Road, Cyberport 4, Hong Kong.
To review the newer treatments for bacterial keratitis.
PubMed literature search up to April 2012. Study Selection. Key words used for literature search: "infectious keratitis", "microbial keratitis", "infective keratitis", "new treatments for infectious keratitis", "fourth generation fluoroquinolones", "moxifloxacin", "gatifloxacin", "collagen cross-linking", and "photodynamic therapy".
Over 2400 articles were retrieved. Large scale studies or publications at more recent dates were selected.
Broad spectrum antibiotics have been the main stay of treatment for bacterial keratitis but with the emergence of bacterial resistance; there is a need for newer antimicrobial agents and treatment methods. Fourth-generation fluoroquinolones and corneal collagen cross-linking are amongst the new treatments. In vitro studies and prospective clinical trials have shown that fourth-generation fluoroquinolones are better than the older generation fluoroquinolones and are as potent as combined fortified antibiotics against common pathogens that cause bacterial keratitis. Collagen cross-linking was shown to improve healing of infectious corneal ulcer in treatment-resistant cases or as an adjunct to antibiotics treatment.
Fourth-generation fluoroquinolones are good alternatives to standard treatment of bacterial keratitis using combined fortified topical antibiotics. Collagen cross-linking may be considered in treatment-resistant infectious keratitis or as an adjunct to antibiotics therapy.
Angelo Zullo, Cesare Hassan, Roberto Lorenzetti, Salvatore MA Campo, Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, 00153 Rome, Italy.
Hepatic encephalopathy (HE) is the second most common major complication in cirrhotics and it significantly impacts quality of life. Therapeutic approaches for HE treatment and prevention mainly continue to rely on ammonia-lowering strategies and non-absorbable disaccharides are currently considered the cornerstone therapy. Non-absorbable antibiotics, such as neomycin and paramomycin, are effective in treatment of acute HE episodes but their prolonged use for recurrence prevention is hampered by possible side-effects. To overcome these limitations, rifaximin use has been proposed. Rifaximin has been shown to be not superior to non-absorbable disaccharides for either HE treatment or prevention, with a similar incidence of side-effects. Cirrhosis significantly increases rifaximin absorption and this could be a cause for concern. Following long-term rifaximin therapy, Clostridium difficile colitis has been observed and Candida albicans has been isolated from 20% of patients. In addition, selection of resistant mutants of both Gram-negative and -positive bacteria in the gastrointestinal tract cannot be definitely ruled out. Electrolyte alterations (sodium and potassium) have been reported during rifaximin therapy, a warning for its long-term use in cirrhotics. Moreover, a potential interference with vitamin K production should be considered which could further impair the already altered clotting status of these patients. The therapeutic cost of rifaximin is markedly higher than non-absorbable disaccharides. While waiting for further safety data, caution should be used to limit the use of rifaximin therapy for a very short-term period in selected HE cirrhotics not responding to non-absorbable disaccharides.
School of Life Sciences, Jawaharlal Nehru University , New Delhi, 110067 , India +91 11 26704511 ; +911126742558 ; firstname.lastname@example.org.
Several microbes have evolved clinically significant resistance against almost every available antibiotic. Yet the development of new classes of antibiotics has lagged far behind our growing need. Frequent and suboptimal use of antibiotics particularly in developing countries aggravated the problem by increasing the rate of resistance. Therefore, developing new and multidimensional strategies to combat microbial infections is warranted. These include i) modification of existing antibiotics, ii) searching new and novel antibiotics, iii) development and improvement of antibiotics carrier system to reduce amount and frequency of antibiotic doses, iv) development of targeted antibiotic delivery systems. Here, the authors discuss trends and development of nano-materials and alternative antimicrobials to solve the problem of antibiotic resistance.
Resistance to antibiotics has increased recently to a dramatic extend, and the pipeline of new antibiotics is almost dry for the 5 next years. Failures happen already for trivial community acquired infections, like pyelonephritis, or peritonitis, and this is likely to increase. Difficult surgical procedures, transplants, and other immunosuppressive therapies will become far more risky. Resistance is mainly due to an excessive usage of antibiotics, in all sectors, including the animal one. Action is urgently needed. Therefore, an alliance against MDRO has been recently created, which includes health care professionals, consumers, health managers, and politicians. The document highlights the different proposed measures, and represents a strong consensus between the different professionals, including general practitioners, and veterinarians.
Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS