General principles of antimicrobial therapy

Enhancement of bacterial growth with the help of immiscible oxygenated oils

Bacterial growth in an aqueous medium in the vicinity of the interface with an immiscible oxygenated fluid is a subject of this study. We tested six oxygenated liquids, including hexadecane, silicone oil, FC-40, FC-70, HFE-7200 and HFE-7500.

Nebulized Gentamicin as an Alternative to Nebulized Tobramycin for Tracheitis in Pediatric Patients

OBJECTIVES

Tracheitis is an infection of the lower respiratory tract and is defined by the US Centers for Disease Control and Prevention (CDC) based on signs and symptoms with no radiographic evidence of pneumonia. One method of treatment involves the use of tobramycin given by nebulizer. The purpose of this study was to compare the safety and efficacy of nebulized gentamicin with nebulized tobramycin.

METHODS

This study was conducted in patients under 21 years of age who received greater than or equal to 1 day of gentamicin, 80 mg, or tobramycin, 300 mg, given twice a day by nebulization within the 14-month study period. The primary endpoint was amount of time until the patient no longer met the CDC definition of tracheitis.

RESULTS

There were 19 patients who presented with 60 separate encounters. The average age of the patients within the gentamicin group was 7.2 and 5 years old within the tobramycin group. The average duration of time for the gentamicin treatment encounters to be free of the CDC definition of tracheitis was 3.36 days compared to 3.17 days with tobramycin. No adverse effects were observed that were attributable to aminoglycoside nebulization.

CONCLUSIONS

No differences were detected between the safety and efficacy of intravenous gentamicin administered twice a day by nebulizer and that of tobramycin inhalation solution given twice daily in children without cystic fibrosis.

Analysis of the third- and fourth-generation cephalosporin use for the treatment of infections caused by Gram-negative bacteria in hospital settings

OBJECTIVE

The aims of our study were to assess the prevalence and distribution of Gram-negative (G-) bacteria in hospital isolates, their sensitivity to the third- and fourth-generation cephalosporins (c3 and c4), therapeutic use of c3 and c4 in the treatment of G- infections and drug utilisation data.

RESEARCH DESIGN AND METHODS

This cross-sectional study collected medical records data from the General Hospital "Gornji Milanovac" (GM) and the University Medical Center "Bezanijska kosa" (BK). The time frame of the study was 12 months. Microbiological and clinical parameters, and c3/c4 drug utilisation were analysed.

RESULTS

Escherichia coli were the most predominant pathogen in GM and BK, accounting for 43% and 28% of all G- isolates, respectively (GM), 884 G- isolates obtained from 606 patients; BK, 1766 isolates obtained from 1045 patients). Nearly half of the isolates (55% and 43%) were obtained from urine samples collected from the surgical ward (GM), and the internal medicine wards and intensive care unit (BK). On average, the resistance rate of G- strains against c3 and c4 reached 40% and 70%, respectively (lowest in E. coli, 8%-25%; highest in Acinetobacer baumannii, 67%-100%). Resistance rate of Pseudomonas spp. to cefepime and ceftazidime was low/moderate (0%-30% and 19%-47%). In BK, the adult patients were older than in GM (75 vs 66 years), with longer hospital stay (19 vs 10 days) and bacteria were isolated later during hospitalisation (10 vs 2 days). C3 and c4 were more often used in empirical therapy (83% vs 64%) in BK. Ceftazidime and cefepime were used more often in BK than in GM (2.036 vs 69 DDD/y and 586 vs. 126 DDD/y, respectively).

CONCLUSION

The use of c3 and c4 in the treatment of G- infections in both hospitals should be re-evaluated in accordance with current guidelines and local resistance.

Practical Considerations in Sepsis Resuscitation

BACKGROUND

Sepsis is a common condition managed in the emergency department, and the majority of patients respond to resuscitation measures, including antibiotics and i.v. fluids. However, a proportion of patients will fail to respond to standard treatment.

OBJECTIVE

This review elucidates practical considerations for management of sepsis in patients who fail to respond to standard treatment.

DISCUSSION

Early goal-directed therapy revolutionized sepsis management. However, there is a paucity of literature that provides a well-defined treatment algorithm for patients who fail to improve with therapy. Refractory shock can be defined as continued patient hemodynamic instability (mean arterial pressure, ≤ 65 mm Hg, lactate ≥ 4 mmol/L, altered mental status) after adequate fluid loading (at least 30 mL/kg i.v.), the use of two vasopressors (with one as norepinephrine), and provision of antibiotics. When a lack of improvement is evident in the early stages of resuscitation, systematically considering source control, appropriate volume resuscitation, adequate antimicrobial coverage, vasopressor selection, presence of metabolic pathology, and complications of resuscitation, such as abdominal compartment syndrome and respiratory failure, allow emergency physicians to address the entire clinical scenario.

CONCLUSIONS

The care of sepsis has experienced many changes in recent years. Care of the patient with sepsis who is not responding appropriately to initial resuscitation is troublesome for emergency physicians. This review provides practical considerations for resuscitation of the patient with septic shock. When a septic patient is refractory to standard therapy, systematically evaluating the patient and clinical course may lead to improved outcomes.

Evaluating the impact of the multiplex respiratory virus panel polymerase chain reaction test on the clinical management of suspected respiratory viral infections in adult patients in a hospital setting

A retrospective cohort design was used to study the impact of a multiplex respiratory virus panel polymerase chain reaction test in 186 adult patients with suspected influenza-like illness. Decisions regarding continuation of empirical antiviral therapy appear to be impacted by the test. However, the impact on reducing antibiotic use remains unclear.

Antibody Production in Response to Staphylococcal MS-1 Phage Cocktail in Patients Undergoing Phage Therapy

In this study, we investigated the humoral immune response (through the release of IgG, IgA, and IgM antiphage antibodies) to a staphylococcal phage cocktail in patients undergoing experimental phage therapy at the Phage Therapy Unit, Medical Center of the Ludwik Hirszfeld Institute of Immunology and Experimental Therapy in Wrocław, Poland. We also evaluated whether occurring antiphage antibodies had neutralizing properties toward applied phages (K rate). Among 20 examined patients receiving the MS-1 phage cocktail orally and/or locally, the majority did not show a noticeably higher level of antiphage antibodies in their sera during phage administration. Even in those individual cases with an increased immune response, mostly by induction of IgG and IgM, the presence of antiphage antibodies did not translate into unsatisfactory clinical results of phage therapy. On the other hand, a negative outcome of the treatment occurred in some patients who showed relatively weak production of antiphage antibodies before and during treatment. This may imply that possible induction of antiphage antibodies is not an obstacle to the implementation of phage therapy and support our assumption that the outcome of the phage treatment does not primarily depend on the appearance of antiphage antibodies in sera of patients during therapy. These conclusions are in line with our previous findings. The confirmation of this thesis is of great interest as regards the efficacy of phage therapy in humans.

