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PubMed1992

A review of traditional resistance surveillance methodologies and infection control.

The hospital affords an excellent environment for the proliferation of pathogenic bacteria and for the selection of antimicrobial-resistant strains. This article traces the evolution of microbiologic surveillance techniques and highlights some of the more effective means of infection control. Traditional surveillance methods relied on nationwide antimicrobial susceptibility data for practical information regarding the nature of infectious disease trends in order to guide the selection of appropriate empiric antibiotic therapy. The application of nationwide antibiograms to the local hospital setting may mask the local emergence of rapidly developing resistances, such as chromosomally mediated type-I beta-lactamase resistance, which has been associated with increased use of certain cephalosporins. "Focused surveillance" techniques yield improved detection of emerging localized resistances within specific hospital units. In addition to unit-specific surveillance, many hospitals are now observing the advantages of an infection site-specific monitoring program. Judicious use of newer antimicrobials and implementation of detailed hospitalwide surveillance procedures will help to minimize the spread of epidemic and resistant infections. It remains the responsibility of the infection control and antibiotic utilization or advisory committees to make appropriate recommendations concerning the selection, restriction, and proper use of the newer extended-spectrum antibiotics. The clinical microbiology laboratory as a source of information remains a key participant in a quality program.

Bacteriological Techniques↗

PubMed1992

Therapeutic and epidemiologic recommendations to reduce the spread of type-I beta-lactamase resistance.

The objectives of this United States Consensus Panel meeting were to evaluate the effectiveness of current surveillance systems for the detection of bacterial resistance as well as to formulate recommendations that can assist hospitals in determining actions that should be taken when a resistance problem is detected. These recommendations may be particularly helpful in controlling the emergence and spread of type-I beta-lactamase resistance. Numerous case reports of antimicrobial resistance among Enterobacter species, Pseudomonas aeruginosa, and other Gram-negative nosocomial pathogens known to produce type-I beta-lactamases have appeared in the literature since the introduction of the newer "third-generation" cephalosporins. The widespread use of these newer antimicrobial agents, often selected as standard therapy for serious hospital-acquired infections, has been associated with a corresponding increase in resistance to them. The failure of hospitalwide surveillance methods to describe the scope of this problem, especially among the most critically ill patients, may have resulted in a false sense of security among some infectious disease specialists and clinicians prescribing these antimicrobials as empiric therapy. High-level resistance in individual hospital units may be masked in hospitalwide antibiograms. A variety of conclusions and recommendations were formulated based on the collective experiences of the Consensus Panel members. Microbiology laboratories must make it a high priority to identify markers that will assist in rapidly identifying resistant organisms. Cooperative efforts are needed among users of commercial and automated microbiology test instruments to standardize results and to improve quality control, thereby making the data more directly comparable between laboratories.(ABSTRACT TRUNCATED AT 250 WORDS)

Anti-Bacterial Agents↗

PubMed1991

[Community-acquired urinary infection: the in vitro activity of trimethoprim and cotrimoxazole].

To evaluate the in vitro sensitivities of trimetoprim (TMP) in our area and to compare them with those to co-trimoxazole (CMX) a prospective study was carried out in females with uncomplicated lower urinary tract infection (UCLUTI), as a preliminary step for the possible use of a monodose of TMP in these patients. Fifty-five cases of UCLUTI were included. Escherichia coli was the predominating organism (70.9%). The general sensitivity to CMX was 80% and that to TMP 76.4%. The E. coli sensitivity to CMX was 79.5%, and 76.9% to TMP. The difference in the sensitivities to both antimicrobials was not statistically significant (p = 0.5). The routine introduction of TMP in the antibiogram would permit to evaluate the resistance to this antimicrobial in each area and, on the basis of the results, to assess the effectiveness of TMP in the treatment of UCLUTI.

Adolescent↗

PubMed1991

Bacteriology of diabetic foot ulcers.

Seventy five diabetic foot ulcers were cultured using optimal aerobic and anaerobic microbiologic techniques. There were a total of 223 isolates (162 aerobes and 61 anaerobes) representing an average of 2.97 bacterial species per specimen. Mixed organisms were the most common isolates. Staphylococcus aureus was the commonest isolate being recovered in 60% of cases. Anaerobic organisms were isolated in 46 patients (61.33%) and the most frequent anaerobe isolated was Bacteroides fragilis. The other organisms predominantly isolated were Proteus, Klebsiella, Pseudomonas, Peptoccus and Clostridia. Antibiogram showed discouraging pattern with commonly used antibiotics. Metronidazole and gentamicin were the most effective antimicrobial agents against anaerobic and aerobic organisms respectively. Appreciation of the causative organisms in diabetic foot and their antibiotic sensitivity is essential for institution of appropriate antibiotic therapy.

