[Efficacy and safety of cefoperazone/sulbactam in the treatment of children with mucoviscidosis during exacerbation of the bronchopulmonary process]

The use of cefoperazone/sulbactam in combination with amikacin in the treatment of 20 patients with mucoviscidosis and exacerbation of bronchopulmonary pathological process resulted in marked positive dynamics of the clinical and functional indices of the lungs state. The bacteriological effect with respect to the main pathogens in the cases of mucoviscidosis was strain-dependent: eradication of 10 (83.4%) out of 12 Staphylococcus aureus strains and only 3 (15.8%) out of 19 Pseudomonas aeruginosa strains. The most frequent adverse reaction was diarrhea (5 children) successfully corrigated by loperamide. Discontinuation of the drug use was required in 3 patients because of macrohematuria (1 child) and allergic eruption.

Chronic plasma cell pneumonia in a patient with long-standing HIV infection

Chronic bibasilar alveolar infiltrates existed for more than 2 years in a 25-year-old woman infected with HIV for more than a decade. Bronchoscopically, there were copious, purulent secretions that grew methicillin-resistant Staphylococcus aureus (MRSA). Transbronchial biopsy specimens demonstrated plasma cell interstitial pneumonia (PCIP). Focal, transient radiographic improvement occurred after antistaphylococcal antimicrobial therapy. With recurrent and progressive symptoms, sustained clinical and radiographic improvement did not occur until corticosteroid therapy was instituted with tuberculosis chemoprophylaxis. Persistent antigenic stimulation in immunosuppressed patients causes PCIP. In this instance, the stimulus is MRSA. The previous model and support for this theory is Pneumocystis carinii. There is good experimental reason for a plasma cell response in persons infected with HIV. To our knowledge, this is the first case of chronic plasma cell interstitial pneumonia caused by indolent MRSA infection.

[The treatment of acute hematogenous osteomyelitis in children and young adults]

On the basis of own experiences and literature from last three years authors presented the role of surgical treatment in children above two years and young people, suffering from acute haematogenous osteomyelitis. Conservative treatment should be limited to these cases, where we can see a quick recovery, reducing of the pain and decreasing of the level of CRP and ESR. The presence of subperiosteal abscessus, positive bacteriological culture from blood and other complications (i.e. staphylococcal pneumonia), are the absolute indications to decompression of the medullary cavity, and local application of antibiotics.

[Linezolid--a new antibiotic for treatment of methicillin resistant Staphylococcus aureus infections in trauma surgery? Report of 2 cases]

PROBLEM

Infections with Methicillin-resistant Staphylococcus aureus are reported increasingly in intensive care unit and ward, that means not only a dangerous disease but also a considerable expenditure factor.

METHODS

In trauma surgery we could observe the Linezolid treatment of 2 patients with a MRSA infection. After treatment with Vancomycin and further evidence of MRSA the application of Linezolid was continued during 3 weeks accompanied by further microbiologic investigations.

RESULTS

In a 73 year old man with humerus shaft fracture the MRSA osteomyelitis was eradicated with Linezolid (600 mg/day per os over 3 weeks) after radical débridement and reosteosynthesis. The MRSA pneumonia in a 14 year old girl was treated successfully by Linezolid (600 mg/day i.v. over 3 weeks) and pneumotherapy. Follow up excluded further MRSA infection.

CONCLUSIONS

Linezolid represents an efficient new reserve antibiotic. In case of pneumonia, severe skin and soft tissue infections good results can be expected. The treatment of osteomyelitis has been reported only in single cases.

Impact of Gram-positive resistance on outcome of nosocomial pneumonia

Among Gram-positive pathogens, Staphylococcus aureus is the leading cause of death from nosocomial pneumonia. The bacterium developed progressive resistance to beta-lactams, and methicillin-resistant strains emerged in the 1980s. In consequence, vancomycin has become the drug of choice for treatment of this infection over the last decade, based on susceptibility tests and the serum antimicrobial levels recorded. However, half of the patients treated with vancomycin have died. In contrast, in patients receiving beta-lactams for pneumonia caused by methicillin-sensitive S. aureus, survival is the rule. These observations, together with the emergence of isolates with reduced susceptibility to glycopeptides, raised concern about the use of vancomycin as standard therapy for pneumonia caused by Gram-positive cocci. Maintaining tissue levels above minimal inhibitory concentration is vital to successful clinical outcome. Optimizing treatment focusing on this goal and new antimicrobials provide new opportunities to improve survival. (Crit Care Med 2001; 29[Suppl.]:N82-N86)

Area under the inhibitory curve and a pneumonia scoring system for predicting outcomes of vancomycin therapy for respiratory infections by Staphylococcus aureus

Treatment factors predictive of clinical and microbiological outcomes and the relationship between a pneumonia scoring system and clinical outcomes in vancomycin-treated patients with a Staphylococcus aureus-associated lower-respiratory-tract infection (LRTI) were studied. A computer database review identified patients for whom S. aureus was isolated from a respiratory-tract specimen between January 1 and December 31, 1998, and who had antimicrobials ordered within 72 hours of isolation of that organism. Through further review of individual patient charts, this group was restricted to those treated with vancomycin for a documented S. aureus-associated LRTI. Classification-and-regression-tree (CART) modeling was performed to determine which clinical variables were correlated with clinical outcomes and microbiological outcomes. Median changes in clinical pneumonia scores from baseline in two patient groups (those with clinical success and those with clinical failure) were compared. Seventy patients met the study criteria. CART modeling found that both outcomes were associated with area under the inhibitory curve (AUIC). The pneumonia scoring system was predictive of eventual clinical success as early as day 3 of treatment; having at least a 4-point decrease in the pneumonia score by day 3 was correlated with an 87% clinical success rate. Both AUIC and a pneumonia scoring system were useful for predicting clinical and microbiological outcomes of vancomycin therapy in patients with LRTIs caused by S. aureus.

Characterization of isolates associated with emerging resistance to quinupristin/dalfopristin (Synercid) during a worldwide clinical program

Quinupristin/dalfopristin (Synercid) is an i.v. antibiotic active against serious Gram-positive infections. Its unique dual mode of action means that the potential for resistance development is expected to be low. To determine the incidence of in vitro emerging resistance in worldwide clinical studies, susceptibility to quinupristin/dalfopristin was measured for baseline pathogens and corresponding on- or post-study isolates from 880 evaluable patients. In comparative studies of community-acquired pneumonia, complicated skin and skin structure infections, and nosocomial pneumonia, the incidence of emerging resistance was low (1 of 453; 0.22%; 95% CI: 0. 01-1.4%). Resistance development occurred in only one pathogen (methicillin-resistant Staphylococcus aureus). In noncomparative studies, six instances (1.8% of 338 evaluable cases; 95% CI: 0.7 to 4.0%) of emerging resistance (all vancomycin-resistant Enterococcus faecium) were confirmed, accompanied by therapeutic failure in four cases. Molecular typing did not confirm the identity of one pair of strains. Overall, the incidence of emerging resistance to quinupristin/dalfopristin was low.

Clarithromycin in the management of community-acquired pneumonia

OBJECTIVE

To review the epidemiology and diagnosis of community-acquired pneumonia (CAP) and examine factors that influence the choice of empiric antimicrobial therapy.

BACKGROUND

CAP remains a common disease with substantial associated morbidity and mortality. Outpatient management of patients with CAP has become increasingly complex because of the availability of newer antimicrobial agents, evolving patterns of resistance, and the increasing recognition of atypical pathogens. Although Streptococcus pneumoniae remains a commonly encountered pathogen, the development and increasing prevalence of antibiotic resistance has become an area of concern, especially in outpatients. The newer macrolide antimicrobial drugs-clarithromycin and azithromycin-are effective against commonly encountered pathogens, are well tolerated, and have an established tolerability profile, although the low serum levels achieved by azithromycin hinder its use in patients with suspected bacteremia.

METHODS

A MEDLINE search was performed of English-language articles published from 1990 to 2000 on the treatment of CAP. This article reviews the treatment of CAP, with emphasis on the use of clarithromycin.

CONCLUSION

Although laboratory surveillance studies have reported macrolide-resistant S. pneumoniae, recent evidence defining the mechanism of this resistance, coupled with the pharmacokinetic properties of the macrolide agents, suggests that the actual rate of clinical macrolide resistance is low.

Treatment of gram-positive nosocomial pneumonia. Prospective randomized comparison of quinupristin/dalfopristin versus vancomycin. Nosocomial Pneumonia Group

Nosocomial pneumonia is a frequent complication in hospitalized patients. Gram-positive pathogens, particularly Staphylococcus aureus, are responsible for the increasing frequency of nosocomial pneumonia. To evaluate the efficacy and safety of intravenous quinupristin/dalfopristin (Synercid) in the treatment of nosocomial pneumonia caused by gram-positive pathogens we conducted a prospective, randomized, open-label, international, multicenter, comparative clinical trial. Two hundred ninety-eight patients with nosocomial pneumonia were enrolled in 74 active centers in five countries: a subgroup of 171 (87 quinupristin/dalfopristin-treated and 84 vancomycin-treated patients) were evaluable for the major efficacy end points. One hundred fifty received 7.5 mg/kg of quinupristin/dalfopristin every 8 h; 148 patients received 1 g of vancomycin every 12 h. Aztreonam at a dose of 2 g every 8 h could be administered in both groups for coverage of gram-negative organisms, and tobramycin was added for coverage against Pseudomonas aeruginosa. The primary efficacy end point was the clinical response between the seventh and the thirteenth day after the end of treatment in clinically evaluable patients with documented causative pathogen(s) at baseline (bacteriologically evaluable population). Therapy was clinically successful (cure or improvement) in 49 (56.3%) of patients receiving quinupristin/dalfopristin and 49 (58.3%) patients receiving vancomycin (difference, -2.0% [95% CI, -16.8% to 12.8%]) in the bacteriologically evaluable population. Equivalent clinical success rates were also observed in the all-treated population (n = 298), and in the bacteriologically evaluable patients intubated in baseline (39/72 [54%] compared with 36/67 [54%]). The by-pathogen bacteriologic response was similar in both treatment groups, with equivalent clinical success rates for Streptococcus pneumoniae, Staphylococcus aureus, and methicillin-resistant Staphylococcus aureus. Adverse events (venous and nonvenous) were equally distributed between groups; 15.3% of quinupristin/dalfopristin patients and 9.5% of vancomycin patients discontinued therapy because of an adverse clinical event. In this study quinupristin/dalfopristin was shown to be equivalent to vancomycin in the treatment of nosocomial pneumonia caused by gram-positive pathogens. Quinupristin/dalfopristin merits further evaluation for the treatment of nosocomial pneumonia caused by methicillin-resistant S. aureus.

Bacteremic pneumonia due to Staphylococcus aureus: A comparison of disease caused by methicillin-resistant and methicillin-susceptible organisms

We performed a prospective study of all patients with bacteremic pneumonia due to Staphylococcus aureus over a period of 6 years during an outbreak of methicillin-resistant S. aureus (MRSA). Patients with bacteremic pneumonia due to MRSA (32 cases) or methicillin-susceptible S. aureus (MSSA; 54 cases) were compared. The patients with MRSA pneumonia were older and were more likely than those with MSSA pneumonia to have predisposing factors for acquisition of the infection. There were no differences in clinical findings, radiological pattern, or complications in clinical evolution among patients with MRSA and MSSA pneumonia. Mortality was significantly higher among MSSA-infected patients treated with vancomycin than among those treated with cloxacillin (47% vs. none; P<.01). Multivariate analysis (stepwise logistic regression method) showed a relationship between mortality and the following variables: septic shock (odds ratio [OR], 61), vancomycin treatment (OR, 14), and respiratory distress (OR, 8).

[Pleuropulmonary staphylococcal infection in infants, in a hospital environment in Ouagadougou (Burkina Faso)]

We observed 36 cases of pleuropulmonary staphylococcal infection (PPS) in infants aged 0 to 30 months, during a prospective study carried out between April 1st 1995 and March 31 1996 at the Pediatrics Department of Ouagadougou University Hospital. PPS accounted for 0.5% of all hospital admissions and 11.6% of all acute basal respiratory infections in children aged less than 30 months. Slightly more boys than girls were affected, with a sex ratio of 1.2. We identified the classic triad of symptoms: cough-fever-polypnea, associated with abdominal ballooning and a change in general condition. On X rays, the typical images showing parenchymatous bubbles were the second most frequent observation (27.8%) after parenchymatous opacities (69.5%). The most frequently used antibiotics were oxacillin (Bristopen), gentamycin (Gentallin) and cefuroxime-axetil (Zinnat). The prognosis of PPS is poor, with a high mortality rate (27.8%) and a risk of pleural recurrence. Being very young, late hospitalization, malnutrition and leukopenia were identified as factors indicating a poor prognosis. Recygling of health care personnel for the management of acute respiratory infections, a decrease in malnutrition and an improvement in vaccination cover are essential if the mortality and morbidity of acute respiratory infections, and PPS in particular, are to be reduced.

[Non-tuberculous bacterial pleuropneumopathies in children in Abidjan]

We carried out a retrospective study to investigate epidemiological and clinical aspects of patient management in a hospital environment. We studied 90 cases of non-tuberculous bacterial pleuropneumopathies in children, observed over a 5-year period, from January 1 1991 to December 31 1995, at the Pediatric Medical Unit of Yopougon University Hospital. Diagnosis was based on the association of an infectious syndrome with respiratory and digestive disorders, and was confirmed by X ray. Bacteria were isolated from pleural pus and identified in fifty-one cases. Non-tuberculous bacterial pleuropneumopathies accounted for 5.22% of all pneumopathies in children, and the sex ratio for the patients affected was 1.9. Protein and energy malnutrition, anemia, being very young and climatic factors (harmattan and rainy seasons) were identified as major risk factors. The three main bacteria identified were Staphylococcus aureus (21 cases), Streptococcus pneumoniae (19 cases) and Haemophilus influenzae (6 cases). In this series of patients, 20% of the Staphylococcus aureus strains isolated were methicillin-resistant. Patients were generally treated with a combination of penicillin A and M and aminoside, with or without a pleural drain. The outcome was favorable in 77.8% of cases, with no severe sequelae detected by X ray. Six of the children died. Bacterial pneumopathies are still common in Sub-Saharan Africa and the patient being very young is indicative of a poor prognosis.

[Community-acquired pneumonia caused by Staphylococcus aureus in non-HIV infected adult patients]

Staphylococcus aureus is the sixth frequent cause of community-acquired pneumonia. We report 19 cases of staphylococcal pneumonia in 3 women and 16 men, mean age 55 years. Predisposing factors were: age > 65 years, alcoholism, chronic bronchopulmonary disease, immunodepression, renal failure, diabetes. The portal was usually the respiratory tract. Symptom onset was progressive. Thirteen patients had signs of severe disease. Radiology showed localized excavated infiltrations in 8 cases, with a pleural reaction in 9. Bacteriological diagnosis was made on fibroscopic brushings on pleural fluid. Blood cultures were positive in 6 of 16 cases. Meti-S S. aureus was found in 17/19 cases. Outcome was favorable in 15 patients. These often severe infections require early antibiotic therapy using beta lactams active against S. aureus, combined when necessary with another antibiotic.

[Staphylococcal pneumonia--analysis of material from patients treated at the Hospital for Lung Diseases in the years 1981-1994]

Retrospective analysis of staphylococcal pneumonia was made in 182 patients, aged 18-88 years /61% more than 60 years old/ treated in hospital in years 1981-1994. Majority of these patients had various concomitant diseases, mostly chronic bronchitis and lung cancer. Strains of Staphylococcus aureus were sensitive mainly to amoxycillin--clavulanic acid, roxitromycin, amikacin, netilmicin, clindamycin, cefamandol, chloramphenicol, rifampicin and resistant mostly to penicillin /90% of strains/, ampicillin, tetracyclines. In many cases initial antibacterial treatment was inadequate in relation to sensitivity pattern of staphylococci--hence many changes of antibiotics were observed in the course of the therapy. Newer antistaphylococcal drugs were applied only in the last years of the study. Despite these therapeutical drawback outcome of staphylococcal pneumonia was good in 85% of patients; 14% of patients died /mainly as a consequence of comorbidities/. Successful therapy of staphylococcal pneumonia requires early recognition of possibility of infection due to Staphylococcus aureus and adjustment of drugs to probable or actual sensitivity of these pathogens.