Broadening the antibacterial spectrum of histidine kinase autophosphorylation inhibitors via the use of ε-poly-L-lysine capped mesoporous silica-based nanoparticles

Two-component systems (TCS) regulate diverse processes such as virulence, stress responses, metabolism and antibiotic resistance in bacteria but are absent in humans, making them promising targets for novel antibacterials. By incorporating recently described TCS histidine kinase autophosphorylation inhibitors (HKAIs) into ε-poly-L-lysine capped nanoparticles (NPs) we could overcome the Gram negative (Gr-) permeability barrier for the HKAIs. The observed bactericidal activity against Gr- bacteria was shown to be due to the enhanced delivery and internalization of the HKAIs and not an inhibitory or synergistic effect of the NPs. The NPs had no adverse effects on mammalian cell viability or the immune function of macrophages in vitro and showed no signs of toxicity to zebrafish larvae in vivo. These results show that HKAIs are promising antibacterials for both Gr- and Gr+pathogens and that NPs are a safe drug delivery technology that can enhance the selectivity and efficacy of HKAIs against bacteria.

Association between inappropriate empirical antimicrobial therapy and hospital length of stay in Gram-negative bloodstream infections: stratification by prognosis

OBJECTIVES

The potential benefit from appropriate empirical antimicrobial therapy in patients with favourable prognosis at initial presentation with Gram-negative bloodstream infection (BSI) remains unclear. This retrospective cohort study examined the impact of inappropriate empirical antimicrobial therapy on hospital length of stay (HLOS) following Gram-negative BSI after stratification by predicted prognosis using the BSI mortality risk score (BSIMRS).

METHODS

Hospitalized adults with first episodes of Gram-negative BSI from 1 January 2010 to 31 December 2013 at Palmetto Health Hospitals in Columbia, SC, USA were identified. Multivariate Cox proportional hazards regression was used to examine the association between inappropriate empirical antimicrobial therapy and HLOS overall and within each predefined BSIMRS category (<5 and ≥5).

RESULTS

Among 830 unique patients with Gram-negative BSI, 469 and 361 had BSIMRS <5 and ≥5, respectively. Overall, the median age was 65 years, 448 (54%) were women, Escherichia coli (444; 53%) was the most common bloodstream isolate and 444 (53%) had a urinary source of infection. After adjustments in the multivariate model, BSIMRS (HR = 1.14 per point, 95% CI = 1.11-1.17, P < 0.001) and inappropriate empirical antimicrobial therapy (HR = 1.41, 95% CI = 1.07-1.91, P = 0.01) were independently associated with increased risk of remaining hospitalized following Gram-negative BSI. Median HLOS with appropriate and inappropriate empirical antimicrobial therapy was 7 and 10 days, respectively, in patients with BSIMRS <5 (P = 0.03) and 13 and 17 days, respectively, in those with BSIMRS ≥5 (P = 0.02).

CONCLUSIONS

Inappropriate empirical antimicrobial therapy is associated with prolonged HLOS following Gram-negative BSI in patients with both good and guarded prognosis.

Using combination therapy to thwart drug resistance

Drug combination therapy is a promising strategy to extend the lifespan of our antimicrobials. Drug combinations used in treatment must be carefully selected to minimize the evolution of resistance, either by carefully determining drug pairs that hinder the acquisition of resistance mechanisms, or by screening for combinations that inhibit growth and show reduced vulnerability to resistance. Modeling of interactions between drugs has provided intriguing insights into strategies for combination therapy deployment. Ultimately, more rigorous clinical trials need to be performed to evaluate the laboratory and modeling results and advance treatment options.

Methodology in improving antibiotic implementation policies

The basic requirements of antibiotic prescribing are components of methodology; knowledge, logical reasoning, and analysis. Antimicrobial drugs are valuable but limited resources, different from other drugs and they are among the most commonly prescribed drugs all over the world. They are the only drugs which do not intentionally affect the patient. They affect the pathogens which invade the host. The emergence and spread of antibiotic-resistant pathogens are accelerated by heavy antibiotic usage. The effective antimicrobial stewardship and infection control program have been shown to limit the emergence of antimicrobial-resistant bacteria. In this respect, education for antibiotic prescribing could be designed by going through the steps of scientific methodology. A defined leadership and a coordinated multidisciplinary approach are necessary for optimizing the indication, selection, dosing, route of administration, and duration of antimicrobial therapy. In scenarios, knowledge is also as important as experience for critical decision making as is designated. In this setting, the prevalence and resistance mechanisms of antimicrobials, and their interactions with other drugs need to be observed. In this respect, infectious disease service should play an important role in improving antimicrobial use by giving advice on the appropriate use of antimicrobial agents, and implementing evidence-based guidelines.

Evaluation of Drug Treatment of Bronchopneumonia at the Pediatric Clinic in Sarajevo

INTRODUCTION

Bronchopneumonia is the most common clinical manifestation of pneumonia in pediatric population and leading infectious cause of mortality in children under 5 years. Evaluation of treatment involves diagnostic procedures, assessment of disease severity and treatment for disease with an emphasis on vulnerability of the population.

AIM

To determine the most commonly used antibiotics at the Pediatric Clinic in Sarajevo and concomitant therapy in the treatment of bronchopneumonia.

PATIENTS AND METHODS

The study was retrospective and included a total of 104 patients, hospitalized in pulmonary department of the Pediatric Clinic in the period from July to December 2014. The treatment of bronchopneumonia at the Pediatric Clinic was empirical and it conformed to the guidelines and recommendations of British Thoracic Society.

RESULTS AND DISCUSSION

First and third generation of cephalosporins and penicillin antibiotics were the most widely used antimicrobials, with parenteral route of administration and average duration of treatment of 4.3 days. Concomitant therapy included antipyretics, corticosteroids, leukotriene antagonists, agonists of β2 adrenergic receptor. In addition to pharmacotherapy, hospitalized patients were subjected to a diet with controlled intake of sodium, which included probiotic-rich foods and adequate hydration. Recommendations for further antimicrobial treatment include oral administration of first-generation cephalosporins and penicillin antibiotics.