Adult↗

PubMed1991

[Rational diagnosis of urinary tract infections].

The basis for a rational diagnostic work-up of urinary tract infections is a detailed history and a maximally standardised examination of the urine, with test strips measuring, measurement of specific density, microscopic examination of the sediment, and determination of the bacterial count in the urine employing dipstick procedures are recommended for use in the doctor's office. Isolation and identification of pathogens and the preparation of an antibiogram require a special knowledge of microbiological techniques. A requirement for the evaluation of the urine and its constituents is a knowledge of how the urine was collected; we recommend spontaneously passed urine in men and young children, and catheter urine in the case of women. Chronic inflammation of the male adnexa and chronic recurrent urinary tract infections requires radiological studies by the urologist, including a urogram, a urethrocystogram, a miction cystogram, urethropyelography and ultrasonography. Occasionally, nuclear-medical investigations and angiography or computed tomography may be necessary to obtain further clarification. In the case of outflow obstructions in the region of the lower urinary tract or urge or stress incontinence, uroflowmetry and cystometry should be performed. With the aid of this "stepwise diagnostic evaluation", both optimal clarification of the urinary tract infection and a saving of costs are possible.

Bacteriuria↗

PubMedDate not supplied

[Staphylococcal colonization rate on neonatal nares and umbilical cord in a newborn nursery].

Staphylococcus aureus and Staphylococcus epidermidis were the most important gram positive pathogens found in a five-year study (1985-1989) of nosocomial infection in this hospital. They caused 56.2% of all nosocomial infections in this newborn nursery, particularly skin infections. To determine the reasons, and to decrease effectively the neonatal staphylococcal colonization rate, three different disinfection methods were selected for management of neonatal umbilical cords. A total of 1578 swabs from neonatal nares and umbilical cords were collected. During the first period no disinfectant was applied to the cord after bathing the baby. Beta-iodine in alcohol and bacitracin ointment were used for the second and the third periods, respectively. The result showed a significant difference (P less than 0.05) in staphylococcal colonization rate on neonatal umbilical cord using different disinfectants even after the first day. The same result for neonatal nares was also found, after infants had been in the nursery for two days. During the third period, no case of skin infection was found. Most Staphylococcus aureus isolated were resistant to ampicillin, erythromycin, tetracycline and penicillin. The percentage of this antibiogram found in neonatal nares and umbilical cords was 44% and 56% respectively. Besides nosocomial infection control and surveillance of medical personnel, environment, materials, instruments and isolation techniques, it is really necessary to choose an effective disinfectant (bacitracin ointment is recommended) to reduce the staphylococcal colonization in newborn nurseries.

Colony Count, Microbial↗

PubMed1991

[Decreasing oxytetracycline resistance in Enterobacteriaceae in veterinary and health conditions after exchange of this substance in animal nutrition].

The national strategy for the use of chemotherapeutics under which there is a distinction between therapeutics and growth promoters for all uses (human medicine, veterinary medicine, animal nutrition) has resulted in a distinct reduction of the selection pressure and a decrease of the OTC resistance among Enterobacteriaceae in the eastern German Länder (formerly GDR) due to a reduction of OTC feeding after 1981 and the final prohibition in 1983. In the following years Enterobacteriaceae were investigated as infectious pathogens for humans and animals using antibiograms. On the one hand, the OTC resistance of porcine and bovine E. coli strains decreased only by 27% and 17%, respectively, during the 1980 to 1988 period, on the other, the OTC resistance of bovine S. typhimurium dropped by 65%, porcine S. typhimurium by 50%, bovine S. dublin by 50%, porcine S. choleraesuis by 30% to a resistance level of about 13% (1989) demonstrating a reduced pressure of resistance. At the same time, OTC resistance became diminished from 50% and 70%, respectively, to 30% also in Enterobacteriaceae (E. coli, Klebsiella) and enterococci isolated from urine and wound infections of patients in the non-agricultural population although therapeutic habits had remained unchanged. The results shown point to a spreading of resistance plasmids which has to be expected far beyond the field of OTC use, for example after the use of antibacterial growth promoters in livestock farming. Control measures should be introduced.

Animal Feed↗

PubMedDate not supplied

[Empyema due to an anaerobic Streptococcus in childhood].

