Nosocomial pneumonia: comparative multicentre trial between monotherapy with cefotaxime and treatment with antibiotic combinations

Chemical pharmacotherapy for hospital-acquired pneumonia in the elderly

INTRODUCTION

Hospital-acquired pneumonia (HAP) is a potentially serious infection that primarily affects older patients. The number of patients affected by multidrug-resistant (MDR) bacteria is increasing, including infection from strains of Staphylococcus aureus, Enterobacteriaceae, and Pseudomonas aeruginosa.

AREAS COVERED

This article focuses specifically on HAP, excluding patients afflicted by ventilator-associated pneumonia (VAP). The pathogenesis and clinical features of HAP in the elderly are discussed as well as specific drug pharmacokinetic and pharmacodynamic considerations in elderly patients. The current recommended guidelines for the management of HAP are also discussed. Finally, the authors provide evidence on the empirical therapy used for the treatment of HAP and widely consider specific-pathogen treatment of HAP in elderly patients.

EXPERT OPINION

In patients not at risk of MDR organism infection, antibiotics including piperacillin-tazobactam, cefepime, carbapenems or fluorquinolones are recommended. However, the emergence of MDR organisms as causal agents of HAP makes it necessary to accurately assess risk factors to these pathogens and revise our knowledge on specific antimicrobial susceptibility patterns from each institution. The authors believe that broader-spectrum empiric antibiotic therapies that target P. aeruginosa and methicillin-resistant S. aureus are best recommended in elderly patients at risk of HAP infection by MDR strains.

Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.These guidelines are intended for use by healthcare professionals who care for patients at risk for hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP), including specialists in infectious diseases, pulmonary diseases, critical care, and surgeons, anesthesiologists, hospitalists, and any clinicians and healthcare providers caring for hospitalized patients with nosocomial pneumonia. The panel's recommendations for the diagnosis and treatment of HAP and VAP are based upon evidence derived from topic-specific systematic literature reviews.

Beta lactam antibiotic monotherapy versus beta lactam-aminoglycoside antibiotic combination therapy for sepsis

BACKGROUND

Optimal antibiotic treatment for sepsis is imperative. Combining a beta lactam antibiotic with an aminoglycoside antibiotic may provide certain advantages over beta lactam monotherapy.

OBJECTIVES

Our objectives were to compare beta lactam monotherapy versus beta lactam-aminoglycoside combination therapy in patients with sepsis and to estimate the rate of adverse effects with each treatment regimen, including the development of bacterial resistance to antibiotics.

SEARCH METHODS

In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 11); MEDLINE (1966 to 4 November 2013); EMBASE (1980 to November 2013); LILACS (1982 to November 2013); and conference proceedings of the Interscience Conference of Antimicrobial Agents and Chemotherapy (1995 to 2013). We scanned citations of all identified studies and contacted all corresponding authors. In our previous review, we searched the databases to July 2004.

SELECTION CRITERIA

We included randomized and quasi-randomized trials comparing any beta lactam monotherapy versus any combination of a beta lactam with an aminoglycoside for sepsis.

DATA COLLECTION AND ANALYSIS

The primary outcome was all-cause mortality. Secondary outcomes included treatment failure, superinfections and adverse events. Two review authors independently collected data. We pooled risk ratios (RRs) with 95% confidence intervals (CIs) using the fixed-effect model. We extracted outcomes by intention-to-treat analysis whenever possible.