CONCLUSION

Results of the drug treatment of bronchopneumonia at the Pediatric Clinic of the University Clinical Center of Sarajevo are comparable to the guidelines of the British Thoracic Society. It is necessary to establish a system for rational use of antimicrobial agents in order to reduce bacterial resistance.

A comparison of different antibiotic regimens for the treatment of infective endocarditis

BACKGROUND

Infective endocarditis is a microbial infection of the endocardial surface of the heart. Antibiotics are the cornerstone of treatment, but their use is not standardised, due to the differences in presentation, populations affected and the wide variety of micro-organisms that can be responsible.

OBJECTIVES

To assess the existing evidence about the clinical benefits and harms of different antibiotics regimens used to treat people with infective endocarditis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE Classic and EMBASE, LILACS, CINAHL and the Conference Proceedings Citation Index on 30 April 2015. We also searched three trials registers and handsearched the reference lists of included papers. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials assessing the effects of antibiotic regimens for treating possible infective endocarditis diagnosed according to modified Duke's criteria. We considered all-cause mortality, cure rates and adverse events as the primary outcomes. We excluded people with possible infective endocarditis and pregnant women.

DATA COLLECTION AND ANALYSIS

Three review authors independently performed study selection, 'Risk of bias' assessment and data extraction in duplicate. We constructed 'Summary of findings' tables and used GRADE methodology to assess the quality of studies. We described the included studies narratively.

MAIN RESULTS

Four small randomised controlled trials involving 728 allocated/224 analysed participants met our inclusion criteria. These trials had a high risk of bias. Drug companies sponsored two of the trials. We were unable to pool the data due to the heterogeneity in outcome definitions and the different antibiotics used.The included trials compared the following antibiotic schedules. The first trial compared quinolone (levofloxacin) plus standard treatment (anti-staphylococcal penicillin (cloxacillin or dicloxacillin), aminoglycoside (tobramycin or netilmicin) and rifampicin) versus standard treatment alone reporting uncertain effects on all-cause mortality (8/31 (26%) with levofloxacin plus standard treatment versus 9/39 (23%) with standard treatment alone; RR 1.12, 95% CI 0.49 to 2.56, very low quality evidence). The second trial compared daptomycin versus low-dose gentamicin plus an anti-staphylococcal penicillin (nafcillin, oxacillin or flucloxacillin) or vancomycin. This showed uncertain effects in terms of cure rates (9/28 (32.1%) with daptomycin versus 9/25 (36%) with low-dose gentamicin plus anti-staphylococcal penicillin or vancomycin, RR 0.89 95% CI 0.42 to 1.89; very low quality evidence). The third trial compared cloxacillin plus gentamicin with a glycopeptide (vancomycin or teicoplanin) plus gentamicin. In participants receiving gentamycin plus glycopeptide only 13/23 (56%) were cured versus 11/11 (100%) receiving cloxacillin plus gentamicin (RR 0.59, 95% CI 0.40 to 0.85; very low quality evidence). The fourth trial compared ceftriaxone plus gentamicin versus ceftriaxone alone and found no conclusive differences in terms of cure (15/34 (44%) with ceftriaxone plus gentamicin versus 21/33 (64%) with ceftriaxone alone, RR 0.69, 95% CI 0.44 to 1.10; very low quality evidence).The trials reported adverse events, need for cardiac surgical interventions, uncontrolled infection and relapse of endocarditis and found no conclusive differences between comparison groups (very low quality evidence). No trials assessed septic emboli or quality of life.

AUTHORS' CONCLUSIONS

Limited and very low quality evidence suggested that there were no conclusive differences between antibiotic regimens in terms of cure rates or other relevant clinical outcomes. However, because of the very low quality evidence, this needs confirmation. The conclusion of this Cochrane review was based on randomised controlled trials with high risk of bias. Accordingly, current evidence does not support or reject any regimen of antibiotic therapy for treatment of infective endocarditis.

Inducing stable reversion to achieve cancer control

How can we stop cancer progression? Current strategies depend on modelling progression as the balanced outcome of mutations in, and expression of, tumour suppressor genes and oncogenes. New treatments emerge from successful attempts to tip that balance, but secondary mutational escape from those treatments has become a major impediment because it leads to resistance. In this Opinion article, we argue for a return to an earlier stratagem: tumour cell reversion. Treatments based on selection and analysis of stable revertants could create more durable remissions by reducing the selective pressure that leads to rapid drug resistance.

Pharmacometric Approaches to Personalize Use of Primarily Renally Eliminated Antibiotics in Preterm and Term Neonates

Sepsis remains a major cause of mortality and morbidity in neonates, and, as a consequence, antibiotics are the most frequently prescribed drugs in this vulnerable patient population. Growth and dynamic maturation processes during the first weeks of life result in large inter- and intrasubject variability in the pharmacokinetics (PK) and pharmacodynamics (PD) of antibiotics. In this review we (1) summarize the available population PK data and models for primarily renally eliminated antibiotics, (2) discuss quantitative approaches to account for effects of growth and maturation processes on drug exposure and response, (3) evaluate current dose recommendations, and (4) identify opportunities to further optimize and personalize dosing strategies of these antibiotics in preterm and term neonates. Although population PK models have been developed for several of these drugs, exposure-response relationships of primarily renally eliminated antibiotics in these fragile infants are not well understood, monitoring strategies remain inconsistent, and consensus on optimal, personalized dosing of these drugs in these patients is absent. Tailored PK/PD studies and models are useful to better understand relationships between drug exposures and microbiological or clinical outcomes. Pharmacometric modeling and simulation approaches facilitate quantitative evaluation and optimization of treatment strategies. National and international collaborations and platforms are essential to standardize and harmonize not only studies and models but also monitoring and dosing strategies. Simple bedside decision tools assist clinical pharmacologists and neonatologists in their efforts to fine-tune and personalize the use of primarily renally eliminated antibiotics in term and preterm neonates.

Real-world daptomycin use across wide geographical regions: results from a pooled analysis of CORE and EU-CORE

Background

Pooled data from two large registries, Cubicin^® Outcomes Registry and Experience (CORE; USA) and European Cubicin^® Outcomes Registry and Experience (EU-CORE; Europe, Latin America, and Asia), were analyzed to determine the characteristics and clinical outcomes of daptomycin therapy in patients with Gram-positive infections across wide geographical regions.