Anaerobic infections are quite rare in pediatric age, being that, they affect only neonates and immunodepressed patients. We think to be somewhat interesting to describe the case of our patient, a 9 year old boy, unaffected by any predisposing factor, came under our observation because of a severe respiratory distress. He showed evident clinical and radiological signs of pleural effusion in the right lung, together with a gas coil in the upper field and a left mediastinal shifting. A thoracentesis was then performed, giving rise to 600 ml of foul smelling purulent material; this procedure promptly improved his respiratory function. A permanent drainage trough the chest wall was set and an antibiotic therapy, based on the clinical picture and the character of the exudate, begun. In effect, the typical smell of the purulent material led us to suspect an anaerobic infection, and for this reason we employed the teicoplanin iv, a rarely used in the pediatric age drug. While blood cultures were negative for any organism, exudate cultures yielded Peptostreptococcus anaerobius; the last one resulted highly sensible following antibiogram to the previously chosen drug. The x-ray pattern and the rapid disappearing of the gas coil induced us to exclude further either congenital or acquired lung diseases. We conclude that, in absence of other proved sources of entry, the air presence in the pleural space was secondary to gas formation by the anaerobic micro-organism. The clinical course was very satisfactory allowing the patient to be dismissed on the 28th hospital day, with no need of further surgical therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Child↗

PubMed1991

[Frequency and antibiotic susceptibility of bacteria responsible for urinary infections in private practice from 1986 to 1990. Results of 5398 samples].

For each year from 1986 to 1990, fourteen private laboratories from all over France collected epidemiological data on germs discovered in urinary infections in France. This retrospective and comparative study covers 5,398 dossiers. The sensitivity of germs in private practice in urinary infections (ampicillin, AM-AC, cephalosporin, ceftriaxone, gentamicin, pipemidic acid, pefloxacin, cotrimoxazol) were analysed. Germ resistance tests carried out by the CMI study in the centre of reference (Pr Thabaut, HIA Bégin) showed variable divergences according to the different antibiogram techniques employed by the private laboratories.

Adolescent↗

PubMed1991

Pseudomonas aeruginosa resistant to aminoglycosides: an assessment of the currently used methods of disk diffusion and dilution susceptibility.

In recent years, a number of clinical microbiology laboratories have isolated Pseudomonas aeruginosa with the unusual aminoglycoside disk diffusion result of resistance to both amikacin and gentamicin but susceptibility to tobramycin (ArGrTs). A total of 27 isolates of P. aeruginosa reported to have this resistance pattern was retested by the standard National Committee for Clinical Laboratory Standards disk diffusion procedure; twenty strains (74%) were confirmed to be ArGrTs. These twenty isolates were further examined for susceptibility to those aminoglycosides by agar dilution and both micro- and macrodilution methods. Only 25, 25 and 24% of the isolates appeared to be ArGrTs by agar, broth microdilution, and broth macrodilution testing respectively. Most of the remaining isolates were resistant to all three aminoglycosides when tested by broth dilution and resistant only to gentamicin when tested by agar dilution. The percentages of strains resistant to any particular aminoglycoside by agar dilution, broth microdilution and broth macrodilution, respectively were 44, 79 and 69 for amikacin, 95, 91 and 100 for gentamicin, 100, 100 and 100 for netilmicin, 28, 85 and 91 for sisomicin, and 11, 54 and 46 for tobramycin. These results indicate that strains showing the unusual aminoglycoside antibiogram are less susceptible to aminoglycosides in general and should probably be considered borderline resistant to all aminoglycosides. The efficacy of aminoglycosides in the treatment of infections produced by these strains is unknown.

Amikacin↗

PubMed1991

[Prosthetic valve endocarditis caused by Gemella haemolysans].

Reported herein is the case of a 47 year old man with mitral and aortic bioprosthetic valves who developed endocarditis. Blood cultures turned out to be positive for Gemella haemolysans, a commensal of the upper respiratory tract. Proper antibiotic therapy was immediately started according to antibiogram, and continued after the acute stage of the disease had been overcome. The aortic prosthesis appeared much more to be incompetent at Doppler and aortography (from 2/4 to 3/4). At surgery, the gross appearance of the explanted xenograft was consistent with infective endocarditis. The case is described for the rarity of the etiology: only 6 cases of infective endocarditis from Gemella haemolysans are reported in the literature, but this is the first involving a prosthetic valve.

Anti-Bacterial Agents↗

PubMedDate not supplied

[Changes in time of the microbial flora in bronchopulmonary infections].