MAIN RESULTS

We included 69 trials that randomly assigned 7863 participants. Twenty-two trials compared the same beta lactam in both study arms, while the remaining trials compared different beta lactams using a broader-spectrum beta lactam in the monotherapy arm. In trials comparing the same beta lactam, we observed no difference between study groups with regard to all-cause mortality (RR 0.97, 95% CI 0.73 to 1.30) and clinical failure (RR 1.11, 95% CI 0.95 to 1.29). In studies comparing different beta lactams, we observed a trend for benefit with monotherapy for all-cause mortality (RR 0.85, 95% CI 0.71 to 1.01) and a significant advantage for clinical failure (RR 0.75, 95% CI 0.67 to 0.84). No significant disparities emerged from subgroup and sensitivity analyses, including assessment of participants with Gram-negative infection. The subgroup of Pseudomonas aeruginosa infections was underpowered to examine effects. Results for mortality were classified as low quality of evidence mainly as the result of imprecision. Results for failure were classified as very low quality of evidence because of indirectness of the outcome and possible detection bias in non-blinded trials. We detected no differences in the rate of development of resistance. Nephrotoxicity was significantly less frequent with monotherapy (RR 0.30, 95% CI 0.23 to 0.39). We found no heterogeneity for all these comparisons.We included a small subset of studies addressing participants with Gram-positive infection, mainly endocarditis. We identified no difference between monotherapy and combination therapy in these studies.

AUTHORS' CONCLUSIONS

The addition of an aminoglycoside to beta lactams for sepsis should be discouraged. All-cause mortality rates are unchanged. Combination treatment carries a significant risk of nephrotoxicity.

Antibiotics and Antifungals in Neonatal Intensive Care Units: A Review

The incidence of infections is higher in the neonatal period than at any time of life. The basic treatment of infants with infection has not changed substantially over the last years. Antibiotics (with or without supportive care) are one of the most valuable resources in managing sick newborn babies. Early-onset (ascending or transplacental) or late-onset (hospital acquired) infections present different chronology, epidemiology, physiology and outcome. Some classes of antibiotics are frequently used in the neonatal period: penicillins, cephalosporins, aminoglycosides, glycopeptides, monobactams, carbapenems. Other classes of antibiotics (chloramphenicol, cotrimoxazole, macrolides, clindamycin, rifampicin and metronidazole) are rarely used. Due to emergence of resistant bacterial strains in Neonatal Intensive Care Units (NICU), other classes of antibiotics such as quinolones and linezolid will probably increase their therapeutic role in the future. Although new formulations have been developed for treatment of fungal infections in infants, amphotericin B remains first-line treatment for systemic Candida infection. Prophylactic antibiotic therapy is almost always undesirable. Challenges from pathogens and antibiotic resistance in the NICU may warrant modification of traditional antibiotic regimens. Knowledge of local flora and practical application of different antibiotic characteristics are key to an effective and safe utilization of antibiotics and antifungals in critical newborns admitted to the NICU, and especially in very low birth weight infants.

Pneumonia due to Pseudomonas aeruginosa: part II: antimicrobial resistance, pharmacodynamic concepts, and antibiotic therapy

Pseudomonas aeruginosa carries a notably higher mortality rate than other pneumonia pathogens. Because of its multiple mechanisms of antibiotic resistance, therapy has always been challenging. This problem has been magnified in recent years with the emergence of multidrug-resistant (MDR) pathogens often unharmed by almost all classes of antimicrobials. The objective of this article is to assess optimal antimicrobial therapy based on in vitro activity, animal studies, and pharmacokinetic/pharmacodynamic (PK/PD) observations so that evidence-based recommendations can be developed to maximize favorable clinical outcomes. Mechanisms of antimicrobial resistance of P aeruginosa are reviewed. A selective literature review of laboratory studies, PK/PD concepts, and controlled clinical trials of antibiotic therapy directed at P aeruginosa pneumonia was performed. P aeruginosa possesses multiple mechanisms for inducing antibiotic resistance to antimicrobial agents. Continuous infusion of antipseudomonal β-lactam antibiotics enhances bacterial killing. Although the advantages of combination therapy remain contentious, in vitro and animal model studies plus selected meta-analyses of clinical trials support its use, especially in the era of MDR. Colistin use and the role of antibiotic aerosolization are reviewed. An evidence-based algorithmic approach based on severity of illness, Clinical Pulmonary Infection Score, and combination antibiotic therapy is presented; clinical outcomes may be improved, and the emergence of MDR pathogens should be minimized with this approach.

Clinical practice guidelines for hospital-acquired pneumonia and ventilator-associated pneumonia in adults

Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are important causes of morbidity and mortality, with mortality rates approaching 62%. HAP and VAP are the second most common cause of nosocomial infection overall, but are the most common cause documented in the intensive care unit setting. In addition, HAP and VAP produce the highest mortality associated with nosocomial infection. As a result, evidence-based guidelines were prepared detailing the epidemiology, microbial etiology, risk factors and clinical manifestations of HAP and VAP. Furthermore, an approach based on the available data, expert opinion and current practice for the provision of care within the Canadian health care system was used to determine risk stratification schemas to enable appropriate diagnosis, antimicrobial management and nonantimicrobial management of HAP and VAP. Finally, prevention and risk-reduction strategies to reduce the risk of acquiring these infections were collated. Future initiatives to enhance more rapid diagnosis and to effect better treatment for resistant pathogens are necessary to reduce morbidity and improve survival.

A survival benefit of combination antibiotic therapy for serious infections associated with sepsis and septic shock is contingent only on the risk of death: a meta-analytic/meta-regression study

OBJECTIVE

To assess whether a potential benefit with combination antibiotic therapy is restricted to the most critically ill subset of patients, particularly those with septic shock.

DATA SOURCES

OVID MEDLINE (1950-October 2009), EMBASE (1980-October 2009), the Cochrane Central Register of Controlled Trials (to third quarter 2009), the ClinicalTrial.gov database, and the SCOPUS database.

STUDY SELECTION

Randomized or observational studies of antimicrobial therapy of serious bacterial infections potentially associated with sepsis or septic shock. Fifty studies met entry criteria.

DATA EXTRACTION

Study design, mortality/clinical response, and other variables were extracted independently by two reviewers. When possible, study datasets were split into mutually exclusive groups with and without shock or critical illness.

DATA SYNTHESIS

Although a pooled odds ratio indicated no overall mortality/clinical response benefit with combination therapy (odds ratio, 0.856; 95% confidence interval, 0.71-1.03; p = .0943; I = 45.1%), stratification of datasets by monotherapy mortality risk demonstrated substantial benefit in the most severely ill subset (monotherapy risk of death >25%; odds ratio of death, 0.51; 95% confidence interval, 0.41-0.64; I = 8.6%). Of those datasets that could be stratified by the presence of shock/critical illness, the more severely ill group consistently demonstrated increased efficacy of a combination therapy strategy (odds ratio, 0.49; 95% confidence interval, 0.35-0.70; p < .0001; I = 0%). An increased risk of death was found in low-risk patients (risk of death <or=15% in the monotherapy arm) exposed to combination therapy (odds ratio, 1.53; 95% confidence interval, 1.16-2.03; p = .003; I = 8.2%). Meta-regression indicated that efficacy of combination therapy was dependent only on the risk of death in the monotherapy group.

CONCLUSION

Combination antibiotic therapy improves survival and clinical response of high-risk, life-threatening infections, particularly those associated with septic shock but may be detrimental to low-risk patients.

Efficacy of monotherapy in the treatment of Pseudomonas ventilator-associated pneumonia in patients with trauma

BACKGROUND

Controversy persists regarding the optimal treatment regimen for Pseudomonas ventilator-associated pneumonia (VAP). Combination antibiotic therapy is used to broaden the spectrum of activity of empiric treatment and provide synergistic bacteriocidal activity. The relevance of such "synergy" is commonly supposed but poorly supported. The purpose of this study was to evaluate the efficacy of monotherapy in the treatment of Pseudomonas VAP as measured by microbiological resolution.