Methods

Patients receiving at least one dose of daptomycin between 2004 and 2012 for the treatment of Gram-positive infections were included. Clinical success was defined as an outcome of ‘cured’ or ‘improved’. Post-treatment follow-up data were collected for a subset of patients (CORE: osteomyelitis and orthopedic foreign body device infection; EU-CORE: endocarditis, intracardiac/intravascular device infection, osteomyelitis, and orthopedic device infection). Safety was assessed for up to 30 days after daptomycin treatment.

Results

In 11,557 patients (CORE, 5482; EU-CORE, 6075) treated with daptomycin (median age, 62 [range, 1–103] years), the most frequent underlying conditions were cardiovascular disease (54.7 %) and diabetes mellitus (28.0 %). The most commonly treated primary infections were complicated skin and soft tissue infection (cSSTI; 31.2 %) and bacteremia (21.8 %). The overall clinical success rate was 77.2 % (uncomplicated SSTI, 88.3 %; cSSTI, 81.0 %; osteomyelitis, 77.7 %; foreign body/prosthetic infection (FBPI), 75.9 %; endocarditis, 75.4 %; and bacteremia, 69.5 %). The clinical success rate was 79.1 % in patients with Staphylococcus aureus infections (MRSA, 78.1 %). An increasing trend of high-dose daptomycin (>6 mg/kg/day) prescribing pattern was observed over time. Clinical success rates were higher with high-dose daptomycin treatment for endocarditis and FBPI. Adverse events (AEs) and serious AEs possibly related to daptomycin therapy were reported in 628 (5.4 %) and 133 (1.2 %) patients, respectively.

Conclusions

The real-world data showed that daptomycin was effective and safe in the treatment of various Gram-positive infections, including those caused by resistant pathogens, across wide geographical regions.

Risk factors for hospital-acquired bacteremia due to carbapenem-resistant Pseudomonas aeruginosa in a Colombian hospital

INTRODUCTION

Bacteremia due to Pseudomonas aeruginosa resistant to carbapenems is a public health problem due to the limitations it places on therapeutic options, as well as the increased time patients must spend in hospital, costs and the risk of mortality. 

OBJECTIVE

To evaluate the risk factors for presentation of bacteremia due to carbapenem-resistant P. aeruginosa acquired in the Hospital Universitario San Ignacio between January 2008 and June 2014. 

MATERIALS AND METHODS

This was a case control study in which the case patients presented bacteremia due to P. aeruginosa resistant to carbapenems and the control group included patients with P. aeruginosa susceptible to this group of antibiotics. Variables such as the previous use of meropenem and ertapenem, immunosuppression and neoplasia were measured. Mortality and duration of hospital were also described. 

RESULTS

In all, 168 patients were evaluated, of which 42 were cases and 126 controls. Using a multivariate model, the risk factors related to bacteremia due to carbapenem-resistant P. aeruginosa acquired in hospital were the following: use of parenteral nutrition (OR=8.28; 95% CI: 2.56-26.79; p=0); use of meropenem (OR=1.15; 95% CI: 1.03-1.28; p=0.01); and use of ciprofloxacin (OR=81.99; 95% CI: 1.14-5884; p=0.043). 

CONCLUSION

In order to prevent the emergence of carbapenem-resistant P. aeruginosa, antimicrobial control programs should be strengthened by promoting the prudent administration of carbapenems and quinolones. The correct use of parenteral nutrition should also be monitored.

Evaluation of a machine learning capability for a clinical decision support system to enhance antimicrobial stewardship programs

OBJECTIVE

Antimicrobial stewardship programs have been shown to limit the inappropriate use of antimicrobials. Hospitals are increasingly relying on clinical decision support systems to assist in the demanding prescription reviewing process. In previous work, we have reported on an emerging clinical decision support system for antimicrobial stewardship that can learn new rules supervised by user feedback. In this paper, we report on the evaluation of this system.

METHODS

The evaluated system uses a knowledge base coupled with a supervised learning module that extracts classification rules for inappropriate antimicrobial prescriptions using past recommendations for dose and dosing frequency adjustments, discontinuation of therapy, early switch from intravenous to oral therapy, and redundant antimicrobial spectrum. Over five weeks, the learning module was deployed alongside the baseline system to prospectively evaluate its ability to discover rules that complement the existing knowledge base for identifying inappropriate prescriptions of piperacillin-tazobactam, a frequently used antimicrobial.

RESULTS

The antimicrobial stewardship pharmacists reviewed 374 prescriptions, of which 209 (56% of 374) were identified as inappropriate leading to 43 recommendations to optimize prescriptions. The baseline system combined with the learning module triggered alerts in 270 prescriptions with a positive predictive value of identifying inappropriate prescriptions of 74%. Of these, 240 reviewed prescriptions were identified by the alerts of the baseline system with a positive predictive value of 82% and 105 reviewed prescriptions were identified by the alerts of the learning module with a positive predictive value of 62%. The combined system triggered alerts for all 43 recommendations, resulting in a rate of actionable alerts of 16% (43 recommendations of 270 reviewed alerts); the baseline system triggered alerts for 38 interventions, resulting in a rate of actionable alerts of 16% (38 of 240 reviewed alerts); and the learning module triggered alerts for 17 interventions, resulting in a rate of actionable alerts of 16% (17 of 105 reviewed alerts). The learning module triggered alerts for every inappropriate prescription missed by the knowledge base of the baseline system (n=5).

CONCLUSIONS

The learning module was able to extract clinically relevant rules for multiple types of antimicrobial alerts. The learned rules were shown to extend the knowledge base of the baseline system by identifying pharmacist interventions that were missed by the baseline system. The learned rules identified inappropriate prescribing practices that were not supported by local experts and were missing from its knowledge base. However, combining the baseline system and the learning module increased the number of false positives.

Nosocomial Infections Caused by Acinetobacter baumannii: Are We Losing the Battle?

BACKGROUND

The incidence of nosocomial infections caused by multi-drug- and extended-drug resistant strains of Acinetobacter is constantly increasing all over the world, with a high mortality rate. We analyzed the in-hospital data on the sensitivity of Acinetobacter baumannii isolates and correlated them with antibiotic treatment and clinical outcomes of nosocomial infections over a 17-mo period.

METHODS

Retrospective analysis was performed at the Clinical Center "Bezanijska kosa," Belgrade, Serbia. Microbiologic data (number and sensitivity of A. baumannii isolates) and clinical data (medical records of 41 randomly selected patients who developed nosocomial infection caused by A. baumannii) were matched.