The authors carried out a study on 100 cases with broncho-pulmonary infections in two different periods: 1963--1964 and 1973--1974. Changes in the microbial flora were investigated, as well as the sensitivity of germs to antibiotics. An increase was noted in the number of chronic bronchitis and a decrease in the number of pneumonia cases. In the microbial flora there was a constant proportion of staphylococcus, streptococcus and coli strains. The proportion of micrococci decreased with time and pneumococci practically disappeared, being replaced by klebsiella germs. Sensitivity to penicilin remained almost identical while that to chloramphenicol decreased significantly, as well as sensitivity to tetracycline and neomycine. The practical conclusion is that in some cases the application of penicilin treatment, before the results of the antibiogram are available appears to be justified.

Anti-Bacterial Agents↗

PubMed1991

[Microbiological care of ventilated intensive care patients. Feasibility of diagnosis and therapy of pulmonary infection].

Pulmonary infections are the most life-threatening infections in mechanically ventilated patients. Methods to avoid these infections by prophylactic systemic or local administration of antibiotics may promote resistance and selection of distinct groups of pathogens. In mechanically ventilated patients we studied the impact of early diagnosis and specific therapy on the prevention of pulmonary infections. Due to the very short interval between colonization and infection, daily microscopic and microbiologic examinations of tracheobronchial secretions proved to be essential for early and successful therapy and even prevention of pulmonary infections. PATIENTS AND METHODS. The present study comprised a total of 190 patients admitted to the surgical intensive care unit who required mechanical ventilation for a period of at least 48 h: 56 were admitted for multiple trauma; 38 had peritonitis; and the remainder had postoperative complications such as renal failure, cardiac problems, septicemia or pneumonia. Multitraumatized patients (16.5 days) and those with peritonitis (13.8 days) needed the most extensive ventilatory support. After admission antibiotic therapy was started with a second-generation cephalosporin or amoxicillin/clavulanic acid. Further antibiotic treatment was directed strictly against the isolated pathogens. Tracheobronchial secretions were monitored daily by microscopy and cultures. Microscopic evaluation was essential to discriminate between colonization and inflammation, and often indicated the infective agent. If infections were suspected provisional antibiograms were performed on the material. This procedure allowed a specific antibiotic treatment to be initiated 8-12 h later. In patients with pulmonary infections, additional bronchoscopic material was taken in order to correlate these findings with those gained from the tracheobronchial secretions. RESULTS. In 85% of cases massive colonization of the trachea with Pseudomonas aeruginosa, enterobacteria, Staphylococcus aureus or Streptococcus pneumoniae resulted in pulmonary infections 24-48 h later. The reduced virulence of Pseudomonas species (non-aeruginosa) and Acinetobacter species is reflected by an infection rate of 50% and an extended period of time to establish an infection (2-4 days). Only 30% of patients highly contaminated with Candida developed pulmonary infections after 3-6 days. A fair correlation (86%) was found between pathogens isolated in tracheobronchial secretions and bronchoscopic material. In the population studied, 68 patients (35.7%) developed pulmonary infections, 32 of them pneumonia (16.8%), and the others purulent tracheobronchitis with fever. Both groups were treated with antibiotics. Patients with multiple trauma, often accompanied by lung contusion, were most frequently affected. In 59 patients (87%) pulmonary infections were treated successfully by specific antibiotic therapy; 9 patients died so rapidly, that the pulmonary complication could not account for the fatal outcome. In 38 patients with massive contamination of the tracheobronchial system by enterobacteria, Pseudomonas aeruginosa or Staph. aureus, progression from colonization to infection was prevented by early administration of specific therapy. CONCLUSIONS. Because pulmonary infections in most cases arise very soon after pathogens have gained access to the tracheobronchial system daily monitoring of tracheobronchial secretions is required for early initiation of specific therapy.

Adolescent↗

PubMed1990

Efficacy of vancomycin plus tobramycin as antiperitonitis regimen for patients on CAPD.

From October 1985 to August 1989, 55 episodes of peritonitis were treated with intraperitoneal (i.p.) use of Vancomycin (V) and Tobramycin (T), in 35 patients (18 males, 17 females). After three rapid IL peritoneal exchanges, the pts received i.p. loading dose of V500 mg/L and an intramuscular dose of T 1.7 mg/Kg, followed by four IL exchanges, with addition of V15 mg/L and T8 mg/L. The length of treatment was 10 days for all pts. The continued administration of V or T as the simple antibiotic regimen was based on the antibiogram, while the combination of both antibiotics was used in negative cultures. Recurrence of peritonitis was seen in 3 episodes (5.4%). No side effects were seen during the therapy. These results indicate that the i.p. use of Vancomycin plus Tobramycin are an appropriate antiperitonitis regimen in the treatment of CAPD peritonitis.