METHODS

Patients admitted to the trauma intensive care unit during a 36-month period with gram-negative VAP diagnosed on initial bronchoalveolar lavage (BAL) (> or = 10(5) colony forming units [CFU]/mL) were evaluated. All patients received empiric antibiotic monotherapy based on the duration of intensive care unit stay. Patients with Pseudomonas VAP were identified and appropriate monotherapy was selected. Repeat BAL was performed on day 4 of appropriate antibiotic therapy to determine efficacy. Microbiological resolution was defined as < or = 10(3) CFU/mL. Combination therapy with an aminoglycoside was reserved for patients with either persistent positive or increasing colony counts on repeat BAL. Recurrence was defined as > or = 10(5) CFU/mL on subsequent BAL after 2 weeks of appropriate therapy.

RESULTS

One hundred ninety-six patients were identified with late gram-negative VAP. There were 84 patients with Pseudomonas VAP. Monotherapy achieved microbiological resolution in 79 patients (94.1%) with zero recurrence. Thirty-six isolates were completely eradicated at repeat BAL. Five patients (5.9%) required combination therapy to achieve resolution.

CONCLUSIONS

Monotherapy in the treatment of Pseudomonas VAP has an excellent success rate in patients with trauma. Empiric monotherapy therapy should be modified once susceptibility of the microorganism is documented (all isolates were sensitive to cefepime) and antibiotic choice should be based on local patterns of susceptibilities. The routine use of combination therapy for synergy is unnecessary. Combination therapy should be reserved for patients with persistent microbiological evidence of Pseudomonas VAP despite adequate therapy.

Guidelines for the management of hospital-acquired pneumonia in the UK: report of the working party on hospital-acquired pneumonia of the British Society for Antimicrobial Chemotherapy

These evidence-based guidelines have been produced after a systematic literature review of a range of issues involving prevention, diagnosis and treatment of hospital-acquired pneumonia (HAP). Prevention is structured into sections addressing general issues, equipment, patient procedures and the environment, whereas in treatment, the structure addresses the use of antimicrobials in prevention and treatment, adjunctive therapies and the application of clinical protocols. The sections dealing with diagnosis are presented against the clinical, radiological and microbiological diagnosis of HAP. Recommendations are also made upon the role of invasive sampling and quantitative microbiology of respiratory secretions in directing antibiotic therapy in HAP/ventilator-associated pneumonia.

Empiric antibiotic therapy for suspected ventilator-associated pneumonia: a systematic review and meta-analysis of randomized trials

OBJECTIVE

To compare specific antibiotic regimens, and monotherapy vs. combination therapy, for the empirical treatment of ventilator-associated pneumonia (VAP).

DESIGN

Meta-analysis.

DATA SOURCE

Medline, Embase, Cochrane register of controlled trials, study authors, and review articles.

STUDY SELECTION

We included randomized controlled trials that evaluated empirical parenteral antibiotic regimens for adult patients with clinically suspected VAP.

DATA SELECTION

Two independent review groups searched the literature, extracted data, and evaluated trial quality. The primary outcome was all-cause mortality; secondary outcomes included treatment failure. Relative risks were pooled using a random effects model.

RESULTS

We identified 41 trials randomizing 7,015 patients and comparing 29 unique regimens. Methodological quality was low, reflecting low rates of complete follow-up (43.9%), use of a double-blinded interventional strategy (14.6%), and randomization concealment (48.6%). Overall mortality was 20.3%; treatment failure occurred in 37.4% of patients who could be evaluated microbiologically. No mortality differences were observed between any of the regimens compared. Only one of three pooled comparisons yielded a significant difference for treatment failure: The combination of ceftazidime/aminoglycoside was inferior to meropenem (two trials, relative risk 0.70, 95% confidence interval 0.53-0.93). Rates of mortality and treatment failure for monotherapy compared with combination therapy were similar (11 trials, relative risk for mortality of monotherapy 0.94, confidence interval 0.76-1.16; and relative risk of treatment failure for monotherapy 0.88, confidence interval 0.72-1.07).