RESULTS

Acinetobacter baumannii, detected in 279 isolates and obtained from 19 patients (12% of all samples), was resistant to almost all antibiotics tested, including carbapenems, with the exception of colistin and tigecycline. It was obtained most often from the respiratory tract samples. Empiric treatment of the nosocomial infections (pneumonia in 75% of cases) involved cephalosporins, metronidazole, and carbapenems (80%, 66%, and 61% of patients, respectively), whereas tigecyclin and colistin were used primarily in targeted therapy (20% and 12% of patients, respectively). The mortality rate of patients treated empirically was significantly higher (p < 0.01), reaching 100% in the elderly.

CONCLUSIONS

Nosocomial A. baumannii infections represent a significant clinical problem because of their high incidence, lack of susceptibility to the most commonly used antibiotics, and the often inappropriate treatment, which favors the development of multi-drug-resistant strains.

Quantitative clinical pharmacology practice for optimal use of antibiotics during the neonatal period

INTRODUCTION

For safe and effective neonatal antibiotic therapy, knowledge of the pharmacokinetic parameters of antibacterial agents in neonates is a prerequisite. Fast maturational changes during the neonatal period influence pharmacokinetic and pharmacodynamic parameters and their variability. Consequently, the need for applying quantitative clinical pharmacology and determining optimal drug dosing regimens in neonates has become increasingly recognized.

AREAS COVERED

Modern quantitative approaches, such as pharmacometrics, are increasingly utilized to characterize, understand and predict the pharmacokinetics of a drug and its effect, and to quantify the variability in the neonatal population. Individual factors, called covariates in modeling, are integrated in such approaches to explain inter-individual pharmacokinetic variability. Pharmacometrics has been shown to be a relevant tool to evaluate, optimize and individualize drug dosing regimens.

EXPERT OPINION

Challenges for optimal use of antibiotics in neonates can largely be overcome with quantitative clinical pharmacology practice. Clinicians should be aware that there is a next step to support the clinical decision-making based on clinical characteristics and therapeutic drug monitoring, through Bayesian-based modeling and simulation methods. Pharmacometric modeling and simulation approaches permit us to characterize population average, inter-subject and intra-subject variability of pharmacokinetic parameters such as clearance and volume of distribution, and to identify and quantify key factors that influence the pharmacokinetic behavior of antibiotics during the neonatal period.

Vancomycin-Resistant Pseudomonas Aeroginosa in the Cases of Trauma

Background:

One of the main problems in the treatment of cases of P. aeruginosa especially in the orthopedic infections is the occurrence of high antibiotic resistance. The present study was carried out in order to investigate the prevalence of vancomycin-resistant P. aeruginosa in the cases of trauma in Iran.

Methods:

Two hundred and fifty swab samples were collected from the site of trauma from the patients who referred to the orthopedic wards of the Iranian health centers. Samples were cultured immediately and those that were P. aeruginosa-positive were analyzed by the disk diffusion method.

Results:

Of 250 swab samples collected, 43 were positive for P. aeruginosa (17.2%). The results of the culture technique were also confirmed by the PCR reaction. Of 43 P. aeruginosa isolates, 32 strains (74.41%) were resistant to vancomycin. Total prevalence of bacteria in Tehran and Mashhad hospitals were 18.46% and 15.83%, respectively. Statistically significant difference was seen for the prevalence of vancomycin-resistant P. aeruginosa between the samples collected from Tehran and Mashhad (P =0.027). More than 55 years old and less than 10 years old patients had the highest prevalence of P. aeruginosa. P. aeruginosa strains of male and more than 55 years old patients harbored the highest levels of resistance against vancomycin.

Conclusions:

It is logical to primary identification of type of bacteria causing infection in the site of trauma and then using from the disk diffusion method to choose the best antimicrobial agent. Highest levels of health care should be performed for the patients less than 10 years and more than 55 years old patients.

Use of Antibiotics and Antimicrobial Resistance in Veterinary Medicine as Exemplified by the Swine Pathogen Streptococcus suis

Use of antimicrobial agents in veterinary medicine is essential to control infectious diseases, thereby keeping animals healthy and animal products safe for the consumer. On the other hand, development and spread of antimicrobial resistance is of major concern for public health. Streptococcus (S.) suis reflects a typical bacterial pathogen in modern swine production due to its facultative pathogenic nature and wide spread in the pig population. Thus, in the present review we focus on certain current aspects and problems related to antimicrobial use and resistance in S. suis as a paradigm for a bacterial pathogen affecting swine husbandry worldwide. The review includes (i) general aspects of antimicrobial use and resistance in veterinary medicine with emphasis on swine, (ii) genetic resistance mechanisms of S. suis known to contribute to bacterial survival under antibiotic selection pressure, and (iii) possible other factors which may contribute to problems in antimicrobial therapy of S. suis infections, such as bacterial persister cell formation, biofilm production, and co-infections. The latter shows that we hardly understand the complexity of factors affecting the success of antimicrobial treatment of (porcine) infectious diseases and underlines the need for further research in this field.

Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

A new approach to Vancomycin utilization evaluation: A cross-sectional study in intensive care unit

Objective:

The risk of methicillin-resistant Staphylococcus aureus infections in Intensive Care Unit (ICU) is increasing in recent years with high rate of morbidity and mortality. Therefore, in this study, we aimed to evaluate the rationale use of vancomycin in ICU patients.

Methods:

A total of 200 patients who received at least 48 h intravenous vancomycin were randomly selected from ICU wards, during 9 months. Vancomycin administration and related clinical and laboratory data were gathered from patients' charts and health information system to evaluate the appropriateness of different aspects of vancomycin use during all days which vancomycin were ordered.

Findings:

During the study, 15,230 ± 1216 mg (mean ± standard error of the mean [SEM]) vancomycin was administered for 200 patients in the mean period of 9.79 ± 0.64 (SEM) days of ICU stay, for prophylaxis and empiric therapy. Results showed the appropriateness of vancomycin uses were 30.5%, 9%, and 5.5% in the first 24 h, after 72 h and during the whole time of treatment, respectively. In addition, infectious consultation was the only significantly different parameter between appropriate and inappropriate vancomycin administration groups (P < 0.001).