Drug Therapy, Combination↗

PubMedDate not supplied

[Clinical, radiological and bacteriological study of pulmonary tuberculosis with bacteria showing drug resistance].

The authors have investigated two groups of patients of young age suffering from tuberculosis with germs showing primary resistance to chemotherapeutic agents (61 cases), and with germs displaying sensitivity to these agents (64 cases). The following conclusions have been reached: tuberculosis with germs showing primary drug resistance did not display onset modalities, clinically and radiologically, that differed significantly from other types of tuberculosis; sputum conversion is more slow in patients with resistant germs than in those with sensitive germs in the first two months of treatment, but following application of the treatment according to the data resulting from the antibiogram, this differences quickly disappeared. The presence of a smaller number of complete recoveries and of a surplus of doubtful recoveries can be explained in the same way in this group of patients: the final results are similar in both groups of patients, evidencing that the treatment of pulmonary tuberculosis due to germs showing parimary drug resistance does not give rise to particular problems.

Adolescent↗

PubMed1991

[An analysis of hospital bacterial infections in cirrhotic patients undergoing selective intestinal decontamination].

Cirrhotic patients with ascites and low levels of ascitic fluid C3 and total protein and cirrhotic patients with gastrointestinal hemorrhage are at high risk of infection. Selective intestinal decontamination with oral norfloxacin is useful to decrease the incidence of infections in cirrhotic patients at high risk. This study analyzes hospital acquired bacterial infections in cirrhotic patients with ascites and low levels of total protein in ascitic fluid (n = 53) and cirrhotic patients with gastrointestinal hemorrhage (n = 26), both submitted to selective intestinal decontamination with norfloxacin during the hospitalization. Seven patients developed eight infections (8.8%): three patients with ascites and low levels of total protein in ascitic fluid and four patients with gastrointestinal hemorrhage (5.6% vs 15.3%, pNS). Gram negative bacilli were not isolated in any case, but Gram positive cocci were isolated in seven cases. These results suggest that Gram positive cocci must be empirically covered when infection is suspected in cirrhotic patients submitted to selective intestinal decontamination. The analysis of antibiograms in these infections showed a high sensitivity of Gram positive cocci to amoxycillin and clavulanic acid, which could be used as empirical treatment when infection is suspected in these patients.

Ascites↗

PubMed1990

[Differences in sensitivity to Augmentin (and other antibiotics) of Staphylococcus aureus strains isolated from various specimens and patients from different clinics].

Susceptibility of 327 S. aureus strains isolated in 1988 from various materials obtained from patients hospitalized in various hospitals of Wrocław city has been studied. Antibiograms were made by the use of diffusion-disc method for 21 antibiotics, including augmentin. Penicillin and oxytetracycline showed weak action on the strains studies; percentage of sensitive strains was 8.6% and 27.6%, respectively. Efficacious effects, more than 90% of strains, showed vancomycin, rifampicin, netilmicin, cefamandole++, amikacin and cefalotin. Susceptibility for augmentin was equal to 89.3%, and for other 12 antibiotics 50 to 89%. Multiresistant strains presented 19.6% of all specimen studied: large percentage of that strains was isolated from Department of Anesthesiology and Intensive Therapy (56.8%) and pediatry departments (26.4%). Most frequently they occur in the urine (33.3%). They showed high susceptibility to vancomycin (100%), rifampicin (98.4%), netilmicin (93.8%) and cefamandole++ (85.9%). Susceptibility to augmentin was 54.7%.

Amoxicillin↗

PubMed1990

[Meningitis caused by Haemophilus influenzae: study of 28 cases].

28 cases of Haemophilus influenzae meningitis were retrospectively treated in a children's hospital between October 1980 and March 1987. The average age was between 23 +/- 36 months, ranged between 3 months and 13 years. Eight were females and 20 males (1/2.5). Antibiograms were obtained from 14 samples (50%), 36% was resistant to ampicillin, 7% to chloramphenicol and 7% to both. All patients, with two exceptions, were treated with third generation cephalosporins. During the hospitalization period, the following complications were found: convulsions (18%), tone and/or mobility alterations (18%), hydrocephalus or transventricular echographic dilations (14%), early deafness (3%). 54% did not develop any complications and only one patient died. Considering the high proportion of cases resistant to ampicillin, chloramphenicol or both, it is suggested to evaluate cephalosporins as an alternative for the standard therapy.

Adolescent↗