CONCLUSIONS

Monotherapy is not inferior to combination therapy in the empirical treatment of VAP. Available data neither identify a superior empirical regimen nor conclusively conclude that available regimens result in equivalent outcomes. Larger and more rigorous trials evaluating the choice of, and even need for, empirical therapy for VAP are needed.

Beta lactam antibiotic monotherapy versus beta lactam-aminoglycoside antibiotic combination therapy for sepsis

BACKGROUND

Optimal antibiotic treatment for sepsis is imperative. Combining a beta-lactam antibiotic with an aminoglycoside antibiotic may have certain advantages over beta-lactam monotherapy.

OBJECTIVES

We compared clinical outcomes for beta lactam-aminoglycoside combination therapy versus beta lactam monotherapy for sepsis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library, Issue 3, 2004); MEDLINE (1966 to July 2004); EMBASE (1980 to March 2003); LILACS (1982 to July 2004); and conference proceedings of the Interscience Conference of Antimicrobial Agents and Chemotherapy (1995 to 2003). We scanned citations of all identified studies and contacted all corresponding authors.

SELECTION CRITERIA

We included randomized and quasi-randomized trials comparing any beta-lactam monotherapy to any combination of one beta-lactam and one aminoglycoside for sepsis.

DATA COLLECTION AND ANALYSIS

The primary outcome was all-cause fatality. Secondary outcomes included treatment failure, superinfections, colonization, and adverse events. Two authors independently collected data. We pooled relative risks (RR) with their 95% confidence intervals (CI) using the fixed effect model. We extracted outcomes by intention-to-treat analysis whenever possible.

MAIN RESULTS

We included 64 trials, randomizing 7586 patients. Twenty trials compared the same beta-lactam in both study arms, while the remaining compared different beta-lactams using a broader spectrum beta-lactam in the monotherapy arm. In studies comparing the same beta-lactam, we observed no difference between study groups with regard to all-cause fatality, RR 1.01 (95% CI 0.75-1.35) and clinical failure, RR 1.11 (95% CI 0.95-1.29). In studies comparing different beta-lactams, we observed an advantage to monotherapy: all cause fatality RR 0.85 (95% CI 0.71-1.01), clinical failure RR 0.77 (95% CI 0.69-0.86). No significant disparities emerged from subgroup and sensitivity analyses, including the assessment of patients with Gram-negative and Pseudomonas aeruginosa infections. We detected no differences in the rate of resistance development. Adverse events rates did not differ significantly between the study groups overall, although nephrotoxicity was significantly more frequent with combination therapy, RR 0.30 (95% CI 0.23-0.39). We found no heterogeneity for all comparisons. We included a small subset of studies addressing patients with Gram-positive infections, mainly endocarditis. We identified no difference between monotherapy and combination therapy in these studies.

AUTHORS' CONCLUSIONS

The addition of an aminoglycoside to beta-lactams for sepsis should be discouraged. All-cause fatality rates are unchanged. Combination treatment carries a significant risk of nephrotoxicity.

Antimicrobial therapy for patients with severe sepsis and septic shock: an evidence-based review

OBJECTIVE

In 2003, critical care and infectious disease experts representing 11 international organizations developed management guidelines for antimicrobial therapy for patients with severe sepsis and septic shock that would be of practical use for the bedside clinician, under the auspices of the Surviving Sepsis Campaign, an international effort to increase awareness and improve outcome in severe sepsis.

DESIGN

The process included a modified Delphi method, a consensus conference, several subsequent smaller meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee.

METHODS

The modified Delphi methodology used for grading recommendations built on a 2001 publication sponsored by the International Sepsis Forum. We undertook a systematic review of the literature graded along five levels to create recommendation grades from A to E, with A being the highest grade. Pediatric considerations to contrast adult and pediatric management are in the article by Parker et al. on p. S591.