Conclusion:

Although vancomycin utilization evaluation were mentioned in previous studies, but data related to ICU patients and during all days of vancomycin therapy are limited. High prevalence of inappropriate use of vancomycin in ICU is alarming for health systems and necessitates implementation of antibiotic policies.

The cystic fibrosis microbiome in an ecological perspective and its impact in antibiotic therapy

The recent focus on the cystic fibrosis (CF) complex microbiome has led to the recognition that the microbes can interact between them and with the host immune system, affecting the disease progression and treatment routes. Although the main focus remains on the interactions between traditional pathogens, growing evidence supports the contribution and the role of emergent species. Understanding the mechanisms and the biological effects involved in polymicrobial interactions may be the key to improve effective therapies and also to define new strategies for disease control. This review focuses on the interactions between microbe-microbe and host-microbe, from an ecological point of view, discussing their impact on CF disease progression. There are increasing indications that these interactions impact the success of antimicrobial therapy. Consequently, a new approach where therapy is personalized to patients by taking into account their individual CF microbiome is suggested.

Effect of Kidney Function on Drug Kinetics and Dosing in Neonates, Infants, and Children

Neonates, infants, and children differ from adults in many aspects, not just in age, weight, and body composition. Growth, maturation and environmental factors affect drug kinetics, response and dosing in pediatric patients. Almost 80% of drugs have not been studied in children, and dosing of these drugs is derived from adult doses by adjusting for body weight/size. As developmental and maturational changes are complex processes, such simplified methods may result in subtherapeutic effects or adverse events. Kidney function is impaired during the first 2 years of life as a result of normal growth and development. Reduced kidney function during childhood has an impact not only on renal clearance but also on absorption, distribution, metabolism and nonrenal clearance of drugs. 'Omics'-based technologies, such as proteomics and metabolomics, can be leveraged to uncover novel markers for kidney function during normal development, acute kidney injury, and chronic diseases. Pharmacometric modeling and simulation can be applied to simplify the design of pediatric investigations, characterize the effects of kidney function on drug exposure and response, and fine-tune dosing in pediatric patients, especially in those with impaired kidney function. One case study of amikacin dosing in neonates with reduced kidney function is presented. Collaborative efforts between clinicians and scientists in academia, industry, and regulatory agencies are required to evaluate new renal biomarkers, collect and share prospective pharmacokinetic, genetic and clinical data, build integrated pharmacometric models for key drugs, optimize and standardize dosing strategies, develop bedside decision tools, and enhance labels of drugs utilized in neonates, infants, and children.

Advances in multiplex nucleic acid diagnostics for blood-borne pathogens: promises and pitfalls

The large number of blood-borne viruses, bacteria and parasites currently of concern, as well as many newly emerging pathogens, presents a daunting challenge to protection of the safety of blood for transfusion and diagnosing infectious diseases. Focusing on nucleic acid diagnostic tests, multiplex devices are coming into use with many more in various developmental stages that promise to offer solutions to the clinical need. The characteristics, advantages and disadvantages of platforms in clinical use and at the research and development stage are examined here. The presence of multiple assays and associated reagents operating simultaneously on one platform, implementation in traditional clinical laboratories and regulatory review will present special challenges. Fortunately, clinical laboratories have made dramatic technical progress in the last two decades and regulatory agencies have publicly expressed support for development of multiplex devices.

Identification of Small-Molecule Inhibitors against Meso-2, 6-Diaminopimelate Dehydrogenase from Porphyromonas gingivalis

Species-specific antimicrobial therapy has the potential to combat the increasing threat of antibiotic resistance and alteration of the human microbiome. We therefore set out to demonstrate the beginning of a pathogen-selective drug discovery method using the periodontal pathogen Porphyromonas gingivalis as a model. Through our knowledge of metabolic networks and essential genes we identified a “druggable” essential target, meso-diaminopimelate dehydrogenase, which is found in a limited number of species. We adopted a high-throughput virtual screen method on the ZINC chemical library to select a group of potential small-molecule inhibitors. Meso-diaminopimelate dehydrogenase from P. gingivalis was first expressed and purified in Escherichia coli then characterized for enzymatic inhibitor screening studies. Several inhibitors with similar structural scaffolds containing a sulfonamide core and aromatic substituents showed dose-dependent inhibition. These compounds were further assayed showing reasonable whole-cell activity and the inhibition mechanism was determined. We conclude that the establishment of this target and screening strategy provides a model for the future development of new antimicrobials.

Intravenous Antibiotics Used in the Treatment of Methicillin-Resistant Staphylococcus Aureus

Methicillin-resistant Staphylococcus aureus (MRSA) continues to cause significant morbidity and mortality. Despite advances in medical care, the prevalence of both community-acquired and hospital-acquired MRSA has progressively increased. Community-acquired MRSA typically occurs in patients without recent illness or hospitalization, presents as acute skin and soft tissue infections, and is usually not multidrug resistant. Hospital-acquired MRSA, however, presents in patients recently hospitalized or treated in long-term care settings and in those who have had medical procedures and is usually associated with multidrug-resistant strains. Both types of infections, if not properly treated, have the potential to become invasive. This article discusses current intravenous antibiotics that are available for the empiric treatment of MRSA infections along with a newer phenomenon known as the "seesaw effect."

Intravenous Antibiotics Used in the Treatment of Methicillin-Resistant Staphylococcus Aureus

Methicillin-resistant Staphylococcus aureus (MRSA) continues to cause significant morbidity and mortality. Despite advances in medical care, the prevalence of both community-acquired and hospital-acquired MRSA has progressively increased. Community-acquired MRSA typically occurs in patients without recent illness or hospitalization, presents as acute skin and soft tissue infections, and is usually not multidrug resistant. Hospital-acquired MRSA, however, presents in patients recently hospitalized or treated in long-term care settings and in those who have had medical procedures and is usually associated with multidrug-resistant strains. Both types of infections, if not properly treated, have the potential to become invasive. This article discusses current intravenous antibiotics that are available for the empiric treatment of MRSA infections along with a newer phenomenon known as the “seesaw effect.”

Inhaled anti-infective chemotherapy for respiratory tract infections: successes, challenges and the road ahead

One of the most common causes of illnesses in humans is from respiratory tract infections caused by bacterial, viral or fungal pathogens. Inhaled anti-infective drugs are crucial for the prophylaxis and treatment of respiratory tract infections. The benefit of anti-infective drug delivery via inhalation is that it affords delivery of sufficient therapeutic dosages directly to the primary site of infection, while minimizing the risks of systemic toxicity or avoiding potential suboptimal pharmacokinetics/pharmacodynamics associated with systemic drug exposure. This review provides an up-to-date treatise of approved and novel developmental inhaled anti-infective agents, with particular attention to effective strategies for their use, pulmonary pharmacokinetic properties and safety.