Clinical and epidemiological findings in mechanically-ventilated patients with methicillin-resistant Staphylococcus aureus pneumonia

Over the 5-year period from 1990 to 1994, a prospective cohort study was conducted to define the clinical and epidemiological characteristics of ventilator-associated methicillin-resistant Staphylococcus aureus (MRSA) pneumonia acquired during a large-scale outbreak of MRSA infection. Of 2411 mechanically ventilated patients, 347 (14.4%) acquired MRSA, 220 (63.4%) had MRSA positive respiratory tract samples and 41 (18.6%) developed ventilator-associated MRSA pneumonia. The overall attack rate for ventilator-associated MRSA pneumonia was 1.56 episodes/1000 ventilator days, but annual attack rates varied according to the trend of the outbreak (range 4.9-0.2). In comparison with methicillin-sensitive Staphylococcus aureus (MSSA), which was implicated in 98 episodes of ventilator-associated pneumonia, MRSA caused exclusively late-onset ventilator-associated pneumonia, while MSSA caused both early-onset [55 of 98 (56.1%) episodes] and late-onset [43 of 98 (43.8%) episodes] ventilator-associated pneumonia. Logistic regression analysis of all patients with Staphylococcus aureus pneumonia revealed intubation for more than 3 days (odds ratio (OR),1.11; confidence interval (CI):1.03-1.18) and prior bronchoscopy (OR,5.8; CI,1.85-18.19) to be independent variables associated with MRSA pneumonia. The results indicate that MRSA ventilator-associated pneumonia is a frequent complication in intensive care patients, manifesting itself as late-onset pneumonia in patients who have been intubated for prolonged periods and/or have often undergoing previous bronchoscopy.

Resistance issues and treatment implications: pneumococcus, Staphylococcus aureus, and gram-negative rods

During the last decade there has been an unexpectedly rapid evolution of antimicrobial resistance in the respiratory pathogens for community- and hospital-acquired pneumonia. In order to choose the most optimal therapy for their patients, it is essential that physicians be aware of the prevalence and mechanisms of resistance and their implications on the effectiveness of the various antimicrobials.

[Pleuropulmonary staphylococcal infection in newborn infants]

Pulmonary pleural staphylococcal infection is common in sub-Saharan Africa. It is rare in temperate zones and occurs in different epidemiological conditions. In African regions, very few staphylococcal infections are hospital-acquired, with most cases resulting from infection in everyday life. Pulmonary pleural staphylococcal infection typically affects infants. The frequency of neonatal forms is unknown. We describe here in the epidemiological, clinical and therapeutic characteristics of a case of pulmonary pleural staphylococcal infection in a newborn. The symptoms of our patient were typical, involving predominantly mechanical and hematological problems. The prevention of infection in very young children and early treatment of such infections could reduce the morbidity of this disease.

Hospital-acquired pneumonia: methicillin resistance and intensive care unit admission

Although epidemiologic investigations of hospital-acquired pneumonia have certain intrinsic limitations because of the heterogeneity of the study populations, the difficulties in making a clinical diagnosis of nosocomial pneumonia, and the need for better microbiologic assays, recent studies have provided new and important data concerning the role of Staphylococcus aureus in this disease. This pathogen has now been identified as the most frequent cause of nosocomial pneumonia in hospitals in both Europe and the United States among patients in general hospital units as well as in the intensive care unit (ICU). Patients who have been treated with mechanical ventilation are at especially high risk for S. aureus pneumonia. The incidence of nosocomial pneumonia related to methicillin-resistant S. aureus (MRSA) has increased in recent years in many countries, especially among patients in the ICU. Because hospitalized patients with suspected nosocomial pneumonia often have many risk factors for MRSA infection, it seems advisable to include coverage of MRSA in the initial therapeutic regimen for these patients until MRSA infection is excluded.

[An antimicrobial experimental study on the traditional drug Anuqitabiao used by the Yi minority nationality]

The result of experimental study on the antimicrobial effect in vitro of the decoction, water-soluble ingredients and liposoluble ingredients of Anuqitabiao shows that decoction and water-soluble ingredients have certain inhibitory effect on all the tested bacteria, while the liposoluble ingredients do not, indicating the antimicrobial ingredients to be water-soluble. The result of antimicrobial experiment in vivo shows that neither different concentrations nor different separated parts of the decoction have any obvious protective effect on the pneumonococci-infected or staphylococciaureus-infected mice.

Transient 5-oxoprolinuria (pyroglutamic aciduria) with systemic acidosis in an adult receiving antibiotic therapy

5-Oxoprolinuria is a recognized condition with increased urinary excretion of 5-oxoproline and is associated with a variety of inborn metabolic defects involving the series of enzyme-linked reactions known as the gamma-glutamyl cycle. We report the unusual case of a 35-year-old woman who initially presented with staphylococcal pneumonia but went on to develop a transient high anion gap metabolic acidosis. The development and subsequent complete recovery from this acidosis were subsequently shown to be related in time to the intravenous administration of the antibiotics flucloxacillin and netilmicin. Analysis of the patient's urine for organic acids revealed massively increased excretions of 5-oxoproline at the peak of her acidosis. We suggest that this patient developed a transient disturbance in the gamma-glutamyl cycle involving the 5-oxoprolinase step, which resulted in accumulation of 5-oxoproline that caused a severe high anion gap metabolic acidosis. The administered antibiotics remain as possible causative agents.

Practical considerations and guidelines for the management of community-acquired pneumonia

Community-acquired pneumonia (CAP) is a common condition which has a significant mortality. The management of a patient with CAP is centred around assessment and correction of gas exchange and fluid balance together with administration of appropriate antibiotics. Up to 10 different pathogens regularly cause CAP, of which Streptococcus pneumoniae is the most important. These different pathogens cannot be distinguished by clinical features or simple laboratory tests. Microbiological tests are slow and insensitive, so empirical therapy is necessary, at least initially. Accurate assessment of illness severity is the most important factor determining initial management, since this assists the decision of whether to admit the patient to hospital in addition to guiding antibiotic choice and route of administration. Two different approaches to severity assessment are outlined. Our antibiotic recommendation for empirical therapy for the patient managed at home and the previously fit patient admitted to hospital is amoxicillin. Amoxicillin/clavulanate plus a macrolide is our choice for the severely ill previously fit patient and a third-generation cephalosporin plus a macrolide is recommended for the severely ill patient with comorbidity. Alternative pathogens and specific treatment regimens are also described. There may be several causes of treatment failure, and in patients who fail to respond to therapy, it is essential to review all the initial clinical and laboratory information, which if necessary must be repeated.