CONCLUSION

Since the prompt institution of therapy that is active against the causative pathogen is one of the most important predictors of outcome, clinicians must establish a system for rapid administration of a rationally chosen drug or combination of drugs when sepsis or septic shock is suspected. The expanding number of antibacterial, antifungal, and antiviral agents available provides opportunities for effective empiric and specific therapy. However, to minimize the promotion of antimicrobial resistance and cost and to maximize efficacy, detailed knowledge of the likely pathogens and the properties of the available drugs is necessary for the intensivist.

The driving force in hospital formularies: economics versus efficacy

The rising cost of pharmaceuticals has created a focus on hospital cost containment. From 1990 to 2000, spending on prescription drugs increased 200%. Through a variety of mechanisms and contracting, hospital formularies have become increasingly more restrictive. Physician choice with regard to antibiotics specifically is becoming more limited. The field of pharmacoeconomics looks at the cost effectiveness of the drugs we use. The pressures on the pharmaceutical industry and hospitals are reviewed here with a discussion of antibiotic prophylaxis, new expensive therapies, and physician responsibility. The driving force behind hospital formulary design is often economic, whereas the physician desires variety and efficacy. This review discusses some of the key issues related to drug costs and expenditures.

[Cefotaxime, twenty years later. Observational study in critically ill patients]

OBJECTIVE

Afer twenty years of commercial availability of cefotaxime, the objective of this study was to know the reasons and modes of use, administration dosage as well as its effectiveness and tolerance in critically ill patients admitted to Intensive Care Units (ICU) in our country.

DESIGN

Open, prospective, observational, multicenter study.

SUBJECTS

All patients who had cefotaxime administered in monotherapy or in combination with other antibiotics were included as cases in this study.

RESULTS

A total of 624 patients were included in 44 ICUs (average 14 cases). Cefotaxime was indicated for therapy of 274 community-acquired infections (43.9%), 194 prophylaxis (31.1%), and 156 nosocomial infections (25.0%). Both community-acquired pneumonia (149, 34.7%) and mechanical ventilation associated pneumonia (62, 14.4%) predominated, followed by trachebronchitis (60, 13.9%) and central nervous system infections (42, 9.8%). Over half of infections (222, 51.6%) presented as systemic inflammatory response syndrome (SIRS), 133 (30.9%) as severe sepsis, and 75 (17.4%) as septic shock. In 374 (87.0%) out of the 430 cases of infection treatment, cefotaxime wan prescribed on an empirical basis and in 150 of them (40.1%) a further confirmation of the causative agent was obtained. In 120 (27.9%) cases, cefotaxime was administered as monotherapy and in the remaining cases in association with one or more antibiotics.The use of cefotaxime as prophylaxis was evaluated as failure in 31 (16.0%) of the cases, whereas in treatment it was considered as failure in 98 (22.8%) of the 430 cases, 51 community-acquired infections, 27 (27.3%) of ICU-acquired infections, and 20 (35.1%) nosocomial infections acquired outside the ICU. In 127 (29.5%) of the 430 infection treatments the initial treatment was changed. The reasons for the change included clinical failure (36, 28.3%), recovery of an uncovered pathogen with the antibiotic (40, 31.5%), emergence of multi-resistant pathogens (28, 22.0%), to decrease the therapeutic spectrum (7, 5.5%), and other reasons (16). Cefotoxime was also changed in 21 (6.0%) of the 194 cases in which it was used as prophylaxis. In 32 (5.1%) patients 37 adverse effects were noted which were associated with a possible or likely use of cefotaxime. Most notably, diarrhoea in 15 (2.4%) occasions and skin rash in 6 cases (1.0%).

CONCLUSIONS

Cefotaxime is still one of the therapies of choice for community-acquired and nosocomial infections as well as in different prophylactic modes. It is mostly used on an empirical basis and associated with other antibiotics. Clinical and microbiological efficiency is high whereas adverse effects related to its use have been scarce.