Combinatorial Activity of Flavonoids with Antibiotics Against Drug-Resistant Staphylococcus aureus

The use of resistance-modifying agents is a potential strategy that is used to prolong the effective life of antibiotics in the face of increasing antibiotic resistance. Since certain flavonoids are potent bacterial efflux pump inhibitors, we assessed morin, rutin, quercetin, hesperidin, and (+)-catechin for their combined activity with the antibiotics ciprofloxacin, tetracycline, erythromycin, oxacillin, and ampicillin against drug-resistant strains of Staphylococcus aureus, including methicillin-resistant S. aureus. Four established methods were used to determine the combined efficacy of each combination: microdilution checkerboard assays, time-kill determinations, the Etest, and dual disc-diffusion methods. The cytotoxicity of the flavonoids was additionally evaluated in a mouse fibroblast cell line. Quercetin and its isomer morin decreased by 3- to 16-fold the minimal inhibitory concentration of ciprofloxacin, tetracycline, and erythromycin against some S. aureus strains. Rutin, hesperidin, and (+)-catechin did not promote any potentiation of antibiotics. Despite the potential cytotoxicity of these phytochemicals at a high concentration (fibroblast IC50 of 41.8 and 67.5 mg/L, respectively), quercetin is commonly used as a supplement for several therapeutic purposes. All the methods, with exception of the time-kill assay, presented a high degree of congruence without any apparent strain specificity.

In Vitro Fractional Inhibitory Concentration (FIC) Study of Cefixime and Azithromycin Fixed Dose Combination (FDC) Against Respiratory Clinical Isolates

INTRODUCTION

Acute respiratory infections (ARI) contribute to more than 75% of health care seeking in primary health care facilities in India. Respiratory tract infections (RTIs) are managed frequently by β-lactam, macrolide and fluroquinolone class of antibiotics. However, these recommended classes of antibiotic have shown resistance in community settings. Antibiotic combinations may provide broader spectrum not only in terms of coverage but also to overcome multiple resistance mechanisms overcoming individual class limitations.

AIM

The study aimed to determine In vitro interactions interpreted according to calculated fractional inhibitory concentration (FIC) index between cefixime and azithromycin against common respiratory clinical isolates.

MATERIALS AND METHODS

Forty four bacterial respiratory clinical isolates from microbiology department of tertiary care hospital from Mumbai were used to determine the minimum inhibitory concentration (MIC) values of cefixime and azithromycin. Synergy testing of cefixime combination with azithromycin was performed by checkerboard method. Interaction was determined according to calculated FIC index.

RESULTS

MIC values were ranging from 2-128 μg/ml and 0.24-128 μg/ml for cefixime and azithromycin respectively against K.pneumoniae, M.catarrhalis, S.pneumoniae and H.influenzae isolates. All the tested isolates were resistant to cefixime. Azithromycin resistance was noted in all the isolates except six M. catarrhalis isolates. FIC index showed synergy and additive effect in 66% (29/44) and 34% (15/44) all bacterial clinical isolates. Maximum synergy between cefixime and azithromycin was observed against K. pneumoniae in 91% isolates.

CONCLUSION

This is one of the first attempts to check the rationality of fixed dose antibiotic combination of cefixime and azithromycin in India market. Though results of this study cannot be generalized considering the limitations of low sample size and in vitro model, our data provides stepping stone for further validation of cefixime and azithromycin fixed dose combinations (FDCs) in clinical setting by conducting randomized controlled trials. We think that judicious and rational use of FDCs may help to reduce the risk of selection of further drug resistance along with better clinical outcome.

In vitro antifungal susceptibility of coelomycete agents of black grain eumycetoma to eight antifungals

Fungal mycetoma (eumycetoma) represents one of the most difficult infections to appropriately manage. The current recommended treatment is based on extensive surgical debridement combined with prolonged antifungal therapy with ketoconazole or itraconazole. Despite the different phylogenetic positions of black-grain eumycetoma species, they are all treated with the same antifungal agents. The in vitro antifungal susceptibility of coelomycetous eumycetoma agents in the order of Pleosporales presently is largely unknown. Here we determined the in vitro activity of eight antifungal agents against seven species causing human eumycetoma using the Sensititre YeastOne method. High minimum inhibitory concentrations (MICs) were found with fluconazole, caspofungin, flucytosine, and amphotericin B. Voriconazole and posaconazole were found to be active against all species tested. Of the species included in the investigation, MICs of Medicopsis romeroi differed from the rest of the mycetoma causative agents belonging to the order of the Pleosporales. We found significantly lower MICs for amphotericin B and significantly higher MICs for fluconazole, ketoconazole, and itraconazole against this species. Our results emphasised that identification of black grain mycetoma agent is important as well as performing susceptibility testing before starting of antifungal treatment.

A need for new generation antibiotics against MRSA resistant bacteria

New antibiotics are highly needed due to continuously emerging resistances, in particular for methicillin-resistant Staphylococcus aureus (MRSA). Only a few new generation antibiotics with new mechanisms of action are available or in development in the recent years. Promising emerging drug candidates with a new mechanism of action are the synthetic guanidine-based polymers based on Akacid. They are highly potent against a wide range of microorganisms and have a beneficial safety profile as reflected in their excellent tolerability when applied to skin, mucosa or eyes. There is a high potential for topical and systemic use of Akacid as an antibiotic in humans and animals, in particular in cases of resistant microorganisms.

Ultrastructural changes in methicillin-resistant Staphylococcus aureus induced by positively charged silver nanoparticles

Silver nanoparticles offer a possible means of fighting antibacterial resistance. Most of their antibacterial properties are attributed to their silver ions. In the present work, we study the actions of positively charged silver nanoparticles against both methicillin-sensitive Staphylococcus aureus and methicillin-resistant Staphylococcus aureus. We use aberration-corrected transmission electron microscopy to examine the bactericidal effects of silver nanoparticles and the ultrastructural changes in bacteria that are induced by silver nanoparticles. The study revealed that our 1 nm average size silver nanoparticles induced thinning and permeabilization of the cell wall, destabilization of the peptidoglycan layer, and subsequent leakage of intracellular content, causing bacterial cell lysis. We hypothesize that positively charged silver nanoparticles bind to the negatively charged polyanionic backbones of teichoic acids and the related cell wall glycopolymers of bacteria as a first target, consequently stressing the structure and permeability of the cell wall. This hypothesis provides a major mechanism to explain the antibacterial effects of silver nanoparticles on Staphylococcus aureus. Future research should focus on defining the related molecular mechanisms and their importance to the antimicrobial activity of silver nanoparticles.