In vitro and in vivo antibacterial activities of CS-834, a novel oral carbapenem

CS-834 is a novel oral carbapenem antibiotic. This compound is an ester-type prodrug of the active metabolite R-95867. The antibacterial activity of R-95867 was tested against 1,323 clinical isolates of 35 species and was compared with those of oral cephems, i.e., cefteram, cefpodoxime, cefdinir, and cefditoren, and that of a parenteral carbapenem, imipenem. R-95867 exhibited a broad spectrum of activity covering both gram-positive and -negative aerobes and anaerobes. Its activity was superior to those of the other compounds tested against most of the bacterial species tested. R-95867 showed potent antibacterial activity against clinically significant pathogens: methicillin-susceptible Staphylococcus aureus including ofloxacin-resistant strains, Streptococcus pneumoniae including penicillin-resistant strains, Clostridium perfringens, Neisseria spp., Moraxella catarrhalis, most members of the family Enterobacteriaceae, and Haemophilus influenzae (MIC at which 90% of strains are inhibited, < or =0.006 to 0.78 microg/ml). R-95867 was quite stable to hydrolysis by most of the beta-lactamases tested except the metallo-beta-lactamases from Stenotrophomonas maltophilia and Bacteroides fragilis. R-95867 showed potent bactericidal activity against S. aureus and Escherichia coli. Penicillin-binding proteins 1 and 4 of S. aureus and 1Bs, 2, 3, and 4 of E. coli had high affinities for R-95867. The in vivo efficacy of CS-834 was evaluated in murine systemic infections caused by 16 strains of gram-positive and -negative pathogens. The efficacy of CS-834 was in many cases superior to those of cefteram pivoxil, cefpodoxime proxetil, cefdinir, and cefditoren pivoxil, especially against infections caused by S. aureus, penicillin-resistant S. pneumoniae, E. coli, Citrobacter freundii, and Proteus vulgaris. Among the drugs tested, CS-834 showed the highest efficacy against experimental pneumonia in mice caused by penicillin-resistant S. pneumoniae.

[Effect of imipenem/cilastatin combined with vancomycin for MRSA infection]

Therapeutic efficacy of the combined regimen, imipenem/cilastatin (IPM/CS) plus vancomycin (VCM), was examined in a total of 13 patients infected with MRSA (10 patients with pneumonia, 2 with sepsis and 1 with urinary tract infection). Based on the results of determination of FIC indices, in vitro combined effects were synergistic in 4 strains and additive in 3 strains. There was, however, no apparent correlation between the in vitro combined effect in terms of FIC index and clinical outcome. No side effects or abnormal laboratory findings were observed. The average daily doses of IPM/CS and VCM were 1.2 g and 1.25 g and the average administration periods were 17.5 and 14.9 days, respectively. The present results suggested that simultaneous use of IPM/CS and VCM at the standard doses could yield an enhancement of both bacteriological and clinical efficacies in treatment of the patients with MRSA infection.

Mixed infection by Staphylococcus and Candida, and Wegener's granulomatosis

We describe the case of a patient who initially presented with pneumonia from Staphylococcus aureus and Candida parapsilosis, which was resolved with antibiotic treatment, but reappeared 6 months later as full-blown Wegener's granulomatosis. The possible pathogenetic correlations between infective agents, in particular Staphylococcus aureus and Candida, and Wegener's granulomatosis are discussed.

[MRSA (methicillin-resistant Staphylococcus aureus) infections in patients with pulmonary diseases]

Methicillin-resistant Staphylococcus aureus (MRSA) has become a major nosocomial pathogen. We investigated MRSA-infections in patients with pulmonary diseases referring to epidemiological aspects. Between 9/92 and 2/92 we found MRSA-infections in our hospital in 24 patients (11 female, 13 male, average age 54.6 years). Clinical presentation, main and accompanying disorders and previous antibiotic therapy regimens were registered. Strains were typed using DNA-RFLP and lysotyping. MRSA detection were done in specimen from sputum (12/24) and from the bronchial secret (9/24). In 18/24 cases the MRSA-colonisation was associated with infection. In 15/24 cases the first acquisition of MRSA happened in our hospital, 6/24 times the germ was carried off other institutions and in 3/24 cases it was possibly community acquired. Most frequently patients suffered from bronchial cancer (6/24), from chronical bronchitis (5/24), from pneumonia (4/24) or Cystic fibrosis (4/24). Usually the patients showed other severe comorbidity. 13/24 patients had an antibiotic course before detecting MRSA. Typing revealed a strain already known in different hospitals of Berlin, another known strain of northern Germany and two so far unknown strains. Of interest was a different behaviour of resistance and the lost of resistance of strains in the course. MRSA-infection in pulmonary medicine emerged as a problem mostly in patients with multimorbidity and severe underlying diseases. Change of resistance in strains and new strains were observed.

[Effectiveness of the treatment of staphylococcal pneumonia with liposomal gentamicin in an experiment]

An in vivo comparative study on penetration of free gentamicin sulfate and liposome-entrapped gentamicin sulfate to macrophages was performed and the efficacy of the treatment of destructive pneumonia was estimated on albino mice. The liposome-entrapped antibiotic was arrested by the cells of the mononuclear phagocytic system thus providing higher concentrations of the drug in the organs with high counts of macrophages, the antibiotic retention time in the organs being longer than that after the use of free gentamicin. The use of liposome-entrapped gentamicin in the treatment of destructive pneumonia made it possible to increase the host protection from 17 to 50 per cent.

[Vancomycin-induced thrombocytopenia for MRSA pneumonia]

Thrombocytopenia occurred after 17 days of administration of vancomycin (VCM) in 2 cases of MRSA pneumonia. The drug lymphocyte stimulation test using VCM and anti-platelet antibody were negative for these 2 cases. However, platelet bound IgG significantly increased and the total number of immature megakaryocytes in the bone marrow increased. Corticosteroid administration after VCM was very effective for thrombocytopenia. In case 1, thrombocytopenia occurred three times after using of VCM, suggesting to have been induced by VCM. The mechanism of thrombocytopenia was immunological destruction. It has been reported that VCM-induced neutropenia might be induced via an immunological mechanism. We reported here 2 cases of thrombocytopenia induced by VCM, which is frequently used for MRSA pneumonia.

Pneumomediastinum and subcutaneous emphysema complicating staphylococcal pneumonia

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[Is methicillin better than cloxacillin in serious infections caused by strong penicillinase-producing staphylococci (phage-type 94/96)?]

An intravenous drug addict was treated with cloxacillin for septicaemia with Staphylococcus aureus because of pneumonia and suspected endocarditis. After 51 days of treatment Staphylococcus aureus was still found in blood and expectorate despite continued treatment with intravenous cloxacillin 1 g three and later four times daily and oral rifampicin. The staphylococcal isolates were all of phage type 94/96. Investigations have shown that Staphylococci aurei of phage type 94/96 produce large amounts of penicillinase, and that methicillin is the most penicillinase-resistant of the penicillinase-resistant penicillins followed by dicloxacillin and cloxacillin. The penicillinase production of the patient's Staphylococcus aureus strain was 304-362 units per mg bacteria which is high compared to typical values of 50-200. After 50 days of cloxacillin treatment, the treatment was changed to methicillin 2 g four times daily. Within a week the staphylococci had disappeared from the expectorate, and were never again recovered from the blood. It is suggested that methicillin should have superior efficiency in serious infections with Staphylococcus aureus of phage type 94/96.

Ventilator-associated pneumonia by Staphylococcus aureus. Comparison of methicillin-resistant and methicillin-sensitive episodes

All episodes of ventilator-associated pneumonia (VAP) caused by Staphylococcus aureus were prospectively analyzed for a 30-mo period. Methicillin-sensitive S. aureus (MSSA) was isolated in 38 episodes and methicillin-resistant S. aureus (MRSA) in 11 others. The two groups were similar regarding sex, severity of underlying diseases, prior surgery, and presence of renal failure, diabetes, cardiopathy, and coma. MRSA-infected persons were more likely to have received steroids before developing infection (relative risk [RR] = 3.45, 95% confidence interval [CI] = 1.38-8.59), to have been ventilated > 6 d (RR = 2.03, 95% CI = 1.36-3.03), to have been older than 25 yr (RR = 1.50, 95% CI = 1.09-2.06), and to have had preceding chronic obstructive pulmonary disease (RR = 2.76, 95% CI = 0.89-8.56) than MSSA-infected patients. MSSA-infected persons were more likely than MRSA-infected patients to have cranioencephalic trauma (RR = 1.94, 95% CI = 1.22-3.09). All patients with MRSA VAP had previously received antibiotics, compared with only 21.1% of those with MSSA infection (p < 0.000001). The incidence of empyema was similar in both groups; nevertheless, the presence of bacteremia and septic shock was more frequent in the MRSA group. Finally, mortality directly related to pneumonia was significantly higher among patients with MRSA episodes (RR = 20.72, 95% CI = 2.78-154.35). This analysis was repeated for monomicrobial episodes, and the difference remained statistically significant. We conclude that MRSA and MSSA strains infect patients with different demographic profiles; previous antibiotic therapy is the most important risk factor for developing MRSA infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute respiratory infections in Nigerian children: prospective cohort study of incidence and case management

A community-based prospective surveillance and case management study of acute respiratory infection (ARI) in children aged 2-60 months of age was carried out over a 12-month period in Pakata, a semi-urban community in Ilorin, Kwara State, Nigeria. A cohort of 481 children was followed by trained community health assistants with thrice weekly home visits to record all symptoms and signs of ARI, and institute treatment based on WHO recommendations. There were three episodes of mild, moderate, or severe ARI per child per year, including 1.3 pneumonia episodes per child per year. The peak of infection corresponded to the rainy season (July-November), and a smaller peak to the dry season (February-April). Most of the health worker decisions were considered appropriate, although there was a tendency toward over-treatment with antibiotic drugs. An effective referral system was established from the community to a tertiary centre. There were no ARI-related deaths during the study period. These data indicate that a system of case management using trained community health workers can improve case management of ARI and may prevent severe ARI-related disease and deaths.

[Clinical studies on the time-difference combination therapy with netilmicin and minocycline in methicillin-resistant Staphylococcus aureus infections]

Twenty-eight patients with methicillin-resistant Staphylococcus aureus (MRSA) infections were clinically studied for the effectiveness of the time-difference combination use of netilmicin (NTL) and minocycline (MINO). The patients were treated with NTL 100 mg and two hours later, with MINO 100 mg intravenously, twice daily, in the morning and evening for 14 days. Of 26 patients, MRSA was eradicated in 16 (61.5%), decreased in one, and unchanged in nine. Superinfections occurred with Serratia marcescens and Pseudomonas aeruginosa in two patients. The clinical efficacies were assessed in two patients with septicemia, 16 with pneumonia, and eight with chronic bronchitis. The obtained results were excellent in four patients, good in 15, fair in six, and poor in one patient. The rate of effectiveness was 73.1% (19/26). The overall clinical effectiveness judged by the committee was good in 19, fair in five, and poor in two patients. The efficacy rate was also 73.1% (19/26). Coagulase type II of MRSA was found in 23 patients, and coagulase type III in three patients, with overall clinical efficacy rates of 73.9% (17/23) and 66.7% (2/3), respectively. A side effect of eruption was observed in one patient, and its incidence was 3.6% (1/28). Abnormal laboratory test results were observed in 16 patients (57.1%), including abnormal liver function in 14 patients, abnormal kidney function in three, and increased eosinophils in three. Laboratory abnormalities occurred twelve of 16 bedridden patients, and this rate was higher than that in non bedridden patients. However, these abnormalities were all mild, transient, and immediately recovered after the treatment. In conclusion, the time-difference combination therapy using NTL and MINO was effective in the treatment of MRSA infections.

Methicillin-resistant Staphylococcus aureus as a cause of community-acquired pneumonia--a critical review

Methicillin-resistant Staphylococcus aureus (MRSA) has been recognized as a nosocomial pathogen in Europe and North America for 3 decades. More recently it has emerged as a problem in long-term care facilities. It is less frequently considered a pathogen in nonfacility, community-acquired infections, where it is most often seen in intravenous drug users. There are no studies in the literature specifically describing the clinical features of MRSA pneumonia. Presumably its presentation and outcome are similar to that of pneumonia caused by susceptible strains. Staphylococcus aureus pneumonia is more often nosocomial- or nursing home-acquired, has a variable association with influenza, has clinical and laboratory features similar to other types of community-acquired pneumonia and carries a relatively high mortality of 20% to 84%. MRSA should be considered resistant to all classes of beta-lactam (beta) antibiotics. In addition, these isolates are frequently resistant to a number of other antibiotics, with vancomycin and only antibiotic to have consistently shown activity against MRSA. Therefore, vancomycin remains the treatment of choice for infections caused by MRSA, although treatment failures have been reported. The use of alternative antibiotics should be based on results of susceptibility testing of the strain isolated from the patient.

[Clinical analysis of MRSA pneumonia. Niigata Research Group of MRSA.ABK]

Aged or immuno-compromised patients were mostly affected, by pneumonia caused by infection of MRSA, and more than half of the cases were superinfected with glucose-nonfermentative Gram-negative rods including Pseudomonas aeruginosa. These patients were treated with a monotherapy of arbekacin (ABK) by intravenous drip administration or with a combination of ABK and imipenem/cilastatin, ceftazidime or antifungals. The clinical efficiencies were 55.6% in 11 monotherapy cases and 83.3% in combined therapy. MRSA was eradicated in 31.9% of the patients. These results are comparable with, or superior to the vancomycin therapy in the treatment of MRSA pneumonia. When MRSA is isolated from sputum of pneumonia patients, the discrimination between colonization and infection is important, but the diagnosis is very difficult in many clinical cases before the initiation of chemotherapy. The number of bacteria and the grade of inflammation should be carefully scored before starting a chemotherapy.

[An evaluation study on arbekacin for MRSA-infectious diseases including pneumonia, septicemia and others]

Availability of arbekacin (ABK) was analyzed in the chemotherapy of 24 MRSA-infected patients with symptoms of pneumonia (12), sepsis (6) and others (6). Most patients had background diseases such as malignant tumors or cerebrovascular disorders. 47% (7/15) of them were immunologically abnormal. 17 of them had been previously treated with cephems, imipenem, minocycline or fosfomycin. The ABK therapy was performed with doses ranging 50-400 mg a day, divided into 1-3 times (mostly 100 mg x 2), and for 5-24 days. (18 patients were treated between 5 and 14 days). 14 patients (58%) received combined therapy with other antibiotics (mostly with beta-lactams, 12). The clinical efficacy rate of the ABK therapy was 62% (good, 13; fair, 4; ineffective, 4; unknown, 3). The bacteriological efficacies were: eradicated, 7 (44%); decreased, 4; no change, 5; unknown, 8. Side effects were found in 3 patients (oliguria, 2; eruption due to drug, 1) and one case resulted in serious renal disorder. Abnormal laboratory data were found in 7 cases. Above results have indicated that ABK is a useful antibiotic in chemotherapy of MRSA-infections.

[Clinical efficacy of arbekacin on MRSA pneumonia]

Arbekacin sulfate (ABK) was administered by intravenous drip to pneumonia patients infected with methicillin-resistant Staphylococcus aureus (MRSA), and the efficacy and the safety were objectively evaluated by the executive committee. The daily dose was determined in principle as 150-200 mg, two times a day, 30-90 minutes drip infusion, and the dose was to be changed at each special occasion. Combined therapy with other antibiotics was scheduled in severe cases at a decision of the physician in charge. Data of 18 cases were accumulated. The efficacy could be evaluated for 12 cases (4 cases with ABK alone, and 8 cases with combined therapy), and the safety was evaluated for 18 cases. The clinical efficacy was: excellent, 1; good, 4; fair, 5; and poor, 2. The efficacy rate was 41.7%. The bacteriological effect was: eradicated, 2 (16.7%); decreased, 2; and no change, 8. There found no side effects except 3 cases of abnormal laboratory data, two abnormal renal functions(11.1%) and one abnormal hepatic function (5.5%). In one of the renal disorders, decreased dose of ABK improved the function. In the other case, the impaired renal function lasted until death by heart failure. In the case of abnormal function, discontinuing the ABK therapy improved the hepatic function. In the 4 out of 5 cases that showed excellent or good clinical efficacy, patients recovered within relatively early days of ABK therapy. The average days for recovery was 7.8.

The choice of empirical antibiotic therapy for nosocomial pneumonia

Nosocomial pneumonia has the highest crude mortality rate of all hospital-acquired infections. The choice of empirical antibiotic therapy can be based on in vitro sensitivities of sputum bacterial isolates. Organisms recovered from purulent sputum of 500 intensive care unit (ICU) patients from five hospitals in Louisville, Kentucky, had antibiotic sensitivities measured by microbroth dilution. The most common isolates were Staphylococcus aureus (26.6%), Pseudomonas species (24.8%), Enterobacter species (11.8%), Escherichia coli (7.2%), Klebsiella species (7.0%), Streptococcus species (4.4%) and Serratia species (4.0%). These organisms were tested for susceptibility to amikacin, ciprofloxacin, imipenem/cilastatin, ticarcillin/clavulanate, piperacillin, ceftriaxone and ceftazidime. The antibiotics effective against more than 80% of the seven most common isolates included amikacin (97%), imipenem (94%), ciprofloxacin (92%) and ticarcillin/clavulanate (84%). These sensitivity patterns may serve as a guide to choosing empirical antibiotics for ICU-acquired pneumonia in Louisville. When the use of a beta-lactam antibiotic alone or in combination with an aminoglycoside is preferred, imipenem or ticarcillin-clavulanate may be considered the antibiotics of choice. Studies are in progress to delineate the clinical use of ciprofloxacin alone or in combination with beta-lactam antibiotics for treating nosocomial pneumonia.

[Clinical studies of arbekacin sulfate in the pediatric field]

A clinical investigation was carried out to evaluate arbekacin, an aminoglycoside, in the treatment of MRSA infections (pneumonia, septicemia, etc.) of pediatric patients. The obtained results are summarized as follows. 1.

CLINICAL RESULTS

Excluding those patients who met the present exclusion criteria and withdrawal cases from a total of 18 patients, 10 patients (3, 6, and 1 cases of septicemia, pneumonia, and urinary tract infection, respectively) were subjected to clinical evaluation. These were composed of 1, 1, 6, and 2 cases of neonate, infants, pre- and school age children, respectively. Excellent, good and fair results were obtained in 5, 2, and 3 patients, respectively; thus, the efficacy rate was 70.0%. The efficacy rate by disease was 100%, 50.0% and 100% in septicemia, pneumonia, and urinary tract infection, respectively. The bacteriological eradication were obtained in 70.0% of the total patients; by disease, these rates were 100% and 50.0% in septicemia/urinary tract infection and in pneumonia, respectively. The MIC50 as well as the MIC80 against MRSA strains isolated from 9 patients were 0.39 microgram/ml and 1.56 micrograms/ml, respectively. No adverse reactions were observed in the 15 patients, while in laboratory test values, one case each out of 12 patients examined showed gamma-GTP elevation, proteinuria, and hematuria. 2. Pharmacokinetics: The pharmacokinetics of the agent was investigated in a total of 9 patients, which included 1 neonate and 4 cases each of pre- and school age children. The Cmax, 4.85-8.83 micrograms/ml, was observed immediately after the termination of the instillation. The T1/2's were 4.96 hours, 1.24-2.54 hours, and 1.78-1.88 hours in the neonate, the pre- and the school age children, respectively; in the neonate the half-life was longer. When 1.92-2.7 mg/kg were administered to 3 each of the pre- and school age children, urinary excretion rates in the first 6-8 hours were 40.1-56.5% of the dosages administered. In all cases, the urinary concentrations were highest in the first 2 hours, after the administration, and then gradually decreased. These results suggest that arbekacin is a useful antibiotic for treating MRSA infections in the pediatric field.

Simulation of human plasma levels of beta-lactams in mice by multiple dosing and the relationship between the therapeutic efficacy and pharmacodynamic parameters

A mathematical multiple dosing model was designed so that human plasma concentration-versus-time curves of beta-lactams are reproduced in mouse plasma. The pharmacokinetic parameters of FK037, a new injective cephalosporin, in volunteers and in the mice model were 6,966 and 6,894 ml, respectively, for Vc, 2.592 and 2.698/h for alpha, 0.2875 and 0.3027/h for beta, and 0.9079 and 1.0506 for K21. Therefore, real pharmacokinetics of humans were reproduced in mice by this method. The 8-hour therapeutic efficacy (the decrease of the viable counts in the lung) against pneumonia with Staphylococcus aureus and Pseudomonas aeruginosa in mice was well correlated with the time above MIC value, but not with AUC, Cmax or AUC above MIC. These results indicate that this model was valuable to evaluate the beta-lactam antibiotics for predicting their clinical efficacy and that the time above MIC is an important factor in selecting beta-lactam agents and determining dosage in pulmonary infection.

ARI control programme: results in hospitalized children

One hundred cases of pneumonia with chest indrawing were treated according to the treatment protocol of the ARI control programme. The majority of children were > 2 months old (85 per cent) with male predominance (61 per cent). All cases with severe pneumonia survived. A mortality rate of 7.7 per cent was seen in cases of very severe pneumonia. Three children in the severe pneumonia group deteriorated on benzyl penicillin to very severe pneumonia but subsequently improved on chloramphenicol. Six patients were treated as cases of Staphylococcal pneumonia and one of them died. Thirteen children (21.3 per cent) in the severe pneumonia group required oxygen for breathing rates > 70 per minute. Seventy-four per cent in the very severe pneumonia group required administration of IV fluids. Blood counts did not prove to be of help in differentiating the children at risk of dying. There was no significant difference in roentgenographic findings in the two groups. Congestive cardiac failure was the most common complication, seen in 33.3 per cent of cases of the very severe pneumonia group. The duration of stay was significantly less in cases of severe pneumonia (4.21 +/- 1.59 days) as compared to very severe pneumonia (9.35 +/- 2.39 days). The data from this study suggest that the treatment protocol for the ARI control programme for hospitalized children is reasonably effective and can be implemented in small hospitals.