Monotherapy versus combination therapy for bacterial infections

The authors discuss the latest findings regarding the use of one or more antimicrobial drugs for a variety of infections. They offer suggestions for treatment based on a host of considerations, including the synergy and antagonism of specific drugs, type of infection, potential toxicities, and cost.

Antibiotics in neonatal infections: a review

The bacteria most commonly responsible for early-onset (materno-fetal) infections in neonates are group B streptococci, enterococci, Enterobacteriaceae and Listeria monocytogenes. Coagulase-negative staphylococci, particularly Staphylococcus epidermidis, are the main pathogens in late-onset (nosocomial) infections, especially in high-risk patients such as those with very low birthweight, umbilical or central venous catheters or undergoing prolonged ventilation. The primary objective of the paediatrician is to identity all potential cases of bacterial disease quickly and begin antibacterial treatment immediately after the appropriate cultures have been obtained. Combination therapy is recommended for initial empirical treatment in the neonate. In early-onset infections, an effective first-line empirical therapy is ampicillin plus an aminoglycoside (duration of treatment 10 days). An alternative is ampicillin plus a third-generation cephalosporin such as cefotaxime, a combination particularly useful in neonatal meningitis (mean duration of treatment 14 to 21 days), in patients at risk of nephrotoxicity and/or when therapeutic monitoring of aminoglycosides is not possible. Another potential substitute for the aminoglycoside is aztreonam. Triple combination therapy (such as amoxicillin plus cefotaxime and an aminoglycoside) could also be used for the first 2 to 3 days of life, followed by dual therapy after the microbiological results. In late-onset infections the combination oxacillin plus an aminoglycoside is widely recommended. However, vancomycin plus ceftazidime (+/- an aminoglycoside for the first 2 to 3 days) may be a better choice. Teicoplanin may be a substitute for vancomycin. However, the initial approach should always be modified by knowledge of the local bacterial epidemiology. After the microbiological results, treatment should be switched to narrower spectrum agents if a specific organism has been identified, and should be discontinued if cultures are negative and the neonate is in good clinical condition. Penicillins and third-generation cephalosporins are generally well tolerated in neonates. There is controversy regarding whether therapeutic drug monitoring of aminoglycosides will decrease toxicity (particularly renal damage) in neonates, and on the efficacy and safety of a single daily dose versus multiple daily doses of these drugs. Toxic effects caused by vancomycin are uncommon, but debate still exists over the need for therapeutic drug monitoring of this agent. When antibacterials are used in neonates, accurate determination of dosage is required, particularly for compounds with a low therapeutic index and in patients with renal failure. Very low birthweight infants are also particularly prone to antibacterial-induced toxicity.

Cefotaxime. A reappraisal of its antibacterial activity and pharmacokinetic properties, and a review of its therapeutic efficacy when administered twice daily for the treatment of mild to moderate infections

Cefotaxime is well established as an effective and well tolerated antibacterial drug for 3 times daily parenteral treatment of a variety of moderate to severe infections in hospitalised patients. Its frequency of administration has recently been reassessed with a 12-hourly regimen. Comparative studies in hospitalised patients with nosocomial or community-acquired lower respiratory tract infections, demonstrate the similar clinical and bacteriological efficacy of twice daily cefotaxime 1 or 2 g and the same daily dose of ceftriaxone, usually administered once daily. Cefotaxime 2 g twice daily was also similar in efficacy to ceftriaxone 2 g once daily. Retrospective and post-marketing studies also reveal the similar efficacy of cefotaxime administered twice and 3 times daily, and pharmacoeconomic studies suggest that total direct costs of treatment with cefotaxime compared is similar to that with other third generation cephalosporins in currently used dosage regimens. When administered twice daily, cefotaxime is, thus, an effective antibacterial agent for the treatment of hospitalised patients outside the intensive care unit with a variety of mild to moderate non-CNS infections caused by susceptible organisms. When appropriately administered twice daily there is potential to lower the cost of antibacterial treatment without compromising efficacy.