Acute kidney injury in septic patients admitted to emergency clinical room: risk factors and outcome

PURPOSE

Acute kidney injury (AKI) is a common source of morbidity in sepsis. We sought to determine risk factors for AKI, by acute kidney injury network (AKIN) criteria, in septic patients admitted in emergency clinical room (ER).

MATERIALS AND METHODS

Prospective cohort study of 200 patients admitted to the ER of a University Hospital, followed for development of AKI over 5 days.

RESULTS

AKI developed in 144/200 (72 %) patients. In multivariable regression analysis, independent risk factors for AKI included age over 65 years (OR 1.28; 95 % CI 1.12-1.89; p = 0.04), mean blood pressure (MBP) lower than 65 mmHg at moment of admission (OR 1.89; 95 % CI 1.43-2.64, p = 0.003) and diabetes mellitus (OR 1.66; 95 % CI 1.30-3.20; p = 0.012). Mortality rate was 51.4 % in AKI patients compared with 26.8 % for those without AKI (p = 0.002). Septic shock (OR = 1.83, 95 % CI 1.23-2.74, p = 0.007), AKIN 3 (OR = 1.64; 95 % CI 1.19-1.89, p = 0.02), APACHE 2 > 20 (OR 1.92, 95 % CI 1.34-2.02, p = 0.009) and need for dialysis (OR = 1.26, 95 % CI 1.13-1.75, p = 0.03) were identified as independent risk factors for death in multivariable regression analysis.

CONCLUSIONS

AKI severity in septic patients admitted in ER is associated with mortality. Diabetes, age over 65 years, and low MBP are independent risk factors for AKI and deserve further study to prevent AKI and, consequently, decreasing mortality.

Antibiotics in dental practice: how justified are we

Antibiotics are prescribed by dentists in dental practice, during dental treatment as well as for prevention of infection. Indications for the use of systemic antibiotics in dentistry are limited because most dental and periodontal diseases are best managed by operative intervention and oral hygiene measures. The use of antibiotics in dental practice is characterised by empirical prescription based on clinical and bacteriological epidemiological factors, resulting in the use of a very narrow range of broad-spectrum antibiotics for short periods of time. This has led to the development of antimicrobial resistance (AMR) in a wide range of microbes and to the consequent inefficacy of commonly used antibiotics. Dentists can make a difference by the judicious use of antimicrobials--prescribing the correct drug, at the standard dosage and appropriate regimen--only when systemic spread of infection is evident. The increasing resistance problems of recent years are probably related to the over- or misuse of broad-spectrum agents. There is a clear need for the development of prescribing guidelines and educational initiatives to encourage the rational and appropriate use of drugs in dentistry. This paper highlights the need for dentists to improve antibiotic prescribing practices in an attempt to curb the increasing incidence of antibiotic resistance and other side effects of antibiotic abuse. The literature provides evidence of inadequate prescribing practices by dentists for a number of factors, ranging from inadequate knowledge to social factors.

Emergency department antimicrobial considerations in severe sepsis

Severe sepsis and septic shock are common problems in the emergency department patient population and require expert clinical skill by members of the emergency department team to maximize optimal patient outcomes. Although various guidelines have been developed for the management of these patients, issues around antimicrobial-related considerations in critically ill patients require further evidence-based attention. In this review article, important factors related to patient illness, microorganism, timing of antimicrobial administration, and source control are discussed.

Influence of real-world characteristics on outcomes for patients with methicillin-resistant Staphylococcal skin and soft tissue infections: a multi-country medical chart review in Europe

Background

Patient-related (demographic/disease) and treatment-related (drug/clinician/hospital) characteristics were evaluated as potential predictors of healthcare resource use and opportunities for early switch (ES) from intravenous (IV)-to-oral methicillin-resistant Staphylococcus aureus (MRSA)-active antibiotic therapy and early hospital discharge (ED).

Methods

This retrospective observational medical chart study analyzed patients (across 12 European countries) with microbiologically confirmed MRSA complicated skin and soft tissue infections (cSSTI), ≥3 days of IV anti-MRSA antibiotics during hospitalization (July 1, 2010-June 30, 2011), and discharged alive by July 31, 2011. Logistic/linear regression models evaluated characteristics potentially associated with actual resource use (length of IV therapy, length of hospital stay [LOS], IV-to-oral antibiotic switch), and ES and ED (using literature-based and expert-verified criteria) outcomes.

Results

1542 patients (mean ± SD age 60.8 ± 16.5 years; 61.5% males) were assessed with 81.0% hospitalized for MRSA cSSTI as the primary reason. Several patient demographic, infection, complication, treatment, and hospital characteristics were predictive of length of IV therapy, LOS, IV-to-oral antibiotic switch, or ES and ED opportunities. Outcomes and ES and ED opportunities varied across countries. Length of IV therapy and LOS (r = 0.66, p < 0.0001) and eligibilities for ES and ED (r = 0.44, p < 0.0001) showed relatively strong correlations. IV-to-oral antibiotic switch patients had significantly shorter length of IV therapy (−5.19 days, p < 0.001) and non-significantly shorter LOS (−1.86 days, p > 0.05). Certain patient and treatment characteristics were associated with increased odds of ES (healthcare-associated/ hospital-acquired infection) and ED (patient living arrangements, healthcare-associated/ hospital-acquired infection, initiating MRSA-active treatment 1–2 days post cSSTI index date, existing ED protocol), while other factors decreased the odds of ES (no documented MRSA culture, ≥4 days from admission to cSSTI index date, IV-to-oral switch, IV line infection) and ED (dementia, no documented MRSA culture, initiating MRSA-active treatment ≥3 days post cSSTI index date, existing ES protocol).

Conclusions

Practice patterns and opportunity for further ES and ED were affected by several infection, treatment, hospital, and geographical characteristics, which should be considered in identifying ES and ED opportunities and designing interventions for MRSA cSSTI to reduce IV days and LOS while maintaining the quality of care.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2334-14-476) contains supplementary material, which is available to authorized users.