Retrospective analysis of risk factors and prognosis in non-ventilated patients with nosocomial pneumonia

Although nosocomial pneumonia in non-ventilated patients continues to be frequent and have high mortality rates, knowledge of the associated risk and prognostic factors is still limited. This retrospective study was designed to analyze epidemiological characteristics, risk and prognostic factors in patients with nosocomial pneumonia admitted to a hospital internal medicine department. Data on epidemiological, clinical and microbiological factors as well as diagnosis and clinical course were obtained from the medical records of 104 patients diagnosed with nosocomial pneumonia, according to Centers for Disease Control criteria, and from 104 control subjects. The incidence of nosocomial pneumonia was 18.8 per 1000 admissions. Risk factors significantly associated with contracting the disease were female sex, hospital stay longer than 14 days, other admission in the previous month and use of antibiotics during the previous six weeks. The most frequent underlying diseases were cardiorespiratory in nature (59.4%). Prognostic factors significantly associated with increased mortality were serious underlying disease, initially critical clinical status, severe and moderate respiratory insufficiency and bilateral radiological signs. More epidemiological data are needed to improve the diagnosis, treatment and prevention of nosocomial pneumonia.

Treatment of severe pneumonia in hospitalized patients: results of a multicenter, randomized, double-blind trial comparing intravenous ciprofloxacin with imipenem-cilastatin. The Severe Pneumonia Study Group

Intravenously administered ciprofloxacin was compared with imipenem for the treatment of severe pneumonia. In this prospective, randomized, double-blind, multicenter trial, which included an intent-to-treat analysis, a total of 405 patients with severe pneumonia were enrolled. The mean APACHE II score was 17.6, 79% of the patients required mechanical ventilation, and 78% had nosocomial pneumonia. A subgroup of 205 patients (98 ciprofloxacin-treated patients and 107 imipenem-treated patients) were evaluable for the major efficacy endpoints. Patients were randomized to receive intravenous treatment with either ciprofloxacin (400 mg every 8 h) or imipenem (1,000 mg every 8 h), and doses were adjusted for renal function. The primary and secondary efficacy endpoints were bacteriological and clinical responses at 3 to 7 days after completion of therapy. Ciprofloxacin-treated patients had a higher bacteriological eradication rate than did imipenem-treated patients (69 versus 59%; 95% confidence interval of -0.6%, 26.2%; P = 0.069) and also a significantly higher clinical response rate (69 versus 56%; 95% confidence interval of 3.5%, 28.5%; P = 0.021). The greatest difference between ciprofloxacin and imipenem was in eradication of members of the family Enterobacteriaceae (93 versus 65%; P = 0.009). Stepwise logistic regression analysis demonstrated the following factors to be associated with bacteriological eradication: absence of Pseudomonas aeruginosa (P < 0.01), higher weight (P < 0.01), a low APACHE II score (P = 0.03), and treatment with ciprofloxacin (P = 0.04). When P. aeruginosa was recovered from initial respiratory tract cultures, failure to achieve bacteriological eradication and development of resistance during therapy were common in both treatment groups (67 and 33% for ciprofloxacin and 59 and 53% for imipenem, respectively). Seizures were observed more frequently with imipenem than with ciprofloxacin (6 versus 1%; P = 0.028). These results demonstrate that in patients with severe pneumonia, monotherapy with ciprofloxacin is at least equivalent to monotherapy with imipenem in terms of bacteriological eradication and clinical response. For both treatment groups, the presence of P. aeruginosa had a negative impact on treatment success. Seizures were more common with imipenem than with ciprofloxacin. Monotherapy for severe pneumonia is a safe and effective initial strategy but may need to be modified if P. aeruginosa is suspected or recovered from